Focusing on women: dissecting sex-specific factors in cardiogenic shock through a large cohort and propensity score matching
Authors: Ortega-Hernandez J A , Gonzalez-Pacheco H , Gopar-Nieto R , Araiza-Garaygordobil D , Sierra-Lara-Martinez D , Manzur-Sandoval D , Briseno-De-La-Cruz J L , Mendoza-Garcia S , Arzate-Ramirez A , Morales-Guzman A , Fierros-Chable K A , Hernandez-Montfort J , Arias-Mendoza A 
Published: October 2024

Abstract

Background
Sex differences in cardiogenic shock (CS) are crucial for tailored interventions. We explored sex-based disparities a CS-registry encompassing both acute myocardial infarction (AMI) and non-AMI-CS.

Purpose
Investigate specific risk variables by type and sex of CS. Compare women-specific risk in CS types and through a propensity score matching (PSM).

Methods
9430 patients in a CS registry, 4414 non-AMI-CS (2432 men, 1982 women) and 5016 AMI-CS (4025 men, 991 women). Utilized KM curves, Cox regression, and a multivariable model (for significant variables P&lt;0.05) to identify sex-specific risk factors. Conducted PSM (K=1, 1:1 radius, caliper 0.2) for significant demographic and management variables, and incorporate age, DM2, MCS, PAC, mechanical ventilation (MV), hemodialysis, and exact for SCAI; and for AMI-CS, considered type of MI and primary reperfusion; to assess sex influence on CS mortality.

Results
Men with AMI an non-AMI-CS are younger, higher BMIs, and smoking history is more prevalent(P&lt;0.05). Women with AMI had higher comorbidities, including HTN, HF, CKD, and AF(P&lt;0.001). Conversely, men with non-AMI exhibit higher dyslipidemia, COPD, previous MI, PCI, and CABG(P&lt;0.001). In terms of CS management, women with AMI are less likely to receive primary reperfusion(P&lt;0.001), while women receive a higher number of vasoactive(P&lt;0.001). Women receive less dobutamine and levosimendan in non-AMI-CS(P&lt;0.001) but more norepinephrine in AMI & non-AMI(P&lt;0.05), finally, more vasopressin in AMI-CS(P=0.006). The SCAI classification indicates that women with AMI tend to have a higher proportion of higher SCAI classes compared to men in AMI-CS (P&lt;0.001) but comparable in non-AMI(P=0.296). Despite these differences, women experience higher mortality in both AMI & non-AMI(P&lt;0.001 & 0.025).(Table 1)
Also, different intensities in management strategies are seen by SCAI, and sex in general has been more intense in MCS(AMI) and vasoactive drugs(non-AMI) in men(data not shown).
In multivariate analysis, we notice differences in the specific risk factors in men vs women.(Fig1).
In mortality, had differences in both AMI and non-AMI-CS. In the case of AMI-CS Logrank(LR) P&lt;0.001, 30 day-RMST of 2.11(1.12-3.08, P&lt;0.001) days less, with a HR of 1.48(1.28-1.72, P&lt;0.001) for women in AMI-CS. In non-AMI-CS LR P=0.006 in 30-days RSMT, a difference of diminished survival of 0.85(0.08-1.62, P=0.03) days, a HR of 1.18(1.05-1.32; P=0.007) for women in non-AMI-CS. (Fig1).
When applying PSM, AMI-CS(931 vs 931) although differences arise in LR P=0.048, no differences are seen in 30-day RSMT 1.09(-0.17-2.35, P=0.09), HR 1.22(1.0-1.48, P=0.052). Non-AMI-CS(1406 vs 1406) no differences were appreciated(LR P=0.359), 30-day RSMT 0.4(-0.55-1.36, P=0.407), a HR 1.07(0.92-1.24, P=0.366). (Fig1).

Conclusion
Women's distinct risk factors may outweigh the impact of sex alone on outcomes. Sex-specific risk factors vary by CS type, underscoring the importance of tailored approaches.Table 1.Differences by CS type & sexFig 1.Forrest plot by CS type & sex