Comparison of baseline characteristics, clinical features, angiographic results, and early outcomes in men vs women with acute myocardial infarction undergoing primary coronary intervention

BACKGROUND: Women have had a higher early mortality rate than men after acute myocardial infarction (AMI) in the prethrombolytic and thrombolytic eras. Primary percutaneous coronary intervention (PCI) has been shown to significantly improve survival of patients with AMI, and to be superior to thrombolytic therapy in terms of immediate restoration of normal flow in the infarct-related artery and reduction of recurrent ischemic events. However, the effect of primary PCI on early outcomes of women vs men remains unknown. Therefore, we examined whether there was any difference in term of 30-day mortality between women and men after primary PCI. METHODS AND RESULTS: Between May 1993 and April 2002, primary PCI was performed in 1,032 consecutive patients (15.3% women and 84.7% men) with AMI. The overall successful reperfusion (final Thrombolysis in Myocardial Infarction grade 3 flow) and 30-day morality rates were 84.0% and 8.5%, respectively. The rate of successful reperfusion did not differ between women and men (84.8% vs 83.9%, p = 0.77). However, mortality at 30 days was significantly higher in women than in men (14.6% vs 7.4%, p = 0.003). In comparison with men, women were older; had significantly higher incidences of hypertension, diabetes mellitus, complete atrioventricular block, and right ventricular infarction; and had longer times of reperfusion (all p values < 0.05). During hospitalization, advanced congestive heart failure (New York Heart Association class 3 or greater), free wall rupture, and major bleeding complications were more likely to occur in women than in men (all p values < 0.05). Compared with men, the unadjusted odds ratio for 30-day death among women was 2.12 (95% confidence interval [CI], 1.27 to 3.53). After adjusting for age, the odds ratio was substantially reduced to 1.66 (95% CI, 0.98 to 2.79). Further adjustment for age and other variables further reduced the odds ratio to 1.06 (95% CI, 0.53 to 2.14). CONCLUSIONS: A gender gap of 30-day mortality existed between women and men with AMI that could not be altered by primary PCI. However, this gap was only an apparent one, and was not truly related to gender alone. In comparison with men, women were older, had significantly higher incidences of comorbidities and major untoward clinical events, and had longer times of reperfusion, which could help explain why the 30-day mortality rate was higher in women than in men.     

Comparison of short-term outcomes following coronary artery stenting in men versus women.

This study sought to determine whether women have more adverse in-hospital outcomes after percutaneous transluminal coronary angioplasty (PTCA) and stenting compared with men. There is still controversy regarding whether female gender is an independent predictor of mortality after PTCA. No study has examined gender differences in outcomes following the dissemination of stenting. Data were obtained from the Nationwide Inpatient Sample. In 1997, there were 118,548 angioplasties (36% occurred in women and 59% involved placement of stents). Outcomes included same-admission mortality and coronary artery bypass grafting (CABG). Analyses were performed separately for patients with and without acute myocardial infarction (AMI). In 1997, women had a roughly twofold higher mortality than men in every comparison group, including conventional PTCA alone and stents. Mortality rates after stenting were 4.0% for women and 2.0% for men with AMI (p <0.0001), and 1.1% and 0.5%, respectively, for patients without AMI (p <0.0001). The adjusted odds ratios were 1.47 (95% confidence interval 1.23 to 1.75), and 1.65 (95% confidence interval 1.33 to 2.04), respectively. Similarly, following stenting, women had significantly higher CABG rates than men in both the AMI (1.6% vs 1.2%, p = 0.025) and no AMI groups (1.5% vs 1.0%, p <0.0001). After multivariate adjustment, the results retained significance in the no AMI setting, whereas there was a trend toward significance in the AMI group. This study demonstrates that, despite improved overall outcomes in patients who received stents, women who underwent stenting had higher rates of same-admission mortality and CABG compared with men. Furthermore, it confirms that female gender is an independent predictor of mortality after conventional PTCA.     

Effects of gender on the number of diseased vessels and clinical outcome in Japanese patients with acute coronary syndrome.

It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is unclear and it is not known if it also applies to unstable angina pectoris (UAP). In addition, most previous studies have not presented angiographic findings. In the present study, the findings from 1,408 patients with AMI (group A: 361 women, 1,047 men) and 332 patients with UAP (group B: 103 women, 229 men) who underwent coronary angiography within 30 days of onset were analyzed. In both groups, the women were older and had a higher rate of hypertension and a lower rate of smoking than the men. There was no significant difference in Killip class or the number of diseased vessels between the women and men in both groups. Interventions (coronary angioplasty and coronary artery bypass grafting) were performed less frequently in the women than in the men (87.2% vs 91.8%, p=0.04) in group A, but not in group B (80.6% vs 81.2%, NS). In both groups, the overall mortality rate during hospitalization was higher in women than in men (group A: 14.4% vs 7.4%, p<0.0001, group B: 7.8% vs 1.7%, p=0.007). Multivariate analysis revealed that female gender was an independent predictor of in-hospital mortality in group B (odds ratio (OR): 6.4, 95% confidence interval (CI) 1.1-37.0, p=0.04), but not in group A (OR: 1.7, 95%CI 0.98-2.9, p=0.06). The independent predictors of in-hospital mortality, other than female gender were age, prior congestive heart failure, prior cerebrovascular disease and a higher Killip class in group A, and in both groups a higher number of diseased vessels. In conclusion, Japanese women with acute coronary syndromes present with similar angiographic findings and hemodynamics, but have a higher in-hospital mortality than male patients. Our results suggest that older age may be a potential explanation for the higher in-hospital mortality in women with AMI, but female gender itself may be an important predictor for it among those with UAP.     

Increased cardiac mortality in women compared with men in patients with acute myocardial infarction

OBJECTIVE: It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is not known. The profile in relation to age, gender and risk factors was evaluated to compare AMI and unstable angina pectoris (UAP). METHODS: Findings from 984 patients including 580 patients with AMI (129 women, 451 men) and 404 patients with UAP (131 women, 273 men) were analyzed by the South Osaka Acute Coronary Syndrome Study Group (SACS). The primary endpoint of the study was in-hospital death. The primary endpoints of interest (cardiac death) were fatal recurrent myocardial infarction, death from congestive heart failure, and sudden death. RESULTS: Cardiac death during hospitalization within 30 days in AMI was higher in women than in men (12.4% vs 6.7%, p < 0.05). On the other hand, in UAP there was no significant difference between women and men (1.5% vs 0.7%, NS). The incidence of cardiac death in AMI was significantly higher for patients 75 years old and older (19.0%) than for patients less than 55 years old (4.2%), 55-64 years old (3.5%) and 65-74 years old (4.7%) (p < 0.001, respectively). CONCLUSIONS: Cardiac death was higher for women compared with men in patients with AMI. The worse prognosis for the AMI women patients was likely to be derived from less performance of percutaneous coronary intervention, and a high incidence of severe myocardial infarction. Further research should be focused on the analysis of various clinical backgrounds.     

Absence of gender differences in clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction. A report from the SHOCK Trial Registry.

OBJECTIVES: The aim of this study was to assess the impact of gender on clinical course and in-hospital mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND: Previous studies have demonstrated higher mortality for women compared with men with ST elevation myocardial infarctions and higher rates of CS after AMI. The influence of gender and its interaction with various treatment strategies on clinical outcomes once CS develops is unclear. METHODS: Using the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) Registry database of 1,190 patients with suspected CS in the setting of AMI, we examined shock etiologies by gender. Among the 884 patients with predominant left ventricular (LV) failure, we compared the patient demographics, angiographic and hemodynamic findings, treatment approaches as well as the clinical outcomes of women versus men. This study had a 97% power to detect a 10% absolute difference in mortality by gender. RESULTS: Left ventricular failure was the most frequent cause of CS for both gender groups. Women in the SHOCK Registry had a significantly higher incidence of mechanical complications including ventricular septal rupture and acute severe mitral regurgitation. Among patients with predominant LV failure, women were, on average, 4.6 years older, had a higher incidence of hypertension, diabetes and a lower cardiac index. The overall mortality rate for the entire cohort was high (61%). After adjustment for differences in patient demographics and treatment approaches, there was no significant difference in in-hospital mortality between the two gender groups (odds ratio = 1.03, 95% confidence interval of 0.73 to 1.43, p = 0.88). Mortality was also similar for women and men who were selected for revascularization (44% vs. 38%, p = 0.244). CONCLUSIONS: Women with CS complicating AMI had more frequent adverse clinical characteristics and mechanical complications. Women derived the same benefit as men from revascularization, and gender was not independently associated with in-hospital mortality in the SHOCK Registry.     

Are predictors for myocardial infarction the same for women and men when evaluated prior to hospital admission?

AIM: To describe predictors of myocardial infarction prior to hospital admission in women and men among patients with a suspected acute coronary syndrome without ST-elevation. DESIGN: Prospective observational study in Stockholm and G?teborg, Sweden. RESULTS: Of 433 patients who did fulfill the inclusion criteria 45% were women. Fewer women (17%) than men (26%) developed acute myocardial infarction (AMI) (p=0.054), particularly among patients with initial ST-depression, in whom AMI was developed in 22% of women and 54% of men (p = 0.001). Predictors for infarct development in women were: a history of AMI and advanced age. Among men they were: initial ST-depression or a Q-wave on ECG and elevation of biochemical markers (both recorded on admission of the ambulance crew). There was a significant interaction between gender and the influence of ST-depression on the risk for development of myocardial infarction (p < 0.05). CONCLUSION: Among patients transported with ambulance due to a suspected acute coronary syndrome and no ST-elevation fewer women than men seem to develop AMI particularly among patients with ST-depression. These results suggest that early prediction of myocardial infarction might differ between women and men with acute chest pain.     

Differences in outcome in primary angioplasty in women.

BACKGROUND: In acute myocardial infarction (AMI), primary percutaneous transluminal coronary angioplasty (PTCA) has proved to be the best therapeutic approach. Several factors have been associated with worse outcome in AMI in females. Are there differences in outcome in women undergoing PTCA for AMI? AIM: To evaluate gender influence on clinical outcome and in-hospital mortality in patients with AMI who undergo primary percutaneous interventions. METHODS: We studied 245 consecutive patients (72 women, 29.4 %), who underwent primary PTCA between January 2000 and December 2001. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PTCA or angina, pain-to-balloon time, extent of coronary disease and outcome. RESULTS: Female patients were older (67.9+/-11.6 vs. 59.6+/-13; p < 0.001) with a higher prevalence of hypertension (65.3 % vs. 47.4 %; p < 0.05) and angina (29.0 % vs. 16.0 %; p < 0.05) and lower prevalence of smoking (27.8 % vs. 54.3 %; p < 0.001). Pain-to-balloon time was longer in women (6.8+/-4.1 vs. 5.4+/-3.7 hours; p < 0.05). Extent of coronary disease was similar in both groups. Glycoprotein IIb/IIIa inhibitors were used in 84.7 % of women and 90.8 % of men. The frequency of hemorrhagic complications (5.6 % vs. 5.2 %) and arrhythmias (15.3 % vs. 10.4%) and in-hospital mortality (9.7 6.4 %) were higher in females, although without statistical significance (p = NS). Hospitalization time was similar in both groups. CONCLUSIONS: Despite the growing awareness of a gender bias in therapeutic approaches to AMI, there are still some differences in outcome, with a trend towards higher mortality rates in women. Older age and longer pain-to-balloon time could account for this.     

Differences in thrombolytic treatment and in-hospital mortality between women and men after acute myocardial infarction

There is evidence for gender differences in the treatment and outcome of acute myocardial infarction (AMI). However, little data exist about these differences in patients from the Arab Middle East. Therefore, we studied the influence of patient gender on the presentation, the use of thrombolytic therapy, and in-hospital mortality after AMI in Kuwaiti nationals. This is a retrospective study of all consecutive Kuwaiti patients admitted to the coronary care unit of a university hospital with the diagnosis of AMI between June 1994 and May 1997. A total of 89 women and 267 men were included. Women were older than men and had significantly higher rates of diabetes (72% vs 46%), hypertension (58% vs 33%) and hypercholesterolemia (80% vs 53%). Women were less likely to receive thrombolytic therapy (40% vs 62%, p=0.001). Fewer women were eligible for thrombolytic therapy (50% vs 66%, p<0.05). Of those who were eligible for thrombolysis there was no sex difference in receiving such treatment. The in-hospital mortality among women younger than 70 years was 2.5 times higher than among men in the same age group, while there was no difference in mortality between women and men aged 70 years and older. We conclude that women and men with AMI have different clinical characteristics and outcomes following AMI. There was no gender bias for the use of thrombolytic therapy. The higher in-hospital mortality in younger women, i.e. less than 70 years, compared to younger men, indicates that younger women with AMI should be considered as a high-risk group.     

Impact of diabetes and gender on survival after acute myocardial infarction in the Province of Quebec,Canada—a population‐based study

Aims To examine the impact of diabetes, gender and their interaction on 30‐day, 1‐year and 5‐year post‐acute myocardial infarction (AMI) mortality in three age groups (20–64, 65–74 and ≥ 75 years). Methods Retrospective analysis including 23 700 patients aged ≥ 20 years (22% with diabetes) admitted to hospital for a first AMI in any hospital in the Province of Quebec, Canada, between April 1995 and March 1997. Administrative databases were used to identify patients and assess outcomes. Results Regarding 30‐day mortality, there was non‐significant interaction between diabetes and gender. Women aged < 75 years had, independently of diabetes status, at least a 38% (P < 0.05) higher mortality than their male counterparts after adjustment for socio‐economic status and co‐morbid conditions. Gender difference disappeared, however, after controlling for in‐hospital complications. Regarding 1‐year mortality (31–365 days), there was no significant gender disparity for all age groups. During the 5‐year follow‐up, no gender differences were seen in any age group, except for younger (< 65 years) women with diabetes, who had a 52% (P = 0.004) higher mortality than men after controlling for co‐variables. This female disadvantage was demonstrated by a significant interaction between diabetes and gender in patients aged < 65 years (P = 0.009). Conclusions The higher 30‐day mortality post‐AMI in younger (20–64 years) and middle‐aged (65–74 years) women compared with men was not influenced by diabetes status. However, during the 5‐year follow‐up, the similar gender mortality observed in patients without diabetes seemed to disappear in younger patients with diabetes, which may be explained by the deleterious, long‐term, post‐AMI impact of diabetes in younger women.     

Gender-age interaction in early mortality following primary angioplasty for acute myocardial infarction

Previous studies have demonstrated a significant interaction between gender and age after medically treated acute myocardial infarction (AMI), when younger women were found to have a higher mortality rate than younger men, but the mortality rate for older men and women was similar. The study objective was to determine whether a gender-age interaction exists for AMI treated exclusively with primary angioplasty. This analysis was a retrospective cohort study of 9,015 consecutive patients who underwent primary angioplasty for AMI in New York State from 1997 to 1999. The primary end point of interest was in-hospital mortality. A logistic regression model was constructed to determine the relation between gender and mortality among patients with AMI treated with angioplasty. Additional analyses were performed to test whether a mortality difference existed according to age. In-hospital mortality rate was twofold higher in women than in men (6.7% vs 3.4%, p <0.001). After adjusting for age, co-morbid conditions, and hemodynamic status by multivariable logistic regression analysis, the odds ratio for in-hospital death for women was no longer significant (odds ratio 1.21, 95% confidence interval 0.69 to 2.10, p = 0.51). Among patients <75 years of age, women had a 37% increased risk of in-hospital mortality (adjusted odds ratio 1.37, 95% confidence interval 1.01 to 1.98, p = 0.04), whereas there was no significant difference in mortality between men and women who were >or=75 years of age. In conclusion, female gender was found to be an independent predictor of in-hospital mortality in patients <75 years of age after primary angioplasty for AMI.     

Influence of age on gender differences in the management of acute inferior or posterior myocardial infarction

STUDY OBJECTIVES: To assess the effect of gender on the in-hospital management of patients with acute inferior or posterior myocardial infarction (MI). DESIGN: Retrospective analysis of clinical records. Gender differences in management and prognosis were assessed by stepwise multiple logistic regression analysis. SETTING: University, large-volume, tertiary hospital. PATIENTS: We studied 1,178 consecutive patients admitted to our coronary care unit with an acute inferior or posterior MI, and evaluated the influence of gender on clinical management and outcome. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Women were older (73 years vs 66 years), had a higher prevalence of diabetes and hypertension, presented later (8 h vs 6 h after symptom onset), and had a higher in-hospital mortality rate (26% vs 9%) [all p values < 0.01]. Women underwent reperfusion therapy (45% vs 61%, p < 0.01), noninvasive studies (30% vs 62%, p < 0.001), and coronary angiography (34% vs 48%, p < 0.01) less often than men. Multivariable analysis revealed that female gender was an independent predictor of a lower use of noninvasive studies (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.24 to 0.63; p < 0.005) and coronary angiography (OR, 0.59; 95% CI, 0.37 to 0.93; p = 0.02). A significant interaction between age and gender was found (p = 0.002); therefore, women > or = 75 years old had a much lower probability of undergoing noninvasive tests and coronary angiography than men of the same age. CONCLUSION: Despite their worse prognosis, women undergo noninvasive studies and coronary angiography less frequently than men after an acute inferior or posterior MI. The gender gap increases in patients > or = 75 years old.     

Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease

OBJECTIVES: This study examined gender differences and temporal changes in the clinical characteristics of patients referred for nuclear stress imaging, their imaging results and subsequent utilization of coronary angiography and revascularization. BACKGROUND: Gender bias may influence resource utilization in patients with coronary artery disease (CAD). No study has analyzed gender differences and time trends in patients referred for noninvasive testing and subsequent use of invasive procedures. METHODS: Between January 1986 and December 1995, 14,499 patients (5,910 women and 8,589 men) without established CAD underwent stress myocardial perfusion imaging. The clinical characteristics, imaging results, coronary angiograms and revascularization outcomes were compared in women and men over time. RESULTS: The mean pretest probability of CAD was lower in women (45%) than in men (70%) (p < 0.001). More women (69%) than men (42%) had normal nuclear images (p < 0.001). Men (17%) were more likely than women (8%) to undergo coronary angiography (p < 0.001). Male gender was independently associated with referral for coronary angiography (multivariate model: chi-square = 16, p < 0.001) but was considerably weaker than the imaging variables (summed reversibility score: chi-square = 273, p < 0.001). Revascularization was performed in more men (46% of the population undergoing angiography) than women (39%) (p = 0.01), but gender was not independently associated with referral to revascularization. There were no significant differences in clinical, imaging or invasive variables between the genders over time. CONCLUSIONS: There was little evidence for a bias against women in this study. Women were somewhat less likely to undergo coronary angiography but were referred for stress perfusion imaging more liberally. Practice patterns remained constant over this 10-year period.     

Gender differences in the management and outcome of acute myocardial infarction in unselected patients in the thrombolytic era

This study compares the clinical features, management, and outcome in men and women from a consecutive, unselected series of patients with acute myocardial infarction (AMI) who were admitted to a university cardiac center over a 3-year period. It is a retrospective observational study of 1,059 admissions with AMI identified through the Hospital In-Patient Enquiry (HIPE) registry, validated according to Minnesota Manual criteria, and followed for a period of up to 5 years (median 36 months). Women comprised 40% of all admissions, had a higher hospital mortality (24% vs. 16%, p<0.001), and were less likely to receive thrombolysis (23% vs. 33%, p<0.01), admission to coronary care (65% vs. 77%, p<0.001), or subsequent invasive or noninvasive investigations (55% vs. 63%, p<0.01). However, women with AMI were older than men with AMI (71 vs. 65 years, p<0.001). After adjusting for age, differences that remained significant were prevalence of hypertension (odds ratio [OR] 2.12, 95% confidence intervals [CI] 1.56 to 2.88) and cigarette smoking (OR 0.47, 95% CI 0.35 to 0.65), management in coronary care (OR 0.66, 95% CI 0.49 to 0.88), and hospital mortality (OR 1.48, 95% CI 1.07 to 2.04). Excess mortality occurred predominantly in women <65 years old (18% vs. 8%, OR [multivariate] 2.35, 95% CI 1.19 to 4.56), among whom multivariate analysis demonstrated a significantly lower thrombolysis rate (OR 0.48, 95% CI 0.27 to 0.86). In this group, lack of thrombolysis independently predicted hospital mortality (OR 5.37, 95% CI 1.45 to 19.82). Female gender was not an independent predictor of mortality following AMI (OR 1.42, 95% CI 0.90 to 2.26). Thus, among unselected patients, female gender is associated with, but not an independent predictor of, reduced survival after AMI. Gender differences in mortality are greatest in younger patients, who are less likely to receive thrombolysis and in whom lack of thrombolysis is independently associated with mortality after AMI.     

Angioplastia primária na mulher: realidade nacional

AimsAlthough mortality after primary percutaneous coronary intervention (PPCI) is higher in women than in men, there is disagreement as to whether gender is an independent risk factor for mortality in ST‐ elevation myocardial infarction (STEMI). Our aim was to assess how gender influenced short‐term prognosis in patients undergoing PPCI in the Portuguese Registry of Interventional Cardiology.MethodsOf 60 158 patients prospectively included in a large registry of contemporary PCI, from 2002 to 2012, we included 7544 patients with STEMI treated by PPCI, of whom 1856 (25%) were female. The effect of gender on in‐hospital mortality was assessed by multivariate logistic regression analysis with propensity score matching.ResultsWomen were older (68±14 vs. 61±13 years, p<0.001), with a higher prevalence of diabetes (30% vs. 21%, p<0.001) and hypertension (69% vs. 55%, p<0.001). Men were more frequently revascularized within six hours of symptom onset (71% vs. 63%, p<0.001). Cardiogenic shock was more frequent in women (7.1% vs. 5.7%, p=0.032). Female gender was associated with a worse short‐term prognosis, with 1.7 times higher risk of in‐hospital death (4.3% in women and 2.5% in men, 95% confidence interval (CI) 1.30‐2.27, p<0.001). After computed propensity score matching based on baseline clinical characteristics, in‐hospital mortality was similar between women and men (odds ratio 1.00, 95% CI 0.68‐1.48, p=1.00).ConclusionsIn the Registry, women with STEMI treated by PPCI had a greater risk‐factor burden, less timely access to treatment and a worse prognosis. However, after risk adjustment, female gender ceases to be an independent predictor of in‐hospital mortality.     

Sex differences in early mortality of patients undergoing primary stenting for acute myocardial infarction.

BACKGROUND: Limited information exists regarding the impact of gender on in-hospital outcome after primary stenting for acute myocardial infarction (AMI). METHODS AND RESULTS: A total of 2,981 patients (790 women and 2,191 men) participated in the study who were admitted within 24 h after symptom onset and underwent emergency primary stenting for AMI. Compared with men, women were significantly older; had higher incidences of hypertension, diabetes mellitus, hyperlipidemia, Killip class > or =2, and cardiogenic shock; had a higher blood glucose level and a lower serum creatinine level on admission. Other baseline characteristics, including the incidences of ST-segment elevation AMI, anterior infarction, 3-vessel disease, initial or final Thrombolysis in Myocardial Infarction (TIMI) flow grade did not significantly differ between the sexes. The in-hospital mortality rate was significantly higher in women than in men (9.4% vs 5.2%, p<0.001). On multivariate analysis, age, Killip class, blood glucose level, serum creatinine level, and final TIMI grade were independent predictors of in-hospital death, but female gender was not (odds ratio 1.01, p=0.69). CONCLUSIONS: Our findings suggest that in patients undergoing primary stenting for AMI, women have higher in-hospital mortality than men, but female gender itself is not independently associated with increased in-hospital mortality after adjustment for baseline differences.     

Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction

OBJECTIVES: The goal of our study was to examine how age and gender affect the use of coronary angiography and the intensity of cardiac follow-up care within the first year after acute myocardial infarction (AMI). Another objective was to evaluate the association of age, gender and treatment intensity with five-year survival after AMI. BACKGROUND: Utilization rates of specialized cardiac services inversely correlate with age. Gender-specific practice patterns may also vary with age in a manner similar to known age-gender survival differences after AMI. METHODS: Using linked population-based administrative data, we examined the association of age and gender with treatment intensity and long-term survival among 25,697 patients hospitalized with AMI in Ontario between April 1, 1992, and December 31, 1993. A Cox proportional hazards model was used to adjust for socioeconomic status, illness severity, attending physician specialty and admitting hospital characteristics. RESULTS: After adjusting for baseline differences, the relative rates of angiography and follow-up specialist care for women relative to men, respectively, fell 17.5% (95% confidence interval [CI], 13.6 to 21.3, p < 0.001) and 10.2% (95% CI, 7.1 to 13.2, p < 0.001) for every 10-year increase in age. Conversely, long-term AMI survival rates in women relative to men improved with increasing age, such that the relative survival in women rose 14.2% (95% CI, 10.1 to 17.5, p < 0.001) for every 10-year age increase. CONCLUSIONS: Gender differences in the intensity of invasive testing and follow-up care are strongly age-specific. While care becomes progressively less aggressive among older women relative to men, survival advantages track in the opposite direction, with older women clearly favored. These findings suggest that biology is likely to remain the main determinant of long-term survival after AMI for women.     

Gender differences and in-hospital mortality in patients undergoing percutaneous coronary interventions

BACKGROUND: Many observational and randomised studies have suggested that women are referred for invasive diagnostics and treatment of coronary artery disease (CAD) less frequently than men, and the effects of percutaneous coronary intervention (PCI) among women are worse than in men. AIM: To compare direct results of PCI in men and women. METHODS: The study was a retrospective assessment of case records of one thousand consecutive patients treated with PCI because of acute myocardial infarction (AMI) (344 patients), unstable angina (UA) (164 patients) and stable angina (SA) (492 patients). We examined the effects of demographic, angiographic and clinical variables on the duration of hospitalisation and in-hospital mortality separately in men and in women. RESULTS: Women constituted 30.7% of patients treated with PCI because of AMI, 39.6% of those with UA and just 25.8% of those with SA. Women were significantly older than men, had a higher BMI, and more often suffered from hypertension and diabetes. The duration of hospitalisation was the same in men and women if the reason for PCI was SA or UA, however, in case of AMI women were hospitalised significantly longer than men. In the univariate analysis gender had no influence on in-hospital mortality regardless of the reason for PCI treatment. Among the variables subjected to multivariate analysis female gender, age, BMI, diabetes, hypercholesterolaemia, indication for PCI, final TIMI flow in the target vessel and cardiogenic shock as a complication of AMI were shown to affect mortality. Significant effects on in-hospital mortality for women were exhibited only by cardiogenic shock. Among men, indication for PCI, age, diabetes and final TIMI flow in the target vessel also had a significant influence on in-hospital mortality. CONCLUSIONS: Stable angina is a reason for performing PCI more rarely in women than in men. Women with CAD are older than men and have more risk factors. The in-hospital mortality among patients treated with PCI because of SA is independent of gender. Cardiogenic shock appeared to be the only factor that influences in-hospital mortality in women. In the case of men such an influence is also observed for indication for PCI (AMI, UA or SA), diabetes and final TIMI flow in the target vessel.     

Prognosis of myocardial infarction in women. Effect of the therapeutic effort and the socioeconomic status]

The causes of the high mortality of acute myocardial infarction in women as compared with men are controversial. The objective of this study is to assess the role of the therapeutic effort and socioeconomic factors on the genesis of this excess of mortality. We studied, using a retrospective cohort design, 491 men and 124 women admitted with the diagnosis of acute myocardial infarction. As a group, women were older (69 versus 61 years of age, p < 0.00001), showed a higher prevalence of cardiac failure on admission (44% versus 26%; p = 0.00008) and a higher mortality in the coronary care unit (29.3% versus 12.9%; p = 0.00002). In addition, the women showed an unfavorable socioeconomic profile and received a lower relative therapeutic effort, as assessed by the Therapeutic Intervention Scoring System. There was statistical interaction between gender and marital status, with a higher mortality in the unmarried male, comparable to that of women. Within the married group, the excess of mortality in women persisted after adjusting for age and Killip group (adjusted odds ratio = 2.48, 95% confidence interval between 1.26 and 4.89). None of the studied socioeconomic variables was independently associated to mortality, once age, Killip group and marital status were taken into account. After adjusting for therapeutic effort, the differences between men and women increased. Women admitted with acute myocardial infarction show a poor short-term prognosis that is not explained by their socioeconomic profile nor by the differences in therapeutic effort.     

Clinical Outcomes in Younger Women Hospitalized With an Acute Myocardial Infarction: A Contemporary Population-Level Analysis

BackgroundFor younger women with acute myocardial infarction (AMI), little is known regarding their contemporary care pathways and clinical outcomes.MethodsWe studied AMI patients aged 18-55 years, hospitalized from April 1, 2009, to March 31, 2019, in Ontario, Canada. We compared trends in comorbidities, angiographic findings, and revascularisation rates in men and women. The primary outcome was 1-year all-cause mortality or readmission for unstable angina, AMI, heart failure, or stroke. Inverse probability of treatment weighting was used to account for differences in baseline clinical characteristics between men and women.ResultsAmong the 38,071 AMI patients included, 8,077 (21.2%) were women. Over the study period, women had increasing rates of diabetes (24.8% to 34.9%; P_trend < 0.001), and declining rates of smoking (53.2% to 41.7%; P_trend < 0.005). Although most patients received coronary angiography (96%), coronary revascularisation was less frequent among women than men (percutaneous coronary intervention: 61.9% vs 78.8% [P < 0.001]; surgery: 4.1% vs 6.0% [P < 0.001]). Women had more normal coronary anatomy (5.8% vs 1.7%; P < 0.001) and nonobstructive disease (22.8% vs 9.3%; P < 0.001) than men. Compared with men, the primary composite end point was significantly increased among women (10.0% vs 7.9%, adjusted HR 1.11; P = 0.02) and related to increased readmission rates for cardiovascular events. All-cause readmission was significantly increased among women (25.8% vs 21.1%, adjusted HR 1.34; P < 0.0001).ConclusionsCoronary angiography is performed almost universally in younger women with AMI; however, coronary revascularisation is less frequent, perhaps reflecting less obstructive disease. Although mortality rates after AMI were similar between sexes, cardiovascular readmission rates and all-cause readmissions were significantly increased among women.     

Gender differences in mortality after acute myocardial infarction with mild to moderate heart failure

BACKGROUND: Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men. AIM: To compare the prognosis of men and women with AMI and mild-moderate HF. METHODS: We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys. RESULTS: Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders. CONCLUSIONS: Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.