Gender differences in management after acute myocardial infarction: not 'sexism' but a reflection of age at presentation

OBJECTIVE: To test whether women receive less intensive treatment and fewer risk stratification tests following acute myocardial infarction (MI), than men. METHODS: A retrospective study of medical records in all district general hospitals and tertiary referral centres for cardiology in Wales was performed. Patients (n = 1595, of which 989 were men) admitted to hospital over 4 months with a diagnosis of acute MI had their case notes reviewed for treatment, stratification of risk factors and secondary prevention. Data were analysed for differences in treatment between men and women and whether these could be attributed to age at presentation. RESULTS: Women were older than men at presentation [mean age 75 (SD 11) versus 66 (12) years, p < 0.01]; fewer women received thrombolysis (34 versus 44 per cent) and low molecular weight heparin (63 versus 71 per cent) (both p < 0.001); and women had higher 30 day mortality (28 versus 17 per cent, p < 0.001). Fewer women received cardiac catheterization, investigations to identify high risk, drugs for secondary prevention on discharge and referral to cardiac rehabilitation. However, intensities of treatment, investigation and secondary prevention were strongly related to age and, after adjusting for age, gender differences remained only for thrombolysis and exercise testing. CONCLUSION: Although women receive fewer investigations and treatments than men, this potential gender bias can be explained by age. The lower use of treatment and investigation among older patients draws attention to the lack of direct evidence of effectiveness for these patients. Further studies are needed to confirm effectiveness of investigations and treatments in older patients.     

Diagnosis and treatment of acute myocardial infarction in tertiary and secondary care hospitals in Estonia

AIM: To compare validity of AMI diagnosis and treatment of AMI patients between tertiary and secondary care hospitals in Estonia. METHODS: Two tertiary and seven secondary care hospitals responsible for the treatment of most AMI patients in Estonia were included in the analysis. A random sample of 520 patients admitted to these hospitals with AMI in 2001 was taken from the Estonian Health Insurance Fund database. Medical records were reviewed by trained experts using a standardized data collection form. RESULTS: Forty cases were excluded due to selection errors by the Health Insurance Fund. Of the remaining cases, a diagnosis of AMI was confirmed in 93.3% of cases in tertiary care hospitals and in 83.5% of cases in secondary care hospitals (p < 0.001). A total of 210 cases from tertiary and 213 cases from secondary care hospitals with confirmed AMI diagnoses were included in subsequent analysis. Utilization of beta-blockers, aspirin, and reperfusion therapy was similar in both types of hospitals. In tertiary care hospitals, ACE inhibitors and statins were more frequently used during hospital stay and recommended at discharge compared with secondary care hospitals. In-hospital mortality was similar in both types of hospitals both before and after adjustment. CONCLUSIONS: Tertiary care physicians adhered more strictly to the current definition and guidelines for the management of AMI than did secondary care physicians. However, there is still a need for further improvement in both hospital settings according to international guidelines.     

Differences in management of heart attack patients between metropolitan and regional hospitals in the Hunter Region of Australia

OBJECTIVES: To test the hypothesis that among patients with acute myocardial infarction (AMI) length of hospital stay, drug use in hospital and on discharge were different between metropolitan and regional hospitals after adjusting for differences in patient baseline risk. METHODS: A retrospective cohort study using a community-based register of heart attack patients assessed 1,406 patients admitted for definite AMI to three metropolitan and five regional hospitals in the Lower Hunter Region of NSW, between January 1, 1990, and March 31, 1994. RESULTS: Patients in metropolitan hospitals were significantly less likely to stay in hospital for more than seven days (adjusted odds ratio = 0.50; 95% CI 0.34-0.73), significantly more likely to receive ACE inhibitors (adj. OR = 1.47; 1.27-1.71) and less likely to receive calcium channel blocker (adj. OR = 0.70; 0.54-0.98). Regardless of disease severity, metropolitan hospitals had a higher percentage of patients for whom drugs shown to decrease mortality after AMI were used (streptokinase, aspirin, ACE inhibitor); a lower percentage of patients received drugs shown to have no benefit or even a detrimental effect (calcium channel blocker). Both groups had relatively low use of beta blocker, also shown to be of benefit. CONCLUSIONS: Regional hospitals had longer hospital stays than metropolitan hospitals and less use of drugs of proven benefit.     

Mortality after admission for acute myocardial infarction in Aboriginal and non-Aboriginal people in New South Wales, Australia: a multilevel data linkage study

ABSTRACT: BACKGROUND: Heart disease is a leading cause of the gap in burden of disease between Aboriginal and non-Aboriginal Australians. Our study investigated short- and long-term mortality after admission for Aboriginal and non-Aboriginal people admitted with acute myocardial infarction (AMI) to public hospitals in New South Wales, Australia, and examined the impact of the hospital of admission on outcomes. METHODS: Admission records were linked to mortality records for 60047 patients aged 25-84 years admitted with a diagnosis of AMI between July 2001 and December 2008. Multilevel logistic regression was used to estimate adjusted odds ratios (AOR) for 30- and 365-day all-cause mortality. RESULTS: Aboriginal patients admitted with an AMI were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients (AOR: 1.07; 95% CI 0.83-1.37) but a higher risk of dying within 365 days (AOR: 1.34; 95% CI 1.10-1.63). The latter difference did not persist after adjustment for comorbid conditions (AOR: 1.12; 95% CI 0.91-1.38). Patients admitted to more remote hospitals, those with lower patient volume and those without on-site angiography had increased risk of short and long-term mortality regardless of Aboriginal status. CONCLUSIONS: Improving access to larger hospitals and those with specialist cardiac facilities could improve outcomes following AMI for all patients. However, major efforts to boost primary and secondary prevention of AMI are required to reduce the mortality gap between Aboriginal and non-Aboriginal people.     

Role of age and sex in short-term and long term mortality after a first Q wave myocardial infarction

STUDY OBJECTIVE: The objective of this study was to analyse whether the risk of death within 28 days and three years after a first Q wave myocardial infarction was higher in hospitalised women than in men. DESIGN: Follow up study. PATIENTS AND SETTING: All consecutive first Q wave myocardial infarction patients aged 25 to 74 years (447 women and 2322 men) admitted to a tertiary hospital in Gerona, Spain, from 1978 to 1997 were registered and followed up for three years. MAIN RESULTS: Women were older, presented more comorbidity and developed more severe myocardial infarctions than men. A significant interaction was found between sex and age. Women aged 65-74 had higher early mortality risk than men of the same age (OR 1.62; 95% CI 1.01, 2.66) after adjusting for age, comorbidity and acute complications including heart failure. Women under 65 tended to be at lower risk of early mortality than men (0.45 (95% CI 0.19, 1.04). Three year mortality of 28 day survivors did not differ between sexes. CONCLUSIONS: These data support the idea that the higher 28 day mortality in hospitalised women with a first Q wave myocardial infarction is mainly attributable to the large number of patients aged 65 to 74 years in whom the risk is higher than that in men. Women under 65 with myocardial infarction do not seem to be a special group of risk.     

Gender differences in the treatment of patients with acute myocardial ischemia and infarction in England.

We conducted a retrospective cohort study based on a case note review to determine whether there are differences in the treatment pathways followed for men and women admitted with acute myocardial ischemia and infarction after adjusting for differences in case mix. Women were as likely as men to receive thrombolysis, but were less likely subsequently to undergo exercise testing (adjusted odds ratio, 0.58; 95% CI, 0.40-0.84) or angiography (adjusted odds ratio, 0.62; 95% CI, 0.39-0.99). Coronary anatomy was the strongest predictor of revascularization regardless of sex. Women with diagnosed cardiac pain are less likely than men to be placed on the investigative pathways that lead to revascularization. Those women who are investigated are as likely as men to undergo revascularization. These findings are independent of the effects of age, angina grade, comorbidity, or cardiac risk factors. Clinicians' and patients' beliefs and preferences about treatment require investigation.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Short- and long-term mortality after acute myocardial infarction: comparison of patients with and without diabetes mellitus

Aims To compare short- and long-term mortality after a first acute myocardial infarction (AMI) in patients with and without diabetes mellitus. Methods and results A nationwide cohort of 2,018 diabetic and 19,547 nondiabetic patients with a first hospitalized AMI in 1995 was identified through linkage of the national hospital discharge register and the population register. Follow-up for mortality lasted until the end of 2000. At 28 days and 5 years respectively, absolute mortality risks were 18 and 53% in diabetic men, 12 and 31% in nondiabetic men, 22 and 58% in diabetic women, and 19 and 42% in nondiabetic women. Crude mortality was significantly higher in diabetic patients than in nondiabetic patients in both men (28-day hazard ratio (HR) 1.55; 95% confidence interval (CI) 1.32–1.81, 5-year HR 2.01; 95% CI 1.84–2.21) and women (28-day HR 1.19; 95% CI 1.03–1.37, 5-year HR 1.53; 95% CI 1.40–1.67). After multivariate adjustment, risk differences became nonsignificant at 28 days, but diabetes was still associated with a significantly higher long-term mortality in both men (28-day HR 1.16; 95% CI 0.99–1.36, 5-year HR 1.49; 95% CI 1.36–1.64) and women (28-day HR 1.12; 95% CI 0.97–1.28, 5-year HR 1.39; 95% CI 1.27–1.52). The interaction between diabetes mellitus and gender did not reach significance in the analyses. Conclusion Our findings in an unselected cohort covering a complete nation show a significantly higher long-term mortality after a first acute myocardial infarction in diabetic patients. Yet, short-term mortality is not significantly higher in diabetic patients. Risks appear to be equally elevated in men and women.     

The implications of age and comorbidity on survival following epithelial ovarian cancer: summary and results from a centers for disease control and prevention study

Abstract Background: Advances in treatment have improved ovarian cancer survival for most women, although less for the elderly. We report on this disparity and add further evidence about the relationship among age, comorbidity, and survival after ovarian cancer. Methods: To examine age and comorbidity, Centers for Disease Control and Prevention (CDC)-funded cancer registries examined 2367 women residing in New York and Northern California diagnosed with epithelial ovarian cancer (1998-2000). Subjects were identified through tumor registries, treatment data were supplemented with physician survey, and comorbidity was identified through hospital discharge database linkages. Proportional hazards modeling was used to estimate the risk of death by age and comorbidity, adjusting for clinical and sociodemographic factors. Results: Crude survival at 1 year and 3 years was 71.9% and 50.1%, respectively. Within stage, age-specific survival rates were lower in the oldest groups, particularly for those with advanced disease. For age 75+, 3-year survival was 13% vs. 50% in those <35 (stage IV). For all stages, women without comorbidity had higher survival rates than those with comorbidity. Older age and comorbidity were both associated with advanced stage and less aggressive treatment. The adjusted risk of death was 40%, and it was 80% higher for the 65-74 and 75+ groups, respectively, compared to women 35-64 (p<0.00). Comorbidity increased the risk of death by 40% (p<0.00). Conclusions: This study confirmed the independent adverse effects of age and comorbidity on survival following ovarian cancer. As the population ages, the co-occurrence of ovarian cancer and comorbidity will increase. Further work identifying critical conditions that impact survival could potentially inform complex treatment decisions.     

Time trends in survival from myocardial infarction in Stockholm County 1976-1984.

In Stockholm county, a rapid decline in mortality from acute myocardial infarction (AMI) was observed among middle-aged men in the early 1980s. In the present study survival among AMI patients from 1976 to 1984 was investigated in order to explore whether improvements in survival may have contributed to this decline. AMI patients aged 30-74 years (n = 16,108) were identified through a hospital discharge register. Deaths within one year of hospital admission were ascertained by means of linkage to the national cause of death register. Survival 1 year after hospital admission increased in both genders during the period 1981-1984, but among women there was no uniform trend over the whole study period. The estimated age-adjusted relative risk of death within one year after hospital admission for patients with a first infarction admitted to hospital in 1983-1984 as compared to in 1981-1982 was 0.88 for men and 0.79 for women. The causes of the observed increase in survival could not be determined from this study, but changes in medical intervention as well as diagnostic improvements may have been important. Improved survival may have contributed to about 30% of the decline in mortality from AMI among middle-aged men in Stockholm county during the early 1980s.     

Occupational exposure to pesticides and risk of adult brain tumors

The authors examined incident glioma and meningioma risk associated with occupational exposure to insecticides and herbicides in a hospital-based, case-control study of brain cancer. Cases were 462 glioma and 195 meningioma patients diagnosed between 1994 and 1998 in three US hospitals. Controls were 765 patients admitted to the same hospitals for nonmalignant conditions. Occupational histories were collected during personal interviews. Exposure to pesticides was estimated by use of a questionnaire, combined with pesticide measurement data abstracted from published sources. Using logistic regression models, the authors found no association between insecticide and herbicide exposures and risk for glioma and meningioma. There was no association between glioma and exposure to insecticides or herbicides, in men or women. Women who reported ever using herbicides had a significantly increased risk for meningioma compared with women who never used herbicides (odds ratio = 2.4, 95% confidence interval: 1.4, 4.3), and there were significant trends of increasing risk with increasing years of herbicide exposure (p = 0.01) and increasing cumulative exposure (p = 0.01). There was no association between meningioma and herbicide or insecticide exposure among men. These findings highlight the need to go beyond job title to elucidate potential carcinogenic exposures within different occupations.     

The risk of acute myocardial infarction after stopping drinking

BACKGROUND: Subjects at high risk of alcohol-related diseases may benefit from alcohol cessation. However, drinkers have a lower risk of acute myocardial infarction (AMI) than abstainers, and there is very scanty information on how the risk changes after stopping drinking. METHODS: Between 1995 and 1999, we administered a structured questionnaire to 507 cases (378 men, 129 women) with a first episode of nonfatal AMI and 478 control patients (297 men, 181 women) admitted to the same network of hospitals in the greater Milan area for acute conditions. RESULTS: Compared to lifelong abstainers, the odds ratio (OR) adjusted for age, sex, and several AMI risk factors was 0.56 (95% confidence interval [CI] 0.41-0.84) for current and 0.65 (95% CI 0.37-1.15) for former drinkers (48 cases and 44 controls). The OR was 2.10 (0.40-11.1) for having stopped since 1 year, 0.64 (95% CI 0.19-2.16) for 2-4 years, 0.46 (95% CI 0.18-1.20) for 5-14 years, and 0.78 (95% CI 0.27-2.27) for > or = 15 years. CONCLUSIONS: Although our data are too limited to draw any definite conclusion, they suggest that the protection of alcohol drinking against AMI may persist, at least in part, for several years after stopping.     

Acute myocardial infarction incidence and hospital mortality: routinely collected national data versus linkage of national registers

Background and Objective To compare levels of and trends in incidence and hospital mortality of first acute myocardial infarction (AMI) based on routinely collected hospital morbidity data and on linked registers. Cases taken from routine hospital data are a mix of patients with recurrent and first events, and double counting occurs when cases are admitted for an event several times during 1 year. By linkage of registers, recurrent events and double counts can be excluded. Study Design and Setting In 1995 and 2000, 28,733 and 25,864 admissions for AMI were registered in the Dutch national hospital discharge register. Linkage with the population register yielded 21,565 patients with a first AMI in 1995 and 20,414 in 2000. Results In 1995 and 2000, the incidence based on the hospital register was higher than based on the linked registers in men (22% and 23% higher) and women (18% and 20% higher). In both years, hospital mortality based on the hospital register and on linked registers was similar. The decline in incidence between 1995 and 2000 was comparable whether based on standard hospital register data or linked data (18% and 20% in men, 15% and 17% in women). Similarly, the decline in hospital mortality was comparable using either approach (11% and 9% in both men and women). Conclusion Although the incidence based on routine hospital data overestimates the actual incidence of first AMI based on linked registers, hospital mortality and trends in incidence and hospital mortality are not changed by excluding recurrent events and double counts. Since trends in incidence and hospital mortality of AMI are often based on national routinely collected data, it is reassuring that our results indicate that findings from such studies are indeed valid and not biased because of recurrent events and double counts. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Inpatient smoking-cessation counseling and all-cause mortality among the elderly

BACKGROUND: Although smoking cessation is essential to the management of acute myocardial infarction (AMI), prevalence and benefits of smoking-cessation counseling in the inpatient setting are not well described among older adults. The objective of this study was to evaluate associations between inpatient smoking-cessation counseling and 5-year all-cause mortality among older adults hospitalized with AMI. METHODS: The Cooperative Cardiovascular Project (January 1994-July 1995) included 788 Medicare beneficiaries aged >/=65 years who were current smokers, admitted to acute care facilities in North Carolina with confirmed AMI, and discharged alive. Information on smoking-cessation advice or counseling prior to discharge was abstracted from medical records. Associations of counseling with 5-year risk of death were assessed with multivariate Cox proportional hazards regression. RESULTS: Smoking-cessation counseling was provided to 40% of AMI patients before discharge. Women (p =0.06) and blacks (p =0.02) were less likely to receive counseling. Counseling was associated with a history of chronic obstructive pulmonary disease (p =0.01). Increasing age, discharge to a skilled nursing facility, and histories of hypertension, heart failure, or stroke were associated with no counseling (p <0.05, all cause). Age-adjusted mortality rates (per 1000 enrollees) at 5 years were 488.3 for patients who were given counseling compared to 579.3 for patients without counseling. After adjustment for age, race, gender, prior histories of hypertension, cardiovascular diseases, diabetes, and chronic obstructive pulmonary disease, Killip class III or IV, and discharge to a skilled nursing facility; inpatient counseling remained associated with improved survival (relative hazard, 0.78; 95% confidence interval, 0.63-0.97). CONCLUSIONS: Inpatient counseling on smoking cessation is suboptimal among older smokers hospitalized with AMI. Even without confirmation of actual cessation, these data suggest that provision of smoking-cessation advice or counseling has a major impact on survival of older adults.     

Variations in the quality of care of patients with acute myocardial infarction among Swiss university hospitals.

OBJECTIVE: The objective of our study was to assess hospital variations in the quality of care delivered to acute myocardial infarction (AMI) patients among three Swiss academic medical centres. DESIGN: Cross-sectional study. SETTING: Three Swiss university hospitals. STUDY PARTICIPANTS: We selected 1129 eligible patients discharged from these hospitals from 1 January to 31 December 1999, with a primary or secondary diagnosis code [International Classification of Diseases, 10th revision (ICD-10)] of AMI. We abstracted medical records for information on demographic characteristics, risk factors, symptoms, and findings at admission. We also recorded the main ECG and laboratory findings, as well as hospital and discharge management and treatment. We excluded patients transferred to another hospital and who did not meet the clinical definition of AMI. MAIN OUTCOME MEASURES: Percentage of patients receiving appropriate intervention as defined by six quality of care indicators derived from clinical practical guidelines. RESULTS: Among 577 eligible patients with AMI in this study, the mean (SD) age was 68.2 (13.9), and 65% were male. In the assessment of the quality indicators we excluded patients who were not eligible for the procedure. Among cohorts of 'ideal candidates' for specific interventions, 64% in hospital A and 73% in hospital C had reperfusion within 12 hours either with thrombolytics or percutaneous transluminal coronary angioplasty (P = 0.367). Further, in hospitals A, B, and C, respectively 97, 94, and 84% were prescribed aspirin during the initial hospitalization (P = 0.0002), and respectively 68, 91, and 75% received angiotensin converting enzyme inhibitors at discharge in the case of left ventricular systolic dysfunction (P = 0.003). CONCLUSIONS: Our results showed important hospital-to-hospital variations in the quality of care provided to patients with AMI between these three university hospitals.     

Access of Women Veterans to Veterans Affairs Hospitals

Women veterans represent a rapidly growing segment of the veteran population. This study examines how the utilization of VA hospitals by women veterans has changed since 1980. Information on the use of VA hospitals was obtained from the discharge database for all VA hospitals. The demographics of the veteran population was compiled from the Veteran Population Files, which contain annual estimates of the number of veterans by age and sex. The VA hospital discharge rate for women increased nearly 29 percent during the 1980's while the VA user rate increased nearly 18.6 percent for women. The increase in the average number of VA stays per user was smaller for women than for men (8.4 percent versus I1 percent). Substantial increases in the utilization of VA hospitals by women veterans occurred during the 1980's. In most cases these increases were larger for women veterans than for men veterans. However, women veterans still use VA hospitals at about one-half the rate for men. Regardless, the VA system will continue to be an important source of health care for women.     

Acute Myocardial Infarction and Coronary Artery Bypass Grafting Outcomes in Specialty and General Hospitals: Analysis of State Inpatient Data

Objective. Compare characteristics and outcomes of patients hospitalized in specialty cardiac and general hospitals for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG).
Data. 2000–2005 all-payor administrative data from Arizona, California, Texas, and Wisconsin.
Study Design. We identified patients admitted to specialty and competing general hospitals with AMI or CABG and compared patient demographics, comorbidity, and risk-standardized mortality in specialty and general hospitals.
Principal Findings. Specialty hospitals admitted a lower proportion of women and blacks and treated patients with less comorbid illness than general hospitals. Unadjusted in-hospital AMI mortality for Medicare enrollees in specialty and general hospitals was 6.1 and 10.1 percent ( p <.0001) and for non-Medicare enrollees was 2.8 and 4.0 percent ( p <.04). Unadjusted in-hospital CABG mortality for Medicare enrollees in specialty and general hospitals was 3.2 and 4.7 percent ( p <.01) and for non-Medicare enrollees was 1.1 and 1.8 percent ( p =.02). After adjusting for patient characteristics and hospital volume, risk-standardized in-hospital mortality for all AMI patients was 2.7 percent for specialty hospitals and 4.1 percent for general hospitals ( p <.001) and for CABG was 1.5 percent for specialty hospitals and 2.0 percent for general hospitals ( p =.07).
Conclusions. In-hospital mortality in specialty hospitals was lower than in general hospitals for AMI but similar for CABG. Our results suggest that specialty hospitals may offer significantly better outcomes for AMI but not CABG.