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December 18, 2019
In comparison to using a contemporary cardiac troponin I (cTn) assay with a common diagnostic threshold for women and men, implementation of a high-sensitivity (hs-cTn) assay with sex-specific thresholds increased by 42% the number of female patients identified as having myocardial injury—nonischemic myocardial injury or type 1 or type 2 myocardial infarction (MI). This was five times higher than the increase in the number of men diagnosed. However, this better recognition did not translate into improved treatments or outcomes for female patients (J Am Coll Cardiol 2019;74:2032-43).
Using hs-cTn I 99th percentile diagnostic thresholds of 16 ng/L for women and 34 ng/L in men in a population of 47,037 patients being evaluated for suspected acute coronary syndrome increased across-the-board recognition of myocardial injury. The diagnosis of type 1 MI, type 2 MI, and nonischemic myocardial injury all rose in both women and men, and in all cases the increase was greater in women (25% versus 6%, 39% versus 9%, and 67% versus 12%, respectively).
Even with this improved diagnosis, however, women with myocardial injury were about half as likely as men to receive recommended interventions, including coronary angiography (26% versus 46%), coronary revascularization (15% versus 34%), and dual antiplatelet therapy (26% versus 43%). Use of the hs-cTn assay with sex-specific diagnostic thresholds also was not associated with substantive improvements in the primary outcomes of recurrent MI or cardiovascular death after 1 year in either women or men.
These findings underscore that more robust tests alone will not carry the day for better cardiovascular care for women, according to both the researchers and editorialists who commented on the study. “It is clear from this study that simply improving diagnostic accuracy cannot remedy deeply embedded gender disparities in attitudes, practice, and outcomes,” wrote editorialists Allan Jaffe, MD, and Sharonne Hayes, MD. “Simply put, if one does not act on the data, no diagnostic test will ever have additional worth” (J Am Coll Cardiol 2019;74:2044-6).
ARTIFICIAL PANCREAS SYSTEM OUTPERFORMS CURRENT GLUCOSE MANAGEMENT TECHNOLOGY
A novel closed-loop insulin delivery and glucose monitoring system (also known as an artificial pancreas) enabled patients to meet glycemic control targets more effectively than current technology (N Engl J Med 2019; doi:10.1056/NEJMoa1907863).
Patients randomly assigned to the new system as part of a 6-month trial of 168 individuals with type 1 diabetes stayed 2.6 hours per day longer in the target glucose range of 70 to 180 mg/dL compared with participants who used a sensor-augmented pump and a continuous glucose monitor.
The 112 individuals using the closed-loop system also experienced 13 minutes less time each day in hypoglycemia. In addition, their HbA1c levels improved, to a median of 7.06±0.79 during the trial period versus 7.40±0.96 during a baseline period while they were learning to use the system and researchers were collecting data. In contrast, individuals using the sensor-augmented pump had a median HbA1c level during the baseline period of 7.40±0.76 versus 7.39±0.92 during the trial period.
Participants using the closed-loop system reported 17 adverse events compared with two among sensor-augmented pump users. Most of the events involving the closed-loop system were caused by infusion set failures, according to the investigators.