Differences in management and outcomes for men and women with ST‐elevation myocardial infarction

Abstract

The known Sex differences in the management and outcomes of patients with acute coronary syndromes have been reported, but many reported analyses were not adjusted for confounding covariates.The new Despite broader awareness of STEMI protocols, revascularisation rates for women with STEMI are lower than for men. In hospital, rates of major adverse cardiovascular events and mortality were similar, but at 6 months were significantly higher for women. Women were less frequently referred for cardiac rehabilitation or prescribed preventive medications on discharge.The implications Clinicians should consider potential barriers to equity for women in the management of STEMI. C ardiovascular disease is the leading cause of morbidity and mortality in both sexes, but an extensive literature has described differences between men and women in clinical presentation and pathophysiology that may influence management and outcomes.1,2 Observational studies have found that women with acute coronary syndromes (ACS) more frequently present with atypical symptoms, 3 with more comorbidities, 4 and at an older age, and that plaque rupture 5 and high risk features 3,6,7 are less likely to be identified during angiography than in men.Large hospital registry studies have found that women with ACS are less likely to receive evidence-based management, including coronary angiography and appropriate medications in hospital and at discharge. 4,6,[8][9][10] Australian data similarly indicate that women with ACS are underinvestigated and that evidence-based therapies are less often prescribed than for male patients. [10][11][12] Some studies have found that the higher mortality rates for women than for men with ACS in hospital, 4,6,9,10,13 at 30 days, 7,14 and at 6 months 3,13 are attenuated after adjusting for age and comorbid conditions, but others have found that differences persist despite adjustment. 8 In our investigation, we wanted to avoid confounding by the significant interactions between sex and type of ACS identified in earlier studies. 7,14 We therefore focused on patients with STEMI, as the clinical presentation and diagnosis of this condition is relatively consistent and the patients receive a largely standardised management plan. We hypothesised that management and outcomes for men and women with STEMI should be similar after adjusting for risk level.Our specific aims were to identify sex differences in the characteristics and outcomes of patients presenting with STEMI; to examine associations between sex and outcomes (morbidity and mortality) after adjusting for relevant covariates; and to explore whether there with differences in the prescribing of preventive medications for men and women after STEMI. MethodsWe analysed data from the CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) registry, an ongoing prospective ACS registry Main outcome measures: Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CAB...

Sex differences in the treatment and outcomes of patients hospitalized with ST‐elevation myocardial infarction

“…We could not identify the time from the onset of symptoms or first medical contact to either treatment or to arrival at the first hospital. Earlier studies have found longer time to reperfusion among women, so it is possible that late presentation is a reason for lower revascularization rates among women in our study. Also, because women have atypical symptoms, there may be a selection bias whereby providers do not recognize these symptoms, and women in the study are more ill than the population of women with STEMI.…”

“…Other studies have shown that women with STEMI are less likely to undergo revascularization or reperfusion than their male counterparts . For example, in a study of 632,930 patients using the Nationwide Inpatient sample databases from 2004 to 2011, Khera et al reported that younger women (age <60 years old) presenting with STEMI were less likely to undergo PCI (AOR = 0.74 [0.73, 0.75]) and less likely to undergo CABG surgery (AOR = 0.61 [0.60, 0.62]).…”

“…Earlier studies have shown that among patients with AMI or STEMI undergoing revascularization, women experience higher risk‐adjusted mortality . For example, in a meta‐analysis of 103,895 patients using adjusted effect estimates of 14 individual studies, Bivishi et al found that women undergoing primary angioplasty had significantly higher inhospital mortality (AOR = 1.31 [1.08, 1.65]) and significantly higher 30‐day mortality (AOR = 1.19 [1.01, 1.39]) than men.…”

“…Various studies have also shown that women, and sometimes just younger women, have higher mortality rates than their male counterparts among patients undergoing percutaneous coronary intervention (PCI) for STEMI . Also, studies have shown that among STEMI patients, women have lower revascularization rates than men …”

Impact of sex, socio‐economic status, and remoteness on therapy and survival in heart failure

“…Disparity in health status and the delivery of evidence‐based treatment for cardiovascular disease based on sex and socio‐economic status (SES) is extremely concerning . Gender inequality in the treatment and outcomes post‐acute coronary syndrome has been extensively reported in the medical literature as has a marked female predominance in the incidence of heart failure with preserved ejection fraction . The same cannot be said for heart failure with reduced ejection fraction (HFrEF).…”