Impact of gender on mortality following primary angioplasty for acute myocardial infarction

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.

Proceedings from the scientific symposium: Sex differences in cardiovascular disease and implications for therapies

A consortium of investigator-thought leaders was convened at the Heart Institute at Cedars-Sinai Medical Center and produced the following summary points: POINT 1: Important sex differences exist in cardiovascular disease (CVD) that affect disease initiation, diagnosis, and treatment.

IMPLICATION

Research that acknowledges these differences is needed to optimize outcomes in women and men. POINT 2: Atherosclerosis is qualitatively and quantitatively different in women and men; women demonstrate more plaque erosion and more diffuse plaque with less focal artery lumen intrusion.

IMPLICATION

Evaluation of CVD strategies that include devices should be used to explore differing anatomical shapes and surfaces as well as differing drug coating and eluting strategies. POINT 3: Bone marrow progenitor cells (PCs) engraft differently based on the sex of the donor cell and the sex of the recipient.

IMPLICATION

PC therapeutic studies need to consider the sex of cells of the source and the recipient. POINT 4: Women have a greater risk of venous but not arterial thrombosis compared with men, as well as more bleeding complications related to anticoagulant treatment. Several genes coding for proteins involved in hemostasis are regulated by sex hormones.

IMPLICATIONS

Research should be aimed at evaluation of sex-based differences in response to anticoagulation based on genotype. POINT 5: Women and men can have differences in pharmacological response.

IMPLICATION

Sex-specific pharmacogenomic studies should be included in pharmacological development. POINT 6: CVD progression results from an imbalance of cell injury and repair in part due to insufficient PC repair, which is affected by sex differences, where females have higher circulating levels of PCs with greater rates of tissue repair.

IMPLICATION

CVD regenerative strategies should be directed at learning to deliver cells that shift the recipient balance from injury toward repair. CVD repair strategies should ideally be tested first in females to have the best chance of success for proof-of-concept.

Hospital mortality in acute coronary syndrome: differences related to gender and use of percutaneous coronary procedures

Background

To identify differences among men and women with acute coronary syndrome in terms of in-hospital mortality, and to assess whether these differences are related to the use of percutaneous cardiovascular procedures.

Methods

Observational study based on the Minimum Basic Data Set. This encompassed all episodes of emergency hospital admissions (46,007 cases, including 16,391 women and 29,616 men) with a main diagnosis of either myocardial infarction or unstable angina at 32 hospitals within the Andalusian Public Health System over a four-year period (2000–2003). The relationship between gender and mortality was examined for the population as a whole and for stratified groups depending on the type of procedures used (diagnostic coronary catheterisation and/or percutaneous transluminal coronary angioplasty). These combinations were then adjusted for age group, main diagnosis and co-morbidityharlson score).

Results

During hospitalisation, mortality was 9.6% (4,401 cases out of 46,007), with 11.8% for women and 8.3% for men. There were more deaths among older patients with acute myocardial infarction and greater co-morbidity. Lower mortality was shown in patients undergoing diagnostic catheterisation and/or PTCA. After adjusting for age, diagnosis and co-morbidity, mortality affected women more than men in the overall population (OR 1.14, 95% CI: 1.06–1.22) and in the subgroup of patients where no procedure was performed (OR 1.16, 95% CI: 1.07–1.24). Gender was not an explanatory variable in the subgroups of patients who underwent some kind of procedure.

Conclusion

Gender has not been associated to in-hospital mortality in patients who undergo some kind of percutaneous cardiovascular procedure. However, in the group of patients without either diagnostic catheterisation or angioplasty, mortality was higher in women than in men.