-          Globally, coronary heart disease remains the major cause of death in women in both high-and low- or middle-income nations. 

-          Gender differences remain in diagnosis, access to investigation and treatment and outcomes. 

-          Women consistently have higher case fatality rates compared to men, and these differences exist despite adjusting for age and comorbid conditions. 

Cardiac Troponin
-          Troponin is a 3-piece regulatory protein complex present in cardiac and skeletal muscle and is integral to muscle contraction.

-          Both cardiac troponin T and troponin I are derived from genes specific to the myocardium, whereas troponin C is present in both cardiac and skeletal muscles. 

-          Given the high specificity of cardiac troponin T and troponin I to the myocardium, quantification of these biomarkers has now become integral to the diagnosis of myocardial infarction. 

-          Over the last decade, troponin assays have become increasingly sensitive which has allowed quantification of circulating troponin in the majority of individuals in a normal healthy reference population.

-          The mechanisms through which cardiac troponin is released into the circulation in the apparent ‘healthy’ state is unclear, but may reflect cardiomyocyte apoptosis and cell turnover, hypertrophy or sub-clinical myocardial fibrosis. 

Sex Specific Cardiac Troponin
-          Sex differences in cardiac troponin concentrations are not widely recognised in clinical practice and may contribute to under-diagnosis of myocardial infarction in women and discrepancies in patient care and outcomes. 

-          An explanation gaining increasing attention, is under-diagnosing myocardial infarction in women by not recognising that there are important differences in the reference range and diagnostic threshold of cardiac biomarkers between men and women. 

-          In acute coronary syndrome, women have lower cardiac troponin concentrations than men.

Cardiovascular Studies
-          In cardiovascular medicine large randomised control trials include a majority of men. As such, the evidence on interventions in acute myocardial infarction are limited in women with data largely derived from their male counterparts. 

-          Women are less likely to be recruited as they are thought to present with less typical symptoms and are older and more likely to have comorbid conditions. 

-          As such, selection bias will influence the generalisability of the findings from diagnostic accuracy studies.

-          Changes in reproductive hormones during the menstrual cycle, pregnancy and menopause influence both vasomotor function and endogenous fibrinolysis. 

-          Oestrogen induced attenuation of ventricular hypertrophy

-          Difference in release and clearance kinetics

-          Greater left ventricle mass in men

-          Age adjusted higher BP in men

-          Greater sympathetic nervous activity in men

Summary
There are three main arguments in favour of adopting sex-specific thresholds:

1^st Cardiac troponin concentrations are consistently lower in women than men, across multiple populations from different ethnic backgrounds. 

2^nd Cardiac troponin concentrations in stable populations infer different prognostic information in men and women with stronger associations noticed in women when uniform thresholds are applied.

3^rd In suspected acute coronary syndrome, sex-specific thresholds for cardiac troponin I identify women at high risk of future myocardial infarction and death. 

·      Altered mental status is among the signs of hypoperfusion in cardiogenic shock, the most severe form of acute heart failure  

·      The purpose of the study was to investigate the prevalence of altered mental status

·      Identify factors associating with it and to assess the prognostic significance of altered mental status in cardiogenic shock   

·      Mental status were assessed as presentation of shock in 215 adult cardiogenic shock patients in a multinational, prospective, observational study

·      Clinical picture, biochemical variables and short-term mortality were compared between patients presenting with altered and normal mental status 

·       Altered mental status was detected in 147 (68%) patients, whereas 68 (32%) patients had normal mental status

·       Patients with altered mental status were older (68 vs. 64 years, p=0.04) and more likely to have an acute coronary syndrome than those with normal mental status (85% vs. 74%, p=0.04)

·       Altered mental status was associated with lower systolic blood pressure (76 vs. 80 mmHg, p=0.03) and lower arterial pH (7.27 vs. 7.35, p<0.001) as well as higher levels of blood lactate (3.4 vs. 2.3 mmol/l, p<0.001) and blood glucose (11.4 vs. 9.0 mmol/l, p=0.01)

·       Low arterial pH (adjusted odds ratio 1.6 (1.1–2.2), p=0.02) was the only factor independently associated with altered mental status

·       Ninety-day mortality was significantly higher (51% vs. 22%, p<0.001) among patients with altered mental status.

 

·      Altered mental status is common clinical sign of systemic hypoperfusion in cardiogenic shock and is associated with poor outcome

·      It is also associated with several biochemical findings that reflect inadequate tissue perfusion, of which low arterial pH is independently associated with altered mental status