Influence of gender in the therapeutic management of patients with acute myocardial infarction in Israel. The Israeli Thrombolytic Survey Group

Institutional and Attitudinal Factors Involved in Higher Mortality of Israeli Women after Coronary Bypass Surgery: Another Case of Gender Bias

Despite their lower cardiovascular risks, women have higher case-fatality ratios after myocardial infarction (MI) and cardiac surgery. Along with women’s older age and co-morbidity, this reflects gender bias in the timely diagnosis and treatment of heart disease in many western countries. Drawing on the theoretical framework offered by McKinlay (1996), current study examined attitudes and practices contributing to late diagnosis and substandard treatment of cardiac symptoms in women. Personal interviews were conducted with 30 women and 25 men sampled via the data set of the national survey of coronary bypass operations in Israel in 1994. In this survey, women’s post-operative mortality has been found to be double that of men, also after adjustment for age and socio-economic factors. Interviews with the survivors helped elucidate some non-biological causes for female mortality disadvantage. Women’s accounts confirmed that primary practitioners often denied cardiac nature of symptoms presented by women and delayed their referral for in-depth testing and intensive treatment, while no such delays occurred with men presenting with similar complaints. Gender bias was stronger during the initial diagnostic process and gradually abated after women were labeled as ‘cardiac cases’ and referred for intensive treatment. At all stages of their ‘cardiac career,’ women received less support from their family members than did men. However, women’s own beliefs about their low cardiac risks and the primacy of family roles over health concerns may have also contributed to later diagnosis and poorer prognosis in women.

Clinical predictors for failure of percutaneous coronary intervention in ST-elevation myocardial infarction

BACKGROUND

Failed percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is associated with adverse outcome. With recent improvements in PCI techniques, the incidence and predictors for failed primary PCI are unclear.

METHODS

A clinical database of consecutive patients who underwent primary or rescue PCI from 1993 to 2011 was used to compare patients with successful versus failed PCI. Clinical follow-up was obtained in-hospital, at 30 days and at 1 year.

RESULTS

Of 2900 patients fulfilling our inclusion criteria, 111 (3.98%) had failed PCI. Patients who had failed PCI were older (65 vs. 61 years), were more likely to be women (46% vs. 32%), were more likely to have previous peripheral vascular disease (19% vs. 11%), previous PCI (29% vs. 20%), and were more likely to present with cardiogenic shock (25% vs. 11%) (all P < 0.05). Multivariable logistic regression analysis identified female gender (OR 1.54; 95% CI 1.01-2.38), cardiogenic shock (2.07; 1.22-3.49), previous PCI (1.71; 1.08-2.70), and type C lesion (2.47; 1.60-3.82) as independent predictors of PCI failure. The in-hospital (18% vs. 4%) and long-term mortality (48% vs. 14%) were worse in the failed PCI group compared to the successful group (P < 0.05).

CONCLUSION

In patients with STEMI, primary PCI failure is uncommon. It is associated with worse short- and long-term clinical outcome compared with a successful procedure. Special care should be taken when PCI is performed in women at higher risk for failure when presenting with STEMI.

Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review

BACKGROUND

Coronary heart disease is the leading cause of morbidity and mortality in American men and women. Although there have been dramatic changes in the management of patients hospitalized with acute myocardial infarction (AMI) over the past several decades, a considerable proportion of patients with AMI continue to delay seeking medical care in a timely manner. This review provides an overview of the published literature that has examined age and sex differences in extent of prehospital delay in patients hospitalized with AMI.

METHODS AND RESULTS

A systematic review of the literature from 1960 to 2008, including publications that provided data on duration of prehospital delay in patients hospitalized with AMI, was conducted. A total of 44 articles (42 studies) were included in the present analysis. The majority of studies showed that in patients hospitalized with AMI, women and older persons were more likely to arrive at the hospital later than men and younger persons. Several factors associated with duration of prehospital delay, including sociodemographic, medical history, clinical, and contextual characteristics differed according to sex.

CONCLUSIONS

The elderly and women were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of AMI compared with other groups. Further research is needed to more fully understand the reasons for delay in these vulnerable groups.

Influence of gender on treatment and short-term mortality of patients with acute myocardial infarction in Berlin

AIMS

Previous studies have shown higher hospital mortality rates in women, especially younger women, than in men. In light of the fact that myocardial infarction therapy is rapidly developing, and since gender-specific aspects have been discussed in detail during recent years, it was our goal to re-evaluate factors influencing hospital mortality rate, especially those involving gender-specific differences, in the city of Berlin, Germany.

METHODS

We prospectively collected data from 5133 patients (3330 men and 1803 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the years 1999 to 2002.

RESULTS

During hospitalization the overall mortality rate was 18.6% among women and 8.4% among men. Women were older (mean age for men 62 years; women 73 years) and less likely to be married (men 74.6%; women 36.9%) than men. Women generally took longer to arrive at the hospital after infarction than did men (median time: men 2.0 h; women 2.6 h). Women furthermore demonstrated a higher proportion of diabetes (men 22.8%; women 36.5%) and hypertension (men 58.0%; women 69.3%). Reperfusion therapy (men 68.8%; women 49.7%) and administration of beta-blockers (men 76.0%; women 66.0%) took place less often for women than for men. A multivariate analysis revealed the following factors to be independent predictors of hospital mortality: age, gender, diabetes mellitus, hypercholesterolemia, pre-existing heart failure, pre-hospital cardiopulmonary resuscitation, cardiogenic shock and pulmonary congestion on admission, admission to a hospital with >600 beds, ST-elevation in the initial ECG, reperfusion therapy, as well as beta-blocker and ACE inhibitor treatment within 48 h of hospitalization.

CONCLUSION

Even after adjustment in multivariate analysis, women with acute myocardial infarction still demonstrate a higher risk for in-hospital death than men.

Outcomes of thrombolytic therapy for acute myocardial infarction in women

Coronary artery disease is the leading cause of mortality in women older than 50 years of age. Thrombolytic therapy substantially reduces mortality in both women and men with ST-elevation acute myocardial infarction. However, the mortality risk reduction is somewhat lower in women, in spite of similar rates of successful coronary reperfusion after thrombolytic therapy in women and men. Hemorrhagic complications including stroke and other major bleeding appear to be more common in women, particularly elderly women. The risk of reinfarction after thrombolytic therapy also is greater in women compared with men. Because of the higher complication rates, women should be monitored closely after thrombolytic therapy. However, this lifesaving treatment should not be withheld or delayed in women when indicated.

Outcomes of percutaneous and surgical revascularization in women

There are gender-related differences both in the natural history of coronary artery disease (CAD) and in the response to revascularization strategies of patients with CAD. This paper reviews the specific pathophysiology of CAD in women as it influences outcome and current interventional and surgical treatment modalities and outcomes for stable and unstable coronary artery syndromes.

New-device angioplasty in women: clinical outcome and predictors in a 7,372-patient registry

BACKGROUND

Female gender has been identified as an independent predictor of early complications and mortality after conventional balloon angioplasty. To gain insight into the outcome of women after new-device angioplasty, we reviewed the early and late clinical outcome of 7,372 patients undergoing new-device angioplasty between 1991 and 1996 at the Washington Hospital Center.

METHODS

Patients (2,077 women and 5,295 men) with native coronary artery (82.5%) or saphenous vein graft lesions undergoing new-device angioplasty were included in the study. In-hospital and 1-year major adverse cardiac events (MACE), including death, myocardial infarction, and target lesion revascularization (TLR), were recorded and compared on the basis of gender. Multivariable logistic regression analysis was performed to identify predictors of in-hospital and late mortality, follow-up MACE, and TLR.

RESULTS

Women had more baseline comorbid risk factors and smaller reference vessel size compared with men. Women had a higher in-hospital cardiac mortality (1.39% vs 0.66%, P = 0.002), TLR (2.78% vs 1.81%, P = 0.008), and congestive heart failure (4.18% vs 2.29%, P < 0.001) compared with men. Overall in-hospital MACE tended to be higher among women (4.2% vs 3.3%, P = 0.074). Women had a higher 1-year mortality rate (4.39% vs 3.26%, P = 0.018), but a lower follow-up TLR (15.0% vs 18.1%, P = 0.001) and a lower overall MACE rate (29.2% vs 32.7%, P = 0.007) compared with men. Female gender was an independent predictor of in-hospital mortality (odds ratio 2.28, P = 0.02), but not late mortality.

CONCLUSIONS

Although female gender appears to carry an inherent risk of in-hospital mortality after new-device angioplasty, the procedural success and mortality rates are favorable compared with those associated with balloon angioplasty series. The long-term clinical outcome of women after new-device angioplasty is excellent. The use of new devices is a safe and effective alternative strategy for the treatment of women with ischemic coronary artery disease. Device-specific outcomes, including stents, will require further evaluation.

Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry)

There is conflicting information about gender differences in presentation, treatment, and outcome after acute ST elevation myocardial infarction (STEMI) in the era of thrombolytic therapy and primary percutaneous coronary intervention. From June 1994 to January 1997, we enrolled 6,067 consecutive patients with STEMI admitted to 54 hospitals in southwest Germany in the Maximal Individual TheRapy of Acute myocardial infarction (MITRA), a community-based registry. Women were 9 years older than men, more often had hypertension, diabetes mellitus, and congestive heart failure, and had a history of previous myocardial infarction less often. Women had a longer prehospital delay (45 minutes), had anterior wall infarction more often (odds ratio [OR] 1.21; 95% confidence interval [CI] 1.08 to 1.36), and received reperfusion therapy less often (OR 0.83; 95% CI 0.74 to 0.94). The percentage of patients who were eligible for thrombolysis and received no reperfusion was higher in women (OR 1.7; 95% CI 1.56 to 1.89). Women had recurrent angina (OR 1.45; 95% CI 1.23 to 1.71) and congestive heart failure (OR 1.26; 95% CI 1.01 to 1.56) more often. There was a trend toward a higher hospital mortality in women (age-adjusted OR 1.16, 95% CI 0.99 to 1.35; multivariate OR 1.21, 95% CI 0.96 to 1.51), but there was no gender difference in long-term mortality after multivariate analysis (age-adjusted OR 0.95, 95% CI 0.78 to 1.15; multivariate OR 0.93, 95% CI 0.72 to 1.19). Thus, women with STEMI receive reperfusion therapy less often than men. They experience recurrent angina and congestive heart failure more often during their hospital stay. The age-adjusted long-term mortality is not different between men and women, but there is a trend for a higher short-term mortality in women.

Do race and gender influence the use of invasive procedures?

OBJECTIVE

To assess the influence of race and gender influence on the use of invasive procedures in patients with acute myocardial infarction (AMI) in community hospitals.

DESIGN

Prospective, observational.

SETTING

Five mid-Michigan community hospitals.

PATIENTS

All patients (838) identified with AMI between January 1994 and April 1995 in 1 of these hospitals.

MEASUREMENTS AND MAIN RESULTS

After adjusting for age, hospital of admission, insurance type, severity of AMI, and comorbidity, using white men as the reference group, the rate of being offered cardiac catheterization (CC) was 0.88 (95% confidence interval [95% CI], 0.60 to 1.29) for white women; 0.79 (95% CI, 0.41 to 1.50) for black men; and 1.14 (95% CI, 0.53 to 2.45)for black women. Among patients who underwent CC, after also adjusting for coronary artery anatomy, the rate of being offered angioplasty, using white men as the reference group, was 1.22 (95% CI, 0.75 to 1.98) for white women; 0.61 (5% CI, 0.29 to 1.28, P =.192) for black men; and 0.40 (95% CI, 0.14 to 1.13) for black women The adjusted rate of being offered bypass surgery was 0.47 (95% CI, 0.24 to 0.89) for white women; 0.36 (95% CI, 0.12 to 1.06) for black men; and 0.37 (95% CI, 0.11 to 1.28)for black women.

CONCLUSIONS

Our study shows that white women are less likely than white men to be offered bypass surgery after AMI. Although black men and women with AMI are less likely than white men to be offered percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in both unadjusted and adjusted analyses, these findings did not reach statistical significance. Our study is limited in power due to the small number of blacks in the sample.

Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study

BACKGROUND

Patients with recurrent acute myocardial infarction (AMI) are at increased risk for morbidity and mortality. We compared the outcome of patients with recurrent AMI hospitalized in coronary care units in the prereperfusion and reperfusion eras.

METHODS

The study population comprised 2 large-scale cohorts with recurrent AMI: (1) 1415 (24%) of 5839 consecutive patients with AMI hospitalized in 1981 to 1983 (Secondary Prevention Reinfarction Israeli Nifedipine Trial [SPRINT] Registry) and (2) 1093 (25%) of 4317 patients with AMI from three national surveys performed in 1992 to 1996.

RESULTS

Patients in the 1990s had significantly lower rates of heart failure and cardiogenic shock. The 7-day mortality declined from 18% in 1981-1983 to 10% in 1992-1996 (adjusted odds ratio [OR] 0.57 [0.44-0.75]), the 30-day mortality rate from 26% to 16% (OR 0.56 [0.44-0.71]), and the 1-year mortality rate from 39% to 26% (adjusted hazard ratio [HR] 0.64 [0.54-0.75]), respectively. In the 1992-1996 cohort, the adjusted risk of 7-day, 30-day, and 1-year mortality for patients with recurrent AMI treated with thrombolysis in comparison to patients without thrombolysis was OR 1.69 (1.07-2.65), 1.52 (1.03-2.23), and HR 1.18 (0.90-1.55), respectively. The mortality rate among patients treated with early percutaneous transluminal coronary angioplasty/coronary artery bypass grafting was 3% versus 12% at 7 days (OR 0.36 [0.16-0.73]), 7% versus 18% at 30 days (OR 0.45 [0.25-0.77]), and 16% versus 29% at 1 year (HR 0.64 [0.46-0.96]), in comparison to patients without revascularization.

CONCLUSION

The prognosis of patients with recurrent AMI improved significantly during the reperfusion era. Although thrombolysis may have a limited therapeutic effect among patients with recurrent AMI, an interventional approach seems more appropriate when indicated. A randomized trial of thrombolysis versus early revascularization is needed in patients with recurrent AMI.

Does gender bias exist in the use of specialist health care?

OBJECTIVES

To investigate the evidence for the existence of gender bias (defined as care provided independently of clinical need) in the use of specialist services by critically appraising the literature.

METHODS

A computer-assisted search of the bibliographic databases PubMed, Medline, EMBASE, Healthstar and Social Science Citation Index for English language papers published from 1966 until May 1999. In addition, four journals were handsearched and the reference lists of identified papers were explored. Retrospective studies were only used when there were insufficient prospective studies.

RESULTS

One hundred and thirty-eight studies were identified covering five major topics: coronary artery disease; renal transplantation; human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); mental illness; and other (mainly invasive) procedures. The majority (94) examined coronary artery disease. It appears that men are more likely to undergo non-invasive investigations than women, but that subsequent investigation and treatment shows no clear evidence of gender differences. Men are more likely to undergo renal transplantation and, for those with HIV and AIDS, to receive azidothymidine (zidovudine, AZT) than women. There are some indications that disparities in favour of men also occur for those suffering from cardiac arrhythmias and cerebrovascular disease, and for those undergoing vascular surgery, hip replacement and heart transplantation. In contrast, women are more likely to undergo liver transplantation and cataract surgery. Mental health services may be provided differently for men and women. All these findings are limited by a lack of accurate denominator information and insufficient ability to adjust for prognostic factors.

CONCLUSIONS

Differences in health care use can be due to demand factors (e.g. differences in the prevalence and severity of disease or in patient preferences), supply factors (particularly clinical judgement), or both. There is a need to examine these explanations thoroughly for gender inequalities in order to ensure that equity (lack of bias) is achieved. There is also a need for higher quality studies if differences are to be attributed conclusively to bias or not.

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction

BACKGROUND

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.

METHODS

To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.

RESULTS

Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).

CONCLUSIONS

After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

Saruplase is a safe and effective thrombolytic agent; observations in 1,698 patients: results of the PASS study. Practical Applications of Saruplase Study

Saruplase (unglycosylated human-type high molecular weight single-chain urokinase-type plasminogen activator) was given to 1698 patients in the open-label Practical Applicability of Saruplase Study (PASS), which assessed the safety and efficacy of saruplase in the treatment of acute myocardial infarction. Thirty-seven hospitals in Europe participated in the study. All patients received 20 mg saruplase as a bolus followed by an infusion of 60 mg saruplase over 1 hour. Prior to the infusion of saruplase, 62% of the patients received a bolus of 5000 U of heparin, and after saruplase a 24-hour intravenous infusion of heparin was given to 95% of patients. The mean age of the patients was 59 years and 80.1% were male. The median delay from the onset of chest pain to the start of saruplase infusion was 145 minutes. Acute angiography was performed in 8 of the participating 37 centers in 350 patients (20.6%), on average 85 minutes (median) after the start of the saruplase infusion. TIMI 3 flow was obtained in 186 patients (53.1%) and TIMI 2 flow in 61 patients (17.4%). Patency rates were similar for patients with anterior and inferior infarction. ECG signs suggestive of reperfusion were seen in 63% of the patients. In-hospital mortality was low (92 patients; 5.4%), and nonfatal recurrent myocardial infarction was seen in 60 patients (3.5%). Severe bleeding complications occurred in 92 patients (5.4%), 21 of whom (1.2%) needed a blood transfusion. An intracerebral hemorrhage was observed in eight patients (0.5%), and seven patients (0.4%) suffered from a thromboembolic stroke. At discharge 85.9% of the patients were in NYHA functional class I. One-year mortality was low (142 patients; 8. 4%). Mortality was high in patients with TIMI 0 or 1 flow at the acute angiography who did not undergo rescue PTCA (9/39; 23.1%), lower in patients with TIMI 0 or 1 flow followed by successful rescue PTCA (7/64; 10.9%), and low in patients with TIMI 2 flow (1/61; 1.6%) or with TIMI 3 flow (2/186; 1.1%). Patency rates and (bleeding) complications did not differ between patients with a body weight greater than or less than 70 kilograms. No antibodies against saruplase were detected in samples from 455 patients. In conclusion, it can be stated that saruplase, given in combination with aspirin and intravenous heparin, can be given safely and effectively to patients with acute myocardial infarction.

Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators

BACKGROUND

Studies have reported that women with acute myocardial infarction have in-hospital and long-term outcomes that are worse than those of men.

METHODS

To assess sex-based differences in presentation and outcome, we examined data from the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb study, which enrolled 12,142 patients (3662 women and 8480 men) with acute coronary syndromes, including infarction with ST-segment elevation, infarction with no ST-segment elevation, and unstable angina.

RESULTS

Overall, the women were older than the men, and had significantly higher rates of diabetes, hypertension, and prior congestive heart failure. They had significantly lower rates of prior myocardial infarction and were less likely ever to have smoked. A smaller percentage of women than men had infarction with ST elevation (27.2 percent vs. 37.0 percent, P<0.001), and of the patients who presented with no ST elevation (those with myocardial infarction or unstable angina), fewer women than men had myocardial infarction (36.6 percent vs. 47.6 percent, P<0.001). Women had more complications than men during hospitalization and a higher mortality rate at 30 days (6.0 percent vs. 4.0 percent, P<0.001) but had similar rates of reinfarction at 30 days after presentation. However, there was a significant interaction between sex and the type of coronary syndrome at presentation (P=0.001). After stratification according to coronary syndrome and adjustment for base-line variables, there was a nonsignificant trend toward an increased risk of death or reinfarction among women as compared with men only in the group with infarction and ST elevation (odds ratio, 1.27; 95 percent confidence interval, 0.98 to 1.63; P=0.07). Among patients with unstable angina, female sex was associated with an independent protective effect (odds ratio for infarction or death, 0.65; 95 percent confidence interval, 0.49 to 0.87; P=0.003).

CONCLUSIONS

Women and men with acute coronary syndromes had different clinical profiles, presentation, and outcomes. These differences could not be entirely accounted for by differences in base-line characteristics and may reflect pathophysiologic and anatomical differences between men and women.

Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction. Israeli Thrombolytic Survey Group

OBJECTIVES

This survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI).

BACKGROUND

Few data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI.

METHODS

A prospective community-based national survey was conducted during January-February 1994 in all 25 coronary care units operating in Israel.

RESULTS

Among 999 consecutive patients with an AMI (72% men; mean age 63+/-12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non-Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non-Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter.

CONCLUSIONS

This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.

Gender differences in mortality after myocardial infarction. Why women fare worse than men

Several studies have indicated that women sustaining a myocardial infarction have a higher unadjusted short-term (i.e., in-hospital or 30-day) mortality than men. The advanced age of women at the time of presentation appears to be the major factor contributing to their worse prognosis relative to men. Controlling for age eliminates the association between female gender and increased mortality in most, but not all studies. This article reviews the data on age and other factors that might explain why women with a myocardial infarction fare worse then men.

[Clinical prediction of the early prognosis in acute myocardial infarct]

Several clinical factors can influence the pathophysiology, clinical course and prognosis of acute myocardial by different means. Some of them may be easily detected through the history, physical examination or ECG in an early phase. The knowledge of these factors may help the therapeutic decision making of patients with myocardial infarction. The influence for the main clinical factors (age, sex, risk factors, cardiologic antecedents and evolutive findings) on the short-term prognosis of acute myocardial infarction is reviewed. An analysis of the likely mechanisms of the influence of these factors on infarct prognosis is also performed.

Improved outcome of elderly patients (> or = 75 years of age) with acute myocardial infarction from 1981-1983 to 1992-1994 in Israel. The SPRINT and Thrombolytic Survey Groups. Secondary Prevention Reinfarction Israel Nifedipine Trial

BACKGROUND

The number of elderly patients experiencing acute myocardial infarction (AMI) is growing rapidly, and their hospital mortality rate remains high, although mortality after AMI declined in the 1990s with the introduction of new therapeutic modalities.

METHODS AND RESULTS

We compared the management, in-hospital complications, and 30-day and 1-year mortality rates in two cohorts of elderly (> or = 75 years of age) AMI patients in the coronary care units in Israel before and after the reperfusion era. The first cohort of 789 consecutive patients was from the Secondary Prevention Reinfarction Israel Nifedipine Trial registry in 1981-1983; the second 366 patients came from two prospective nationwide surveys in 1992 and 1994. Reperfusion therapies were not used in 1981-1983 but were used in 1992-1994. The 30-day mortality rate declined from 38% in 1981-1983 to 27% in 1992-1994 (odds ratio, 0.49; 95% confidence interval [CI], 0.34 to 0.71), and the cumulative 1-year mortality rate declined from 52% to 38% (hazard ratio [HR], 0.62; 95% CI, 0.50 to 0.76). In the 1992-1994 cohort, the decline in mortality was most marked in patients reperfused by thrombolysis and/or percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery but was also evident in nonreperfused patients: cumulative 1-year mortality rate was 29% in the former (HR, 0.45; 95% CI, 0.31 to 0.67) and 42% in the latter (HR, 0.60; 95% CI, 0.46 to 0.78).

CONCLUSIONS

During the last decade, elderly (> or = 75 years) AMI patients experienced fewer in-hospital complications and lower 30-day and 1-year mortality rates, which declined approximately 30%, most markedly in reperfused patients. The favorable outcome in 1992-1994 was related to changes in patient management. Reperfusion therapy is therefore also advocated in elderly AMI patients, unless specific contraindications are present.

Refining the treatment of women with unstable angina--a randomized, double-blind, comparative safety and efficacy evaluation of Integrelin versus aspirin in the management of unstable angina

BACKGROUND

Although women typically develop coronary artery disease several years after men, once they have symptomatic disease their thromboembolic complications are worse than in men. The mechanism mediating this gender difference in outcome after thromboembolic events is unknown. We previously studied platelet functions in siblings from patients with premature coronary artery disease. We observed that platelets from women are responsive than their male counterparts. In particular, platelets from women stimulated ex vivo with various agonists bind more fibrinogen molecules than platelets from men.

HYPOTHESIS

We hypothesized that in patients with acute coronary events, the control of platelet activity might require stronger antagonists in women than in men.

METHODS

To test this hypothesis, we investigated retrospectively the results of a trial on Integrelin in unstable angina.

RESULTS

We report that platelet aggregation and Holter-detected ischemic episodes are significantly reduced in women with unstable angina treated with the specific GPIIb-IIIa inhibitor, Integrelin, compared with the standard platelet inhibitor aspirin. In contrast, both platelet aggregation and Holter-detected ischemic events are well controlled in men with unstable angina treated with standard therapy including aspirin.

CONCLUSION

Integrelin does provide protection in men, but, in contrast with women, not beyond what can be achieved with aspirin. Our data are consistent with the concept that the platelets from women require stronger and more specific inhibitors to limit their activity, and that platelets may play a more important role in women with acute coronary syndromes than in men. Most important, specific GPIIb-IIIa inhibitors may represent a therapeutic option which provides as much suppression of ischemic events in women as they do in men with coronary artery disease.

Differences in treatment of acute myocardial infarction by sex, age, and other factors (the Stanford Five-City Project)

This study examines the temporal trends in the use of angiography followed by revascularization procedures for acute myocardial infarction (AMI) in 2,021 hospitalized men and 995 women aged 30 to 74 years who participated in the Stanford Five-City Project during the years 1986 to 1992. Our sample included hospitalized patients who received a discharge diagnosis code of 410 through 414 and met study criteria for either a definite or possible AMI. Incident and recurrent infarctions occurring in the years 1986 through 1992 were included, but only the first event in this period for each patient. We performed stepwise multiple logistic regression analysis to determine the probability of: (1) receiving coronary angiography, (2) revascularization by either coronary bypass surgery or angioplasty among those with angiogram, and (3) thrombolytic therapy. Age, year of procedure, disease severity, and time between symptom onset and medical treatment were included as covariates. After adjustment of these factors, women were less likely than men to undergo angiography but were equally likely to undergo revascularization and thrombolysis. Hispanics and whites were equally likely to receive angiography and thrombolysis, but Hispanics were less likely than whites to undergo revascularization. Age and disease severity were inverse predictors of coronary angiography but not of revascularization. Age, severity, and delay time between onset of symptoms and medical therapy were inverse predictors of thrombolysis; delay time was significantly greater in women than in men and averaged > 6 hours in both sexes. The likelihood of receiving angiography, revascularization, and thrombolysis increased sharply over the study period.

Trends in coronary thrombolytic therapy for acute myocardial infarction (the Minnesota Heart Survey Registry, 1990 to 1993)

Between 1990 and 1993, patient selection and relative effectiveness of thrombolytic agents were issues for clinical trials of thrombolytic therapy, particularly the Third International Study of Infarct Survival (ISIS-3) and the Second Gruppo Italiano per Lo Studio della Streptochinasi nell'Infarto Miocardico trials. The purpose of this report is to document the use of coronary thrombolytic therapy in community hospital practice during this period. Patients admitted to the coronary care unit of 6 hospitals with suspect acute myocardial infarction (AMI) between 1990 and 1993 were prospectively enrolled in the Minnesota Heart Survey Registry. Of the 1,225 patients with AMI enrolled, 310 men (37%) and 103 women (26%) received thrombolytic therapy (p < 0.001). The age-adjusted male-to-female odds ratio (95% confidence interval) for receiving thrombolysis among patients with < or = 12 hours since symptom onset was 1.33 (0.94, 1.87). The proportion of those treated receiving tissue plasminogen activator declined from 196 (64%) to 102 (34%) between 1990 and 1991 and 1992 and 1993. Use of streptokinase increased from 48 (16%) to 156 (52%) during the same time period. There were no statistically significant gender or lytic agent type differences in complications from thrombolytic therapy. Changes in type of agent used coincided with the release of results from the ISIS-3 trial.

Influence of sex on the short-term outcome of elderly patients with a first acute myocardial infarction

BACKGROUND

Sex seems to affect the course of acute myocardial infarction (AMI) in the general population. Although the epidemiological importance of female sex among patients with AMI is more important from the sixth decade of life, little is known about the impact of sex on the outcome of AMI in the elderly.

METHODS AND RESULTS

To determine the differences between sexes in the outcome of AMI in the elderly, we compared the clinical history and evolution of 204 consecutive patients (99 men, 105 women) > or = 75 years of age admitted with a first AMI. Women had a higher prevalence (P < .01) of hypertension (60% versus 32%) and diabetes (41% versus 18%), whereas men were more frequently smokers (41% versus 4%, P < .0001); these factors were associated with higher rates of congestive heart failure. Women showed lower ejection fractions and higher rates of congestive heart failure (odds ratio [OR], 2.32; 95% CI, 1.32 to 4.12) and shock (OR, 2.78; 95% CI, 1.29 to 6.40). Mortality rate was higher in women (40% versus 23%, P = .01; OR, 2.29; 95% CI, 1.26 to 4.26); however, sex was excluded as an independent predictor of in-hospital mortality in every regression model tested (OR, 0.75; 95% CI, 0.25 to 2.21).

CONCLUSIONS

After a first AMI, elderly women experience a more complicated hospital course than men. The increase in mortality risk seems to be related to the impact of cardiovascular risk factors on left ventricular function more than to sex itself.

Twenty-five-year mortality rate decrease in patients in Israel with a first episode of acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial Study Group. Israeli Thrombolytic Survey Group

The aim of our study was to compare the outcome of patients with a first acute myocardial infarction (AMI) among three large cohorts of patients hospitalized between 1966 and 1992 in Israel, in view of changes in treatment facilities and investigation methods. Patients with a first AMI constituted 71% of all myocardial infarctions in 1966, 74% in 1981-1983, and 71% in 1992. The male-female ratio and the distribution of the site of infarction also remained stable from 1966 to 1992. The mean age of patients increased over time. Thrombolytic therapy was not available in 1966 and 1981-1983, whereas 53% of patients were treated with a thrombolytic agent and 22% examined with coronary angiography in 1992. The 21-day mortality rate decreased markedly, from 22% in 1966 to 14% in 1981-1983 and to 8% in 1992. The decrease was similar in both genders and among 10-year age groups. The 1-year postdischarge mortality rate (not evaluated in 1966) decreased from 7% in 1981-1983 to 6% in 1992. We conclude that a significant reduction in mortality rate after a first AMI took place over the 25-year period. Changes in treatment modality and management of the acute phase may explain this decrease in mortality rate over time.