Short- and long-term prognosis after acute myocardial infarction in men versus women

Sex Differences in Delayed Hospitalization in Patients with Non-ST-Segment Elevation Myocardial Infarction Undergoing New-Generation Drug-Eluting Stent Implantation

We compared the effects of sex differences in delayed hospitalization (symptom-to-door time [SDT], ≥24 h) on major clinical outcomes in patients with non-ST-segment elevation myocardial infarction after new-generation drug-eluting stent implantation. A total of 4593 patients were classified into groups with (n = 1276) and without delayed hospitalization (SDT < 24 h, n = 3317). Thereafter, these two groups were subdivided into male and female groups. The primary clinical outcomes were major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, repeat coronary revascularization, and stroke. The secondary clinical outcome was stent thrombosis. After multivariable- and propensity score-adjusted analyses, in-hospital mortalities were similar between the male and female groups in both the SDT < 24 h and SDT ≥ 24 h groups. However, during a 3-year follow-up period, in the SDT < 24 h group, all-cause death (p = 0.013 and p = 0.005, respectively) and cardiac death (CD, p = 0.015 and p = 0.008, respectively) rates were significantly higher in the female group than those in the male group. This may be related to the lower all-cause death and CD rates (p = 0.022 and p = 0.012, respectively) in the SDT < 24 h group than in the SDT ≥ 24 h group among male patients. Other outcomes were similar between the male and female groups and between the SDT < 24 h and SDT ≥ 24 h groups. In this prospective cohort study, female patients showed higher 3-year mortality, especially in the SDT < 24 h, compared to male patients.

Young Women With Coronary Artery Disease Exhibit Higher Concentrations of Interleukin-6 at Baseline and in Response to Mental Stress

Background

Young women with coronary artery disease (CAD), a group with high psychosocial burden, were previously shown to have higher levels of interleukin‐6 (IL‐6) compared with men of similar age. We sought to examine IL‐6 response to acute stress in CAD patients across sex and age, and contrast results to healthy controls and other biomarkers known to increase with mental stress (monocyte chemoattractant protein‐1 and matrix metallopeptidase‐9) and known limited stress‐reactivity (high‐sensitivity C‐reactive protein).

Methods and Results

Inflammatory biomarkers were measured at rest and 90 minutes after mental stress (speech task) among 819 patients with CAD and 89 healthy controls. Repeated‐measures models were used to investigate age (continuous) and sex differences across time, before and after adjusting for demographics, CAD risk factors, depressive symptoms, medication use, and CAD severity. Among patients with CAD, the mean age was 60 years (range, 25–79) and 31% were women. Younger women with CAD had significantly higher concentrations of IL‐6 at rest, 90 minutes after mental stress, as well as a higher response to stress, compared with similarly aged men (P<0.05 for sex by age interactions). In contrast, IL‐6 increased with age, and there were no sex differences in IL‐6 levels or response to stress among controls. Inflammatory responses to stress for high‐sensitivity C‐reactive protein, monocyte chemoattractant protein‐1, and matrix metallopeptidase‐9 among CAD patients were similar in women and men.

Conclusions

IL‐6 response to mental stress are higher in young women with CAD than men of similar age.

Heart failure awareness in the Korean general population: Results from the nationwide survey

BACKGROUND

For a better heart failure outcome, it is fundamental to improve the awareness of heart failure at the general population level. We conducted this study to identify the current status of awareness of heart failure in the Korean general population.

METHODS

This cross-sectional nationwide survey recruited a total of 1,032 participants aged 30 years or older, based on a stratification systematic sampling method. A 23-item questionnaire was surveyed through telephone interviews.

RESULTS

Although 80% of the participants had heard of heart failure, 47% exactly defined what heart failure is. A minority of participants correctly recognized the lifetime risk of developing heart failure (21%) as well as the mortality (16%) and readmission risk (18%) of heart failure and the cost burden of heart failure admission (28%). Regarding preferred treatment options, 71% of the participants chose a treatment option that could improve the quality of life. Approximately two-thirds of the participants agreed that current medical treatment could reduce mortality and improve the quality of life. More than half of the participants (59%) thought that heart failure patients should live quietly and reduce all physical activities. Across survey items, we found a lower awareness state in the elderly groups and people at lower income and educational levels.

CONCLUSIONS

The current awareness status of heart failure in the Korean general population is still low. Proactive educational efforts should be made to improve public awareness with special attention to individuals with lower disease awareness.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.

Cost-Effectiveness Analysis of the DiagnOSAS Screening Tool Compared With Polysomnography Diagnosis in Dutch Primary Care

STUDY OBJECTIVES

The growing recognition of obstructive sleep apnea (OSA) as a serious health condition, increasing waiting lists for sleep tests, and a high proportion of unnecessary referrals from general practice highlight the need for alternative diagnostic strategies for OSA. This study's objective was to investigate the cost-effectiveness of DiagnOSAS, a screening tool that strives to facilitate fast and well-informed referral to hospitals and sleep clinics for diagnosis, in The Netherlands.

METHODS

A Markov model was constructed to assess cost-effectiveness in men aged 50 years. The diagnostic process of OSA was simulated with and without DiagnOSAS, taking into account the occurrence of hazardous OSA effects: car accidents, myocardial infarction, and stroke. The cost-effectiveness of "DiagnOSAS Strategy" and a "Rapid Diagnosis Scenario," in which time to diagnosis was halved, was assessed.

RESULTS

Base case results show that, within a 10-year time period, DiagnOSAS saves €226 per patient at a negligible decrease (< 0.01) in quality-adjusted life-years (QALYs), resulting in an incremental cost-effectiveness ratio of €56,997/QALY. The "Rapid Diagnosis Scenario" dominates usual care (ie, is both cheaper and more effective). For a willingness-to-pay threshold of €20,000/QALY the probability that the "DiagnOSAS Strategy" and "Rapid Diagnosis Scenario" are cost-effective equals 91.7% and 99.3%, respectively.

CONCLUSIONS

DiagnOSAS appears to be a cost-saving alternative for the usual OSA diagnostic strategy in The Netherlands. When DiagnOSAS succeeds in decreasing time to diagnosis, it could substantially improve health outcomes as well.

Women live longer than men even during severe famines and epidemics

Women live longer than men in nearly all populations today. Some research focuses on the biological origins of the female advantage; other research stresses the significance of social factors. We studied male–female survival differences in populations of slaves and populations exposed to severe famines and epidemics. We find that even when mortality was very high, women lived longer on average than men. Most of the female advantage was due to differences in mortality among infants: baby girls were able to survive harsh conditions better than baby boys. These results support the view that the female survival advantage is modulated by a complex interaction of biological environmental and social factors.

Women in almost all modern populations live longer than men. Research to date provides evidence for both biological and social factors influencing this gender gap. Conditions when both men and women experience extremely high levels of mortality risk are unexplored sources of information. We investigate the survival of both sexes in seven populations under extreme conditions from famines, epidemics, and slavery. Women survived better than men: In all populations, they had lower mortality across almost all ages, and, with the exception of one slave population, they lived longer on average than men. Gender differences in infant mortality contributed the most to the gender gap in life expectancy, indicating that newborn girls were able to survive extreme mortality hazards better than newborn boys. Our results confirm the ubiquity of a female survival advantage even when mortality is extraordinarily high. The hypothesis that the survival advantage of women has fundamental biological underpinnings is supported by the fact that under very harsh conditions females survive better than males even at infant ages when behavioral and social differences may be minimal or favor males. Our findings also indicate that the female advantage differs across environments and is modulated by social factors.

Physician specialty and long-term survival after myocardial infarction - A study including all German statutory health insured patients

BACKGROUND

With a mortality rate above European average, myocardial infarction (MI) is the second most common cause of death in Germany. Data about post-MI ambulatory care and mortality is scarce. We examined the association between ambulatory treating physicians' specialty and the mortality of post-MI patients.

METHODS

Medical claims data of all 17 German regional Associations of Statutory Health Insurance physicians were analyzed, which cover approximately 90% of the German population. Patients with a new diagnosis of a MI in 2011 were divided into treatment groups with and without ambulant cardiology care within the first year after MI diagnosis. Propensity-score matching based on socio-demographic and clinical variables was performed to achieve comparability between groups. The 18-month mortality rate was derived employing a validated method.

RESULTS

158,494 patients with a new diagnosis of MI had received post-MI ambulatory care in 2011. Half of them (51%) had at least one ambulatory contact with a cardiologist within the first year. During a follow-up of 18months, the mortality rate before and after propensity-score matching was 19% and 14% in patients without cardiology care and 6%, respectively, in patients with cardiology care (χ²=666.7; P<0.000 after propensity adjustment). Patients who only saw a cardiologist and had no additional contact to an ambulant general practitioner (GP)/internist within the first year did not have increased survival rates.

CONCLUSIONS

Outpatient follow-up care by a cardiologist in combination with consultations of GP/internists within the first year may be of importance for the prognosis of MI patients.

Young Women With Acute Myocardial Infarction: Current Perspectives

In recent years, there has been growing public awareness and increasing attention to young women with acute myocardial infarction (AMI), who represent an extreme phenotype. Young women presenting with AMI may develop coronary disease by different mechanisms and often have worse recoveries, with higher risk for morbidity and mortality compared with similarly aged men. The purpose of this cardiovascular perspective piece is to review recent studies of AMI in young women. More specifically, we emphasize differences in the epidemiology, diagnosis, and management of AMI in young women (when compared with men) across the continuum of care, including their pre-AMI, in-hospital, and post-AMI periods, and highlight gaps in knowledge and outcomes that can inform the next generation of research.

Survival prospects after acute myocardial infarction in the UK: a matched cohort study 1987-2011

OBJECTIVES

Estimate survival after acute myocardial infarction (AMI) in the general population aged 60 and over and the effect of recommended treatments.

DESIGN

Cohort study in the UK with routinely collected data between January 1987 and March 2011.

SETTING

310 general practices that contributed to The Health Improvement Network (THIN) database.

PARTICIPANTS

4 cohorts who reached the age of 60, 65, 70, or 75 years between 1987 and 2011 included 16 744, 43 528, 73 728, and 76 392 participants, respectively. Participants with a history of AMI were matched on sex, year of birth, and general practice to 3 controls each.

OUTCOME MEASURES

The hazard of all-cause mortality associated with AMI was calculated by a multilevel Cox's proportional hazards regression, adjusted for sex, year of birth, socioeconomic status, angina, heart failure, other cardiovascular conditions, chronic kidney disease, diabetes, hypertension, hypercholesterolaemia, alcohol consumption, body mass index, smoking status, coronary revascularisation, prescription of β-blockers, ACE inhibitors, calcium-channel blockers, aspirin, or statins, and general practice.

RESULTS

Compared with no history of AMI by age 60, 65, 70, or 75, having had 1 AMI was associated with an adjusted hazard of mortality of 1.80 (95% CI 1.60 to 2.02), 1.71 (1.59 to 1.84), 1.50 (1.42 to 1.59), or 1.45 (1.38 to 1.53), respectively, and having had multiple AMIs with a hazard of 1.92 (1.60 to 2.29), 1.87 (1.68 to 2.07), 1.66 (1.53 to 1.80), or 1.63 (1.51 to 1.76), respectively. Survival was better after statins (HR range across the 4 cohorts 0.74-0.81), β-blockers (0.79-0.85), or coronary revascularisation (in first 5 years) (0.72-0.80); unchanged after calcium-channel blockers (1.00-1.07); and worse after aspirin (1.05-1.10) or ACE inhibitors (1.10-1.25).

CONCLUSIONS

The hazard of death after AMI is less than reported by previous studies, and standard treatments of aspirin or ACE inhibitors prescription may be of little benefit or even cause harm.

Excess long-term mortality among hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction (SAMI) project

OBJECTIVES

We evaluated long-term survival after acute myocardial infarction (AMI) in unselected 'real life' patients according to the various risk groups, and it's persistence with time after AMI as compared with the matched general population.

STUDY DESIGN

Retrospective study.

METHODS

Data were collected from 2671 AMI hospital survivors (tertiary medical centre in Israel), which included demographics, clinical characteristics of AMI, comorbidities, interventions and test results. All-cause mortality during the 10-year follow-up period was compared with age-, sex- and ethnicity/religion-matched general population using standardized mortality ratios (SMRs).

RESULTS

Overall mortality of AMI patients (48.6%) was higher than the general population (SMR, 2.2; P < 0.001). Mortality rates and SMRs tended to be greater in higher risk strata of patients, Jews vs Muslims, women vs men, non-ST-elevation acute myocardial infarction (NSTEMI) vs ST-elevation acute myocardial infarction (STEMI), non-invasive treatment vs invasive treatment, and recurrent vs first AMI. Mortality rates increased with age, but SMRs were highest in the youngest group. Through the follow-up period, SMR was highest during the first year after discharge (SMR, 4.85; P < 0.001) and higher in 7th-10th years compared with 2nd-6th years.

CONCLUSION

Patients who survived hospital admission with AMI continue to be at higher (approximately twice) risk of death compared with the general population for at least 10-year follow-up period and especially throughout the first and 7th-10th years after AMI, young women, high-risk patients, Jews, NSTEMI, non-invasively treated and recurrent AMI. These findings can assist healthcare providers and decision makers prioritizing targets of secondary prevention and allocation of resources.

Gender differences in outcomes in patients with acute coronary syndrome in the current era: A review

Coronary heart disease is the most common cause of death worldwide. In the United Kingdom in 2010, over 80,000 deaths were attributed to coronary heart disease, and one in 10 female deaths were due to coronary heart disease. Acute coronary syndrome, a subset of coronary heart disease, was responsible for 175,000 inpatient admissions in the United Kingdom in 2012. While men have traditionally been considered to be at higher risk of acute coronary syndrome, various studies have demonstrated that women often suffer from poorer outcomes following an adverse cardiovascular event. This gap is gradually narrowing with the introduction of advanced interventional strategies and pharmacotherapy. However, a better understanding of these differences is of crucial importance for the improvement of the pharmacological and interventional management of acute coronary syndrome and for the development of possible new gender-specific diagnostic and therapeutic options. The goals of this review are to evaluate gender differences in outcomes in patients with acute coronary syndrome in the current era and identify potential mechanisms behind these differences in outcomes following percutaneous coronary intervention.

Characteristics of and outcomes for elderly patients with acute myocardial infarction: differences between females and males

Objectives

This study analyzed age-adjusted sex differences among acute myocardial infarction (AMI) patients aged 75 years and above with regard to 7-year mortality (primary end point) and the frequency of angiograms and admission to the coronary care unit (CCU) as well as 1-year mortality (secondary end points).

Methods

A retrospective cohort study comprised 1,414 AMI patients (748 females and 666 males) aged at least 75 years, who were admitted to Sahlgrenska University Hospital in Gothenburg, Sweden, during two periods (2001/2002 and 2007). All comparisons between female and male patients were age adjusted.

Results

Females were older and their previous history included fewer AMIs, coronary artery bypass grafting procedures, and renal diseases, but more frequent incidence of hypertension. On the contrary, males had higher age-adjusted 7-year mortality in relation to females (hazard ratio [HR] 1.16 with corresponding 95% confidence interval [95% CI 1.03, 1.31], P=0.02). Admission to the CCU was more frequent among males than females (odds ratio [OR] 1.38 [95% CI 1.11, 1.72], P=0.004). There was a nonsignificant trend toward more coronary angiographies performed among males (OR 1.34 [95% CI 1.00, 1.79], P=0.05), as well as a nonsignificant trend toward higher 1-year mortality (HR 1.18 [95% CI 0.99, 1.39], P=0.06).

Conclusion

In an AMI population aged 75 years and above, males had higher age-adjusted 7-year mortality and higher rate of admission to the CCU than females. One-year mortality did not differ significantly between the sexes, nor did the frequency of performed coronary angiograms.

Sex Differences in Cardiac Risk Factors, Perceived Risk, and Health Care Provider Discussion of Risk and Risk Modification Among Young Patients With Acute Myocardial Infarction: The VIRGO Study

BACKGROUND

Differences between sexes in cardiac risk factors, perceptions of cardiac risk, and health care provider discussions about risk among young patients with acute myocardial infarction (AMI) are not well studied.

OBJECTIVES

This study compared cardiac risk factor prevalence, risk perceptions, and health care provider feedback on heart disease and risk modification between young women and men hospitalized with AMI.

METHODS

We studied 3,501 AMI patients age 18 to 55 years enrolled in the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study in U.S. and Spanish hospitals between August 2008 and January 2012, comparing the prevalence of 5 cardiac risk factors by sex. Modified Poisson regression was used to assess sex differences in self-perceived heart disease risk and self-reported provider discussions of risk and modification.

RESULTS

Nearly all patients (98%) had ≥1 risk factor, and 64% had ≥3. Only 53% of patients considered themselves at risk for heart disease, and even fewer reported being told they were at risk (46%) or that their health care provider had discussed heart disease and risk modification (49%). Women were less likely than men to be told they were at risk (relative risk: 0.89; 95% confidence interval: 0.84 to 0.96) or to have a provider discuss risk modification (relative risk: 0.84; 95% confidence interval: 0.79 to 0.89). There was no difference between women and men for self-perceived risk.

CONCLUSIONS

Despite having significant cardiac risk factors, only one-half of young AMI patients believed they were at risk for heart disease before their event. Even fewer discussed their risks or risk modification with their health care providers; this issue was more pronounced among women.

Young women post-MI have higher plasma concentrations of interleukin-6 before and after stress testing

OBJECTIVES

Young women have poorer prognosis after myocardial infarction (MI) and a higher rate of mental stress-induced ischemia compared with similarly aged men. A higher inflammatory status may help explain these sex differences.

METHODS

We examined 98 patients (49 women and 49 men) age 18-59years with recent MI (past 6months). Women and men were matched for age, type of MI, and time since MI. Interleukin 6 (IL-6) concentrations were measured at baseline, after mental stress using a speech task, and after exercise/pharmacologic stress (60 and 90min). Depressive symptoms were measured with the Beck Depression Inventory (BDI-II) and angiographic coronary artery disease (CAD) severity was quantified with the Gensini score. Single-photon emission computed tomography (SPECT) was used to obtain a computerized measurement of stress-induced ischemia (summed difference score, or SDS) and determine whether severity of stress-induced ischemia affects the inflammatory response to stress. Analysis was stratified by the median age of 50. Geometric mean concentrations of IL-6 were obtained from general linear regression models.

RESULTS

In both age groups, women had less angiographic CAD and a similar level of conventional risk factors compared with men. Despite this, baseline IL-6 geometric means before both mental and physical stress were twice as high in women ⩽50years of age compared to age-matched men (3.8 vs. 1.8pg/mL, p=0.001, across both conditions), while they were similar in women and men age >50years (2.3 vs. 2.2pg/mL, p=0.83). After mental stress, IL-6 concentrations increased in both women and men in a similar fashion and remained twice as high in women ⩽50years than men at both 60min (5.4 vs. 2.6pg/mL, p=0.002) and 90min (5.9 vs. 3.4pg/mL, p=0.01). No significant difference was found between women and men >50years of age at any time point after mental stress. Results were similar for physical stress. After accounting for SDS, IL-6 concentrations in young women remained higher after both mental and physical stress. Baseline IL-6 concentrations were not significantly related to inducible ischemia.

CONCLUSIONS

After MI, young women aged 50years or younger, compared with age-matched men, have remarkably higher concentrations of inflammation at baseline and after both mental and physical stress, with a similar inflammatory response to both stressors. Sustained concentrations of inflammation in young women, not their response to stress, may contribute to their adverse outcomes post-MI.

Differences Between Women and Men in Phase I Cardiac Rehabilitation After Acute Myocardial Infarction: A Nationwide Population-Based Analysis

Although numerous studies have investigated gender-related differences in patients who have had an acute myocardial infarction (AMI), few studies have examined the gender-related differences among inpatients receiving Phase I inpatient cardiac rehabilitation following AMI.Using data from the Taiwan National Health Insurance Research Database, this study analyzed 6713 adult patients who received inpatient cardiac rehabilitation following AMI between 2002 and 2011. The differences in comorbidity, medical service use, and prognosis between the male and female patients were analyzed to determine whether the comorbidities affecting their prognoses differed.Female patients accounted for 23.18% of the sample, had a higher average age, and exhibited severe comorbidities; furthermore, they had significantly more days of hospitalization and days in an intensive care unit than did male patients. The gender-related differences in hospital mortality rate and 30-day mortality rate were nonsignificant, but female patients exhibited a significantly higher 1-year mortality rate. Moreover, the risk for 1-year mortality was higher among female patients with moderate or severe renal disease (odds ratio: 1.94, 95% confidence interval: 1.29-2.92) than among their male counterparts. However, the 1-year mortality rate for the female patients did not increase after all risk factors were adjusted.Gender-related differences in age, comorbidity, and prognosis were confirmed in AMI patients receiving Phase I inpatient cardiac rehabilitation. In addition, gender-related differences were observed in the comorbidity risk factors affecting prognosis. However, being female did not affect the prognosis.

Mortality hazard and survival after tuberculosis treatment

OBJECTIVES

We compared mortality among tuberculosis (TB) survivors and a similar population.

METHODS

We used local health authority records from 3 US sites to identify 3853 persons who completed adequate treatment of TB and 7282 individuals diagnosed with latent TB infection 1993 to 2002. We then retrospectively observed mortality after 6 to 16 years of observation. We ascertained vital status as of December 31, 2008, using the Centers for Disease Control and Prevention's National Death Index. We analyzed mortality rates, hazards, and associations using Cox regression.

RESULTS

We traced 11 135 individuals over 119 772 person-years of observation. We found more all-cause deaths (20.7% vs 3.1%) among posttreatment TB patients than among the comparison group, an adjusted average excess of 7.6 deaths per 1000 person-years (8.8 vs 1.2; P < .001). Mortality among posttreatment TB patients varied with observable factors such as race, site of disease, HIV status, and birth country.

CONCLUSIONS

Fully treated TB is still associated with substantial mortality risk. Cure as currently understood may be insufficient protection against TB-associated mortality in the years after treatment, and TB prevention may be a valuable opportunity to modify this risk.

Impact of the joint association between sex, age and diabetes on long-term mortality after acute myocardial infarction

BACKGROUND

The role of sex, and its joint effect with age and diabetes mellitus, on mortality subsequent to surviving an acute myocardial infarction (AMI) beyond 30 days are unclear. The high prevalence of diabetes mellitus in an ethnically diverse Asian population motivates this study.

METHODS

The study population comprised of a nationwide cohort of Asian patients with AMI, hospitalized between 2000 to 2005, who survived the first 30 days post-admission and were followed prospectively until death or 12 years.

RESULTS

Among the 13,389 survivors, there were fewer women (25.5%) who were older than men (median 70 vs. 58 years) and a larger proportion had diabetes mellitus at admission (51.4% vs. 31.4%). During follow-up 4,707 deaths (women 13.2%; men 22.0%) occurred, with women experiencing higher mortality than men with an averaged hazard ratio (HR): 2.08; 95% confidence interval : 1.96-2.20. However the actual adverse outcome, although always greater, reduced over time with an estimated HR: 2.23 (2.04-2.45) at 30 days to HR: 1.75; (1.47-2.09) 12 years later. The difference in mortality also declined with increasing age: HR 1.80 (1.52-2.13) for those aged 22-59, 1.26 (1.11-1.42) for 60-69, 1.06 (0.96-1.17) and 0.96 (0.85-1.09) for those 70-79 and 80-101 years. Significant two-factor interactions were observed between sex, age and diabetes (P < 0.001). Diabetic women <60 years of age had greater mortality than diabetic men of the same age (adjusted HR: 1.44; 1.14-1.84; P = 0.003), while diabetic women and men ≥60 years of age had a less pronounced mortality difference (adjusted HR: 1.12; 0.99-1.26).

CONCLUSIONS

One in two women hospitalized for AMI in this Asian cohort had diabetes and the sex disparity in post-MI mortality was most pronounced among these who were <60 years of age. This underscores the need for better secondary prevention in this high-risk group.

Age-specific gender differences in long-term recurrence and mortality following incident myocardial infarction: a population-based study

BACKGROUND

Higher mortality following myocardial infarction (MI) is reported in women compared with men with short-term follow-up. Our study aim was to compare long-term gender- and age-specific outcomes following incident MI.

METHODS

30-day survivors of incident MI from 2003-2009 were identified from linked administrative data in Western Australia. Outcomes identified were recurrent MI, and cardiovascular and all-cause mortality. Follow-up data was available until 30(th) June 2011. Unadjusted risk out to eight-years was estimated from Kaplan-Meier survival curves, and multivariate Cox regression models were used to estimate relative risk in women compared with men by age group.

RESULTS

There were 12,420 30-day survivors of incident MI from 2003-2009 (males 71.2%). Women had higher levels of comorbidities across all age groups compared with men. Unadjusted event risks were higher in women than men overall, underpinned by higher risk of recurrent MI in 55-69 year-old women and of cardiovascular mortality across all age groups in women. Gender differences were generally attenuated after adjustment for demographic factors and comorbidities.

CONCLUSIONS

This study highlights the elevated risk of cardiovascular events in women compared with men with long-term follow-up, and demonstrates the need for improved long-term secondary prevention in this patient group.

Gender Differences in Left Ventricular Function Following Percutaneous Coronary Intervention for First Anterior Wall ST-Segment Elevation Myocardial Infarction

Little is known regarding gender differences in left ventricular (LV) function after anterior wall ST-segment elevation myocardial infarction (STEMI), despite it being a major determinant of patients' morbidity and mortality. We therefore sought to investigate the impact of gender on LV function after primary percutaneous coronary intervention (PCI) for first anterior wall STEMI. Seven hundred eighty-nine consecutive patients (625 men) with first anterior STEMI were included in the analysis. All patients underwent an echocardiographic study within 48 hours of PCI. Women were older and more likely to have diabetes, hypertension, chronic renal failure, and a higher Killip score. Women had prolonged ischemic time, which was driven by prolonged symptom-to-presentation time (2.75 [interquartile range 1.5 to 4] vs 2 [interquartile range 1 to 3.5] hours, p = 0.005). A higher percentage of women had moderate or worse LV dysfunction (LV ejection fraction <40%; 61.6% vs 48%, p = 0.002). In a univariable analysis female gender was associated with moderate or worse LV function (p = 0.002). However, after accounting for variable baseline risk profiles between the 2 groups using multivariable and propensity score techniques, ischemic time >3.5 hours, leukocytosis, and pre-PCI Thrombolysis In Myocardial Infarction flow grade <2 were independent predictors of moderate or worse LV dysfunction, whereas female gender was not. Data on LV function recovery at 6 months, which were available for 45% of female and male patients with moderate or worse LV dysfunction early after PCI, showed no significant gender related difference in LV function recovery. In conclusion, women undergoing PCI for the first event of anterior STEMI demonstrate worse LV function than that of men, which might be partially attributed to delay in presentation. Hence greater efforts should be devoted to increasing women's awareness of cardiac symptoms during the prehospital course of STEMI.

Sex differences in long-term mortality after myocardial infarction: a systematic review

BACKGROUND

Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge.

METHODS AND RESULTS

We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization.

CONCLUSIONS

Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality.

Sex differences in mental stress-induced myocardial ischemia in young survivors of an acute myocardial infarction

OBJECTIVES

Emotional stress may disproportionally affect young women with ischemic heart disease. We sought to examine whether mental stress-induced myocardial ischemia (MSIMI), but not exercise-induced ischemia, is more common in young women with previous myocardial infarction (MI) than in men.

METHODS

We studied 98 post-MI patients (49 women and 49 men) aged 38 to 60 years. Women and men were matched for age, MI type, and months since MI. Patients underwent technetium-99m sestamibi perfusion imaging at rest, after mental stress, and after exercise/pharmacological stress. Perfusion defect scores were obtained with observer-independent software. A summed difference score (SDS), the difference between stress and rest scores, was used to quantify ischemia under both stress conditions.

RESULTS

Women 50 years or younger, but not older women, showed a more adverse psychosocial profile than did age-matched men but did not differ for conventional risk factors and tended to have less angiographic coronary artery disease. Compared with age-matched men, women 50 years or younger exhibited a higher SDS with mental stress (3.1 versus 1.5, p = .029) and had twice the rate of MSIMI (SDS ≥ 3; 52% versus 25%), whereas ischemia with physical stress did not differ (36% versus 25%). In older patients, there were no sex differences in MSIMI. The higher prevalence of MSIMI in young women persisted when adjusting for sociodemographic and life-style factors, coronary artery disease severity, and depression.

CONCLUSIONS

MSIMI post-MI is more common in women 50 years or younger compared with age-matched men. These sex differences are not observed in post-MI patients who are older than 50 years.

Sex-based differences in clinical features, management, and 28-day and 7-year prognosis of first acute myocardial infarction. RESCATE II study

INTRODUCTION AND OBJECTIVES

To analyze sex-based differences in clinical characteristics, management, and 28-day and 7-year prognosis after a first myocardial infarction.

METHODS

Between 2001 and 2003, 2042 first myocardial infarction patients were consecutively registered in 6 Spanish hospitals. Clinical characteristics, management, and 28-day case-fatality were prospectively recorded. Seven-year vital status was also ascertained by data linkage with the National Mortality Index.

RESULTS

The registry included 449 women and 1593 men with a first myocardial infarction. Compared with men, women were older, had a higher prevalence of hypertension and diabetes, and were more likely to receive angiotensin-converting enzyme (ACE) inhibitors but were less likely to receive beta-blockers or thrombolysis. No differences were observed in use of invasive procedures. More women had non-ST-segment elevation and unclassified myocardial infarction than men (37.9% vs 31.3% and 9.8% vs 6.1%, respectively; both P<.001). Case-fatality at 28 days was similar in women and men (5.57% vs 4.46%; P=.39). After multivariate adjustment, the odds ratio of 28-day mortality for men was 1.06 (95% confidence interval: 0.49-2.27; P=.883) compared with women. After multivariate adjustment, men had higher 7-year mortality than women, hazard ratio 1.93 (95% confidence interval: 1.46-2.56; P<.001).

CONCLUSIONS

There are demographic and clinical differences between men and women with a first myocardial infarction. The short-term prognosis of a first myocardial infarction in this century is similar in both sexes. However, the long-term vital prognosis after a first myocardial infarction is worse in men than in women. These results are observed in both ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction events.

Presentation, management, and outcomes of ischaemic heart disease in women

Scientific interest in ischaemic heart disease (IHD) in women has grown considerably over the past 2 decades. A substantial amount of the literature on this subject is centred on sex differences in clinical aspects of IHD. Many reports have documented sex-related differences in presentation, risk profiles, and outcomes among patients with IHD, particularly acute myocardial infarction. Such differences have often been attributed to inequalities between men and women in the referral and treatment of IHD, but data are insufficient to support this assessment. The determinants of sex differences in presentation are unclear, and few clues are available as to why young, premenopausal women paradoxically have a greater incidence of adverse outcomes after acute myocardial infarction than men, despite having less-severe coronary artery disease. Although differential treatment on the basis of patient sex continues to be described, the extent to which such inequalities persist and whether they reflect true disparity is unclear. Additionally, much uncertainty surrounds possible sex-related differences in response to cardiovascular therapies, partly because of a persistent lack of female-specific data from cardiovascular clinical trials. In this Review, we assess the evidence for sex-related differences in the clinical presentation, treatment, and outcome of IHD, and identify gaps in the literature that need to be addressed in future research efforts.

Gender differences in long-term outcome after primary percutaneous intervention for ST-segment elevation myocardial infarction

BACKGROUND

Previous studies on gender differences in outcome in patients with ST segment elevation myocardial infarction (STEMI) have been performed, but most of those are from before the current era of PCI technique and medical therapy and have a short duration of follow-up. The objective of our study is to assess the influence of gender on long-term outcome in patients with STEMI who underwent primary percutaneous intervention (PCI) between January 2006 and May 2008.

METHODS

Two-year follow-up data from 202 female and 668 male patients undergoing primary PCI for STEMI were available from the DEBATER (A Comparison of Drug Eluting and Bare Metal Stents for Primary Percutaneous Coronary Intervention with or without Abciximab in ST-segment elevation Myocardial Infarction: The Eindhoven Reperfusion Study) trial database. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction, and target vessel revascularization.

RESULTS

Women were older (64.7 ± 11.7 vs. 59.0 ± 10.7; P < 0.001), and had more often diabetes mellitus (15% vs. 9%; P = 0.01) and hypertension (44% vs. 25%; P < 0.001). At two years, the rate of MACE was significantly higher in women (21% vs. 14%; P = 0.02). The mortality rate in women was 8% versus 2.6% in men (P < 0.001). However, multivariate analysis after adjustment for age and the baseline characteristics hypertension, smoking, diabetes mellitus, stent diameter, and time between onset of symptoms and arrival of the ambulance showed similar MACE and mortality rates in men and women.

CONCLUSION

Women have higher rates of both MACE and mortality after primary PCI for STEMI compared to men because of higher age with higher baseline risk profiles.

Remarkable decline in ischemic stroke mortality is not matched by changes in incidence

BACKGROUND AND PURPOSE

In Western Europe, mortality from ischemic stroke (IS) has declined over several decades. Age-sex-specific IS mortality, IS incidence, 30-day case fatality, and 1-year mortality after hospital admission are essential for explaining recent trends in IS mortality in the new millennium.

METHODS

Data for all IS deaths (1980-2010) in the Netherlands were grouped by year, sex, and age. A joinpoint regression was fitted to detect points in time at which significant changes in the trends occur. By linking nationwide registers, a cohort of patients first admitted for IS between 1997 and 2005 was constructed and age-sex-specific 30-day case fatality and 1-year mortality were computed. IS incidence (admitted IS patients and out-of-hospital IS deaths) was computed by age and sex. Mann-Kendall tests were used for trend evaluation.

RESULTS

IS mortality declined continuously between 1980 and 2000 with an attenuation of decline in the 1990s in some of the age-sex groups. A remarkable decline in IS mortality after 2000 was observed in all age-sex groups, except for young men. An improved decline in 30-day case fatality and in 1-year mortality was also observed in almost all age-sex groups. In contrast, IS incidence remained stable between 1997 and 2005 or even increased slightly.

CONCLUSIONS

The recent remarkable decline in IS mortality was not matched by a decline in the number of incident nonfatal IS events. This is worrying, because IS is already a leading cause of adult disability, claiming a heavy human and economic burden. Prevention of IS is therefore now of the greatest importance.

Gender differences in contrast-enhanced magnetic resonance imaging after acute myocardial infarction

Besides different risk profiles for cardiovascular events in men and women, several studies reported gender differences in mortality after acute myocardial infarction (AMI). As infarct size has been shown to correlate with mortality, it is widely accepted as surrogate marker for clinical outcome. Currently, cardiovascular imaging studies covering the issue of gender differences are rare. As magnetic resonance scar characterization parameters are emerging as additional prognostic factors after acute myocardial infarction, we sought to evaluate gender differences in CMR infarct characteristics in patients after acute myocardial infarction. We prospectively analyzed patients (n = 448) with AMI and primary angioplasty, who underwent contrast-enhanced cardiac magnetic resonance (CMR) imaging on a 1.5 T scanner in median 5 [4, 6] days after the acute event. [corrected]. CMR scar size was measured 15 min after gadolinium injection. In addition presence and extent of microvascular obstruction (MVO) was assessed. A matched pair analysis was performed in order to exclude confounding by gender related co-morbidities and gender differences in established clinical risk factors. Matching process according to clinical risk defined by GRACE score resulted in 93 mixed gender couples. Women were significantly older than men (64.4 ± 11.9 vs. 60.5 ± 12.3, p = 0.03) and presented with a significantly better ejection fraction before angioplasty (48.9 ± 8.4 vs. 46.2 ± 8.9, p = 0.04). Infarct size did not differ significantly between women and men (13.5 ± 10.7 vs. 15.1 ± 11.8, p = 0.32). Size of MVO was significantly smaller in women than in men (0.48 ± 1.3 vs. 1.2 ± 3.0, p = 0.03). Comparing scar characterization between women and men with similar risk profiles revealed no gender differences in scar size. Size of MVO, however, was significantly smaller in women and might reflect better cardioprotective mechanisms in women. Whether these changes have prognostic implications has to be tested on a larger patient population.

Stress-induced cardiomyopathy in Sweden: evidence for different ethnic predisposition and altered cardio-circulatory status

BACKGROUND

In this paper, we report about new insights regarding clinical course, long-term outcome, ethnic/genetic predisposition and cardio-circulatory status in the large stress-induced cardiomyopathy (SIC) cohort from Sweden.

METHODS AND RESULTS

We have included 115 consecutive SIC patients between January 2005 and January 2010 at Sahlgrenska University Hospital in Gothenburg. Hemodynamic status and sympathetic nerve activity were evaluated and compared with those of healthy controls. Mean age was 64, and 14% were males. Thirty-day and 3-year mortality was 6 and 10%, respectively. Eleven percent had ischemic heart disease, 3% developed thromboembolic complications, 6% had cardiac arrest and 14% developed cardiogenic shock. The great majority of SIC patients (93%) were ethnic Swedes. In three families, several close relatives developed SIC. Fourteen percent developed two or more episodes of SIC. Hemodynamic evaluation has shown subnormal systemic vascular resistance, 22% lower sympathetic activity and preserved cardiac output in SIC patients.

CONCLUSIONS

SIC affects both men and women of different ages and is associated with significant short- and long-term mortality. There is a strong signal for the presence of ethnic/genetic predisposition to develop SIC. Sympathetic activity and systemic vascular resistance are lower in SIC patients, suggesting that SIC is a cardio-circulatory phenomenon.

Long-Term Survival and Recurrence After Acute Myocardial Infarction in England, 2004 to 2010

Background—

There are limited population-based national data on prognosis in survivors of acute myocardial infarction (AMI), particularly on long-term survival and the risk of recurrence.

Methods and Results—

Record linkage of hospital and mortality data identified 387 452 individuals in England who were admitted to hospital with a main diagnosis of AMI between 2004 and 2010 and who survived for at least 30 days. Seven years after an AMI, the risk of death from any cause in survivors of first or recurrent AMI was, respectively, 2 and 3 times higher than that in the English general population of equivalent age. For all survivors of a first AMI, the risk of a second AMI was highest during the first year and the cumulative risk increased more gradually thereafter. For men, 1- and 7-year cumulative risks were 5.6% (95% confidence interval [CI], 5.5–5.7) and 13.9% (95% CI, 13.7–14.1); for women, they were 7.2% (95% CI, 7.1–7.4) and 16.2% (95% CI, 16.0–16.5). Older age, higher deprivation, no revascularization procedures, and presence of comorbidities were associated with higher recurrence risk.

Conclusions—

Survivors of both first and recurrent AMI remained at a significantly higher risk of death compared with the general population for at least 7 years after the event. For survivors of first AMI, the influence of predisposing factors for second AMI lessened with time after the initial event. The results reinforce the importance of acute clinical care and secondary prevention in improving long-term prognosis of hospitalized AMI patients.

The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study

We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.

Gender gap in acute coronary heart disease: Myth or reality?

AIM

To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS).

METHODS

A systematic literature search was performed through Medline using pre-specified keywords. An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found.

RESULTS

Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were at highest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women.

CONCLUSION

Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.

Comparison of gender-specific mortality in patients < 70 years versus ≥ 70 years old with acute myocardial infarction

The aim of the present study was to investigate the gender-specific mortality after acute myocardial infarction in those aged < 70 years versus ≥ 70 years. The present study consisted of 2,677 consecutive patients with acute myocardial infarction who had undergone coronary angiography within 24 hours after the onset of symptoms. The patients were divided into 2 groups: 1,810 patients < 70 years old and 867 patients ≥ 70 years old. Women were older and had a greater incidence of hypertension and diabetes mellitus and a lower incidence of current smoking and previous myocardial infarction in both groups. The in-hospital mortality rate was significantly greater in women ≥ 70 years old age than in men ≥ 70 years old (16.2% vs 9.3%, respectively; p = 0.003) but was comparable between women and men in patients < 70 years old (5.7% vs 4.9%, respectively; p = 0.59). On multivariate analysis, the association between female gender and in-hospital mortality in patients ≥ 70 years old remained significant (odds ratio 1.78, 95% confidential interval 1.05 to 3.00), but the gender difference was not observed in patients < 70 years old (odds ratio 1.09, 95% confidence interval 0.53 to 2.24). In conclusion, female gender was associated with in-hospital mortality after acute myocardial infarction in patients ≥ 70 years old but not in patients < 70 years old.

Sex differences in short- and long-term case-fatality of myocardial infarction

Declining trends in case fatality (CF) of MI events have been generally reported in western countries. It is, however, not clear whether the development has been equally beneficial in both sexes. Data from two large population based registers, FINAMI and the Finnish National Cardiovascular Disease Register (CVDR) were used to determine whether the CF of incident MI events has declined less in women than in men. All patients aged 35 and over were included. CF was calculated for different time periods after the onset of the MI event, the main emphasis was in pre-hospital, 28-day, and 1-year CF. Figures were compared between two study periods: 1994-1996 and 2000-2002. A total of 6,342 incident MI events were recorded in FINAMI and 117,632 events in CVDR during the study periods. Comparison between the two study periods showed that the CF was generally declining. However, a slower decline in short-term CF was seen among young (aged<55 years) women (P for sex by study period interaction in pre-hospital CF=0.028 in FINAMI and 0.003 in CVDR, and for 28-day CF P=0.016 in FINAMI and <0.0001 in CVDR). In conclusion, the short and long-term prognosis of MI events has improved in both sexes. Pre-hospital CF has declined less among younger women than among men and among older women. This slower decline in early CF was responsible for the slower improvement in 28-day and 1-year prognosis in young women.

Individual and population benefits of daily aspirin therapy: a proposal for personalizing national guidelines

BACKGROUND

Clinical practice guidelines that help clinicians and patients to understand the magnitude of expected individual risks and benefits would help with patient-centered decision-making and prioritization of care. We assessed the net benefit from taking daily aspirin to estimate the individual and public health implications of a more individualized decision-making approach.

METHODS AND RESULTS

We used data from the National Health and Nutrition Examination Survey representing all US persons aged 30 to 85 years with no history of myocardial infarction and applied a Markov model based on randomized evidence and published literature to estimate lifetime effects of aspirin treatment in quality-adjusted life years (QALYs). We found that treatment benefit varies greatly by an individual's cardiovascular disease (CVD) risk. Almost all adults have fewer major clinical events on aspirin, but for most, events prevented would be so rare that even a very small distaste for aspirin use would make treatment inappropriate. With minimal dislike of aspirin use (disutility, 0.005 QALY per year), only those with a 10-year cardiac event risk >6.1% would have a net benefit. A disutility of 0.01 QALY moves this benefit cut point to 10.6%. Multiple factors altered the absolute benefit of aspirin, but the strong relationship between CVD risk and magnitude of benefit was robust.

CONCLUSIONS

The benefits of aspirin therapy depend substantially on an individual's risk of CVD and adverse treatment effects. Understanding who benefits from aspirin use and how much can help clinicians and patients to develop a more patient-centered approach to preventive therapy.

Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. An analysis of 8630 patients in the northern Sweden MONICA study

BACKGROUND

There is conflicting and only scant evidence on the effect of gender on long-term survival after a myocardial infarction (MI). Our aim was to analyse sex-specific survival of patients for up to 23 years after a first MI in northern Sweden and to describe time trends.

METHODS

The Northern Sweden MONICA Myocardial Infarction Registry was linked to The Swedish National Cause of Death Registry for a total of 8630 patients, 25 to 64 years of age, 6762 men and 1868 women, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008.

RESULTS

Median follow-up was 7.1 years, maximum 23 years and the study included 70 072 patient-years. During the follow-up 45.3% of the men and 43.7% of the women had died. Median survival for men was 187 months (95% confidence interval (CI) 179-194) and for women 200 months (95% CI 186-214). The hazard ratio (HR) for all cause mortality after adjustment for age group was 1.092 (1.010-1.18, P = 0.025) for females compared to males, i.e. 9 percent higher survival in women. After excluding subjects who died before reaching hospital HR declined to 1.017 (95%CI 0.93-1.11, P = 0.7). For any duration of follow-up a higher proportion of women were alive, irrespective of age group. The 5-year survivals were 75.3% and 77.5%, in younger (<57 years) men and women and were 65.5% and 66.3% in older (57-64 years) men and women, respectively. For each of four successive cohorts survival improved. Survival time was longer for women than for men in all age groups.

CONCLUSIONS

Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.

Sex differences in hospital mortality following acute myocardial infarction in China: findings from a study of 45 852 patients in the COMMIT/CCS-2 study

OBJECTIVE

To assess the sex difference in hospital mortality following ST elevation myocardial infarction (STEMI) in China.

DESIGN

Observational study of patients enrolled into a large trial, adjusting for age, presenting characteristics and hospital treatments using logistic regression.

SETTINGS

1250 hospitals in China during 1999-2005.

PATIENTS

42 683 STEMI patients, including 31 309 men and 11 374 women.

INTERVENTION

In the original trial, all patients received 162 mg of aspirin plus 75 mg of clopidogrel daily or matching placebo and metoprolol (15 mg intravenous then 200 mg oral daily) or matching placebo. All other aspects of patients' treatments were at the discretion of responsible doctors.

MAJOR OUTCOMES

Hospital mortality from any cause during the scheduled trial treatment period (ie, up to 4 weeks in hospital).

RESULTS

Overall, 8% of the patients died in hospital, with the crude hospital mortality being twice as high in women as in men (12.6% vs 6.3%). After adjusting for age, the sex difference in hospital mortality attenuated but remained highly significant (OR 1.54; 95% CI 1.43 to 1.66). Further adjustment for other baseline characteristics and for the treatments given in hospital had little effect on the sex difference in hospital mortality (OR 1.50, 95% CI 1.38 to 1.62). The difference in hospital mortality was greater at a younger age, with the adjusted ORs being 2.14, 1.70, 1.48 and 1.18, respectively, for ages <55, 55-64, 65-74 and ≥75 years (p=0.0001 for trend).

CONCLUSION

Compared with men of the same age, women had approximately a 50% higher mortality following hospital admission for STEMI, with a particularly higher excess risk at age <55 years.

Sex differences in relative survival and prognostic factors in patients with a first acute myocardial infarction in Guipuzcoa, Spain

INTRODUCTION AND OBJECTIVES

To determine 28-day and 5-year survival rates in patients who have experienced a first acute myocardial infarction and to identify prognostic factors for survival.

METHODS

This study involved 1,677 patients with a first acute myocardial infarction who were treated at a hospital in Guipuzcoa, Spain between 1997 and 2000.

RESULTS

Women were approximately 10 years older than men, presented more often with diabetes and hypertension, were in a less favorable clinical condition, and consumed fewer medical resources, but were less likely to smoke. Survival rates at 28 days and 5 years were higher in men over 60 years of age. In the period from 29 days to 5 years, the relative survival rate was higher in men from all age groups. Factors associated with short- and long-term survival varied between the sexes. Disease severity in the acute phase and, later on, age were associated with survival in both men and women, whereas the effect of other variables differed between the sexes.

CONCLUSIONS

Myocardial infarction is a condition associated with high mortality in the acute phase. There is an interaction between sex and age that affects survival after an acute myocardial infarction. A number of factors are associated with poor short- and long-term prognoses in both sexes.

The dynamics of mortality in follow-up time after an acute myocardial infarction, lower extremity arterial disease and ischemic stroke

BACKGROUND

Most studies providing data on survival in patients with atherosclerosis only address a single disease site: heart, brain or legs. Therefore, our objective was to determine risk of death after first hospital admission for atherosclerotic disease located at different sites.

METHODS

A nationwide cohort of patients hospitalized for the first time for acute myocardial infarction (AMI), peripheral arterial disease of the lower extremities (PAD) or ischemic stroke was identified through linkage of national registers. The mortality rate in AMI patients was compared to mortality rate in ischemic stroke and PAD patients by estimating relative risks (with 95%CI). Cox's proportional hazard models were used to estimate sex differences in risk of death.

RESULTS

Case fatality was high for ischemic stroke patients (men:21.0%, women:23.8%) and AMI patients (men:12.7%, women:20.9%) though low for PAD patients (men:2.4%, women:3.5%). The five-year risk of death was similar for male AMI compared to PAD patients (men: RR1.04; 95%CI 0.98-1.11). The risk of death for ischemic stroke patients remained the highest though the differences with AMI and PAD patients attenuated.

CONCLUSIONS

The dynamics of mortality over follow-up time clearly differ between atherosclerotic diseases, located at different vascular beds. The risk of death increases considerably over follow-up time for PAD patients, and 5 years after first hospital admission the differences in risks of death between AMI- and PAD patients and between AMI- and ischemic stroke patients have largely attenuated. Clinicians should be aware of these dynamics of mortality over follow-up time to provide optimal secondary prevention treatment.

Short-term and long-term case fatality in 11 878 patients hospitalized with a first acute myocardial infarction, 1979-2001: the Western Norway cardiovascular registry

BACKGROUND

Few studies have direct estimates of long-term survival after acute myocardial infarction (AMI). Our objective was to provide such estimates, and trends in these estimates, using data from a single hospital over a 23-year period.

DESIGN

A retrospective cohort study.

METHODS

We examined 28-day, 1-year and 10-year case fatality among 7635 men and 4243 women admitted to Haukeland University Hospital with a first AMI, during 1979-2001. Information on cardiovascular diagnoses and procedures were registered in the Western Norway Cardiovascular Registry, and data on deaths were obtained from the Cause of Death Registry, Statistics Norway.

RESULTS

From 1979-1985 to 1994-2001, crude 28-day case fatality declined from 31.1 to 19.8% in men and from 37.3 to 26.8% in women (both, P-trend <0.0001). Crude 10-year case fatality declined from 69.5-55.5% in men and from 80.8-66.1% in women (both, P-trend <0.0001). Landmark analysis showed a decline in 1-10-year case fatality, among patients less than 60 years of age from 26.1 to 13.8% in men, and from 33.3 to 6.4% in women. In patients > or =60 years, the 28-day, 1-year and 10-year age-adjusted case-fatality rates were significantly lower in women than men.

CONCLUSION

Landmark analysis showed substantial improvement in up to 10 years survival after hospitalization for a first AMI. A significantly lower age-adjusted case fatality in women > or =60 years already after 28 days compared with men is specifically noticed.