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

Long-term all-cause mortality of metabolic-dysfunction associated steatotic liver disease based on body weight phenotypes following acute myocardial infarction: A retrospective cohort study

OBJECTIVE

Metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity increases risk of cardiovascular disease. This cohort study examines the prognostic value of MASLD, across body weight categories, in a secondary preventative acute myocardial infarction (AMI) cohort.

METHODS

Patients with AMI were stratified into four phenotypes-obesity MASLD, non-obesity MASLD, obesity non-MASLD, non-obesity non-MASLD. The primary outcome was all-cause mortality. Cox regression analysis was performed to investigate determinants of long-term all-cause mortality.

RESULTS

Of 5702 patients, majority were in the non-obesity non-MASLD group (66.7%), followed by obesity MASLD (16.1%), non-obesity MASLD (11.2%) and non-obesity MASLD (6.0%). Across the four phenotypes, obesity MASLD had the highest cardiometabolic burden, followed by non-obesity MASLD. Non-obesity MASLD had the highest risk of heart failure (p = 0.034), cardiogenic shock (p < 0.001), and all-cause long-term mortality (p = 0.019). The non-obesity MASLD (HR 1.400, 95%CI 1.077-1.820, p = 0.012) and obesity MASLD phenotypes (HR 1.222, 95%CI 1.005-1.485, p = 0.044) were independently associated with long-term all-cause mortality.

CONCLUSIONS

Obesity and non-obesity MASLD phenotypes were predictors of all-cause mortality following AMI, with an even larger magnitude of mortality risk in the non-obesity MASLD group. The recognition of MASLD and its body weight phenotypes will be beneficial in the prognostication following AMI.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Closing the sex gap in cardiovascular mortality by achieving both horizontal and vertical equity

Addressing sex differences and disparities in coronary heart disease (CHD) involves achieving both horizontal and vertical equity in healthcare. Horizontal equity in the context of CHD means that both men and women with comparable health statuses should have equal access to diagnosis, treatment, and management of CHD. To achieve this, it is crucial to promote awareness among the general public about the signs and symptoms of CHD in both sexes, so that both women and men may seek timely medical attention. Women often face inequity in the treatment of cardiovascular disease. Current guidelines do not differ based on sex, but their applications based on gender do differ. Vertical equity means tailoring healthcare to allow equitable care for all. Steps towards achieving this include developing treatment protocols and guidelines that consider the unique aspects of CHD in women. It also requires implementing guidelines equally, when there is not sex difference rather than inequities in application of guideline directed care.

Between-Sex Differences in Risk Factors for Cardiovascular Disease among Patients with Myocardial Infarction-A Systematic Review

Between-sex differences in the presentation, risk factors, management, and outcomes of acute myocardial infarction (MI) are well documented. However, as such differences are highly sensitive to cultural and social changes, there is a need to continuously re-evaluate the evidence. The present contemporary systematic review assesses the baseline characteristics of men and women presenting to secondary, tertiary, and quaternary centres with acute myocardial infarction (MI). Over 1.4 million participants from 18 studies, including primary prospective, cross sectional and retrospective observational studies, as well as secondary analysis of registry data are included in the study. The study showed that women were more likely than men to have a previous diagnosis of diabetes, hypertension, cerebrovascular disease, and heart failure. They also had lower odds of presenting with previous ischaemic heart disease and angina, dyslipidaemia, or a smoking history. Further work is necessary to understand the reasons for these differences, and the role that gender-specific risk factors may have in this context. Moreover, how these between-gender differences are implicated in management and outcomes also requires further work.

Sex-Related Differences in Platelet Aggregation: A Literature Review Supplemented with Local Data from a Group of Generally Healthy Individuals

The process of platelet aggregation is often influenced by several factors including sex and age. A literature review confirmed the existence of sex-related differences in platelet aggregation. Although 68 out of 78 papers found such differences, there are still some controversies regarding these differences, which can be due to multiple factors (age, trigger, concomitant disease, sample handling, etc.). These outcomes are discussed in line with novel results obtained from a local study, in which blood samples from a total of 53 overall healthy women and men with ages ranging from 20 to 66 years were collected. Aggregation was induced with seven different triggers (ristocetin, thrombin receptor activating peptide 6 [TRAP-6], arachidonic acid [AA], platelet-activating factor 16 [PAF-16], ADP, collagen, or thromboxane A₂ analog U-46619) ex vivo. In addition, three FDA-approved antiplatelet drugs (vorapaxar, ticagrelor, or acetylsalicylic acid [ASA]) were also tested. In general, women had higher aggregation responses to some agonists (ADP, TRAP), as well as lower benefit from inhibitors (ASA, vorapaxar). The aggregatory responses to AA and TRAP decreased with age in both sexes, while responses to ADP, U-46619, and PAF were affected by age only in women. In conclusion, more studies are needed to decipher the biological importance of sex-related differences in platelet aggregation in part to enable personalized antiplatelet treatment.

Sex Differences in Outcomes After Myocardial Infarction in the Community

PURPOSE

Prior studies observed that women experienced worse outcomes than men after myocardial infarction but did not convincingly establish an independent effect of female sex on outcomes, thus failing to impact clinical practice. Current data remain sparse and information on long-term nonfatal outcomes is lacking. To address these gaps in knowledge, we examined outcomes after incident myocardial infarction for women compared with men.

METHODS

We studied a population-based myocardial infarction incidence cohort in Olmsted County, Minnesota, between 2000 and 2012. Patients were followed for recurrent myocardial infarction, heart failure, and death. A propensity score was constructed to balance the clinical characteristics between men and women; Cox models were weighted using inverse probabilities of the propensity scores.

RESULTS

Among 1959 patients with incident myocardial infarction (39% women; mean age 73.8 and 64.2 for women and men, respectively), 347 recurrent myocardial infarctions, 464 heart failure episodes, 836 deaths, and 367 cardiovascular deaths occurred over a mean follow-up of 6.5 years. Women experienced a higher occurrence of each adverse event (all P <0.01). After propensity score weighting, women had a 28% increased risk of recurrent myocardial infarction (hazard ratio: 1.28, 95% confidence interval: 1.03-1.59), and there was no difference in risk for any other outcomes (all P >0.05).

CONCLUSION

After myocardial infarction, women experience a large excess risk of recurrent myocardial infarction but not of heart failure or death independently of clinical characteristics. Future studies are needed to understand the mechanisms driving this association.

Seventeen-Year Mortality following the Acute Coronary Syndrome: Gender-Specific Baseline Variables and Impact on Outcome

BACKGROUND

Gender differences in outcome and its predictors in patients with acute coronary syndrome (ACS) continue to be debated.

OBJECTIVES

To assess long-term mortality and explore its association with the baseline variables in women and men.

METHODS

We followed 2,176 consecutive patients (665 women and 1,511 men) with ACS admitted to a single hospital and still alive after 30 days for a median of 16 years 8 months.

RESULTS

At the end of the follow-up, 415 (62.4%) women and 849 (56.2%) men had died (unadjusted hazard ratio [HR] for women/men 1.18 (95% confidence interval [CI], 1.05-1.33, p =0.005). After adjustment for age, the HR was reversed to 0.88 (95% CI, 0.78-1.00, p =0.04). Additional adjustment for potential confounders yielded a HR of 0.86 (95% CI, 0.76-0.98, p = 0.02). Using multivariable Cox regression, previous heart failure, previous or new-onset atrial fibrillation, and psychotropic drugs at discharge were significantly associated with increased long-term mortality in men only. Known hypertension, elevated creatinine, and inhospital Killip class >1/cardiogenic shock were significantly associated with mortality only in women. For late mortality, hypertension and inhospital Killip class >1/cardiogenic shock interacted significantly with gender.

CONCLUSION

For patients with ACS surviving the first 30 days, late mortality was lower in women than in men after adjusting for age. The effects of several baseline characteristics on late outcome differed between women and men. Gender-specific strategies for long-term follow-up of ACS patients should be considered.

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.

Women and Ischemic Heart Disease: Recognition, Diagnosis and Management

Cardiovascular disease is one of the most frequent causes of death in both males and females throughout the world. However, women exhibit a greater symptom burden, more functional disability, and a higher prevalence of nonobstructive coronary artery disease (CAD) compared to men when evaluated for signs and symptoms of myocardial ischemia. This paradoxical sex difference appears to be linked to a sex-specific pathophysiology of myocardial ischemia including coronary microvascular dysfunction, a component of the 'Yentl Syndrome'. Accordingly, the term ischemic heart disease (IHD) is more appropriate for a discussion specific to women rather than CAD or coronary heart disease. Following the National Heart, Lung, and Blood Institute Heart Truth/American Heart Association, Women's Ischemia Syndrome Evaluation and guideline campaigns, the cardiovascular mortality in women has been decreased, although significant gender gaps in clinical outcomes still exist. Women less likely undergo testing, yet guidelines indicate that symptomatic women at intermediate to high IHD risk should have further test (e.g. exercise treadmill test or stress imaging) for myocardial ischemia and prognosis. Further, women have suboptimal use of evidence-based guideline therapies compared with men with and without obstructive CAD. Anti-anginal and anti-atherosclerotic strategies are effective for symptom and ischemia management in women with evidence of ischemia and nonobstructive CAD, although more female-specific study is needed. IHD guidelines are not "cardiac catheterization" based but related to evidence of "myocardial ischemia and angina". A simplified approach to IHD management with ABCs (aspirin, angiotensin-converting enzyme inhibitors/angiotensin-renin blockers, beta blockers, cholesterol management and statin) should be used and can help to increases adherence to guidelines.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Ambulatory treatment gaps in patients with ischemic stroke or transient ischemic attack

BACKGROUND

This study evaluated goal attainment for patients with a history of non-cardioembolic ischemic stroke (NCIS) or transient ischemic attack (TIA).

METHODS

A cross-sectional study was conducted in patients aged 18 to 85 years with a history of validated NCIS or TIA. Data collected were demographics, comorbidities, blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) values, and medications within 365 days and most proximal to December 31, 2010. Goal LDL-C and BP were defined as < 100 mg/dL and < 140/90 mm Hg, respectively. Differences in sex and age (< 65 vs ≥ 65 years) were evaluated.

RESULTS

There were 1731 patients evaluated (mean age: 73.6 years; 58% women). Stroke type was NCIS in 51.9% and TIA in 48.1%. The LDL-C and BP were measured in 75.4% and 50.3% of patients, respectively. No difference in LDL-C screening rates existed for sex or age. Men and patients younger than age 65 years were significantly more likely to have BP measured. Overall, LDL-C and BP goals were attained by 48.9% and 43.3% of patients, respectively. Men and patients age 65 years or older were likelier than women and patients younger than age 65 years to attain LDL-C goals (p < 0.01). Men were also likelier than women to attain BP < 140/90 mm Hg (p < 0.01), but more patients younger than age 65 years vs older than age 65 years attained this goal (p < 0.01). Statins and antihypertensives were received by 51.9% and 46.9% of the patients, respectively.

CONCLUSION

Although attaining guideline-recommended goals for LDL-C and BP may present challenges, future research should focus on innovative methods to help patients attain optimal treatment goals.

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.

[The ambulatory care of the acute myocardial infarction in Quebec: description, classification and typology]

OBJECTIVE

Description of ambulatory care of AMI, in Quebec population.

DESIGN

A retrospective cohort study was designed to classify and propose a typology of ambulatory care.

METHODS

The studied population was included in all 25 years and older inpatients residing in Quebec, whose admission were from January to December 2000. The principal variables were: the number of medical visits, the type of consulted physicians and the place of consultation. The secondary variables were: age, sex and the presence of a revascularization.

RESULTS

A typology of ambulatory care was created from principal variables. Men, younger patients and receiving a revascularization in the index hospitalization were cared for by a specialist.

Comparison of hospital versus out of hospital coronary death rates in women and men

Young women hospitalized with acute myocardial infarction (MI) have greater in-hospital mortality than young men. However, the reasons for this difference have not been well characterized. We analyzed the data from 423,067 patients (247,701 men and 175,366 women) who were discharged with the diagnosis of MI from nonfederal hospitals in New Jersey and 355,569 coronary heart disease (CHD) deaths in New Jersey from 1990 to 2004 in 4 age strata: 35 to 54, 55 to 64, 65 to 74 and > or =75 years. Of the patients hospitalized for MI, young (35 to 54 years) women had greater in-hospital mortality than young men (5.2% vs 2.5%, adjusted odds ratio 1.64, 95% confidence interval 1.48 to 1.81, p <0.0001). However, in a community-wide analysis, when the total out-of-hospital CHD deaths in New Jersey were examined, young women had a lower out-of-hospital death rate than young men (11 vs 55/100,000). Statewide, young women were 4 times less likely to be hospitalized for MI (78 vs 297/100,000, relative risk 0.26), but they were only 1/2 as likely to die from MI in the hospital (7 vs 17/100,000, relative risk 0.41). Thus, women had a greater odds ratio for in-hospital mortality but a lower odds ratio for out-of-hospital CHD death than men. In conclusion, the greater in-hospital mortality of young women hospitalized for MI compared to young men could be explained in part by the finding that young men were more likely to have out-of-hospital CHD death.

The heart truth professional education campaign on women and heart disease: needs assessment and evaluation results

BACKGROUND

Heart disease is the leading cause of death for women in the United States. Research has identified that women are less likely than men to receive medical interventions for the prevention and treatment of heart disease.

METHODS AND RESULTS

As part of a campaign to educate healthcare professionals, 1245 healthcare professionals in 11 states attended a structured 1-hour continuing medical education (CME) program based on the 2004 AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women and completed a pretest and posttest evaluation. We identified significant knowledge deficits in the pretest: 45% of attendees would initially recommend lifestyle changes alone, rather than statin therapy, for women diagnosed with coronary artery disease (CAD); 38% identified statin therapy as less effective in women compared with men for preventing CAD events; 27% identified Asian American women at low risk (rather than high risk) for type 2 diabetes mellitus (DM); and 21% identified processed meat (rather than baked goods) as the principal dietary source of trans fatty acids. Overall, healthcare professionals answered 5.1 of 8 knowledge questions correctly in the pretest, improving to 6.8 questions in the posttest (p < 0.001). Family physicians, obstetrician/gynecologists, general internists, nurse practitioners/physician assistants, and registered nurses all statistically significantly improved knowledge and self-assessed skills and attitudes as measured by the posttest.

CONCLUSIONS

Significant knowledge deficits are apparent in a cross-section of healthcare providers attending a CME lecture on women and heart disease. A 1-hour presentation was successful in improving knowledge and self-assessed skills and attitudes among primary care physicians, nurse practitioners, physician assistants, and registered nurses.

Comparison of men and women with acute coronary syndrome in six Middle Eastern countries

The aim of this study was to evaluate the gender differences in baseline characteristics, therapy, and outcomes in patients with acute coronary syndromes in 6 Middle Eastern countries. Over a 6-month period in 2007, 8,169 consecutive patients (74% men, 24% women) presenting with acute coronary syndromes were enrolled in a prospective, multicenter study from 6 adjacent Middle Eastern countries. Women were 9 years older than men and more likely to have diabetes, hypertension, and dyslipidemia. Women were more likely to present with unstable angina and more often had atypical presentations of ST elevation myocardial infarction. Compared to men, women were significantly less treated with beta blockers and antiplatelet therapy, whereas reperfusion therapy was nonsignificantly less used in women. In all patients with acute coronary syndromes, women not only ranked higher on Global Registry of Acute Coronary Events risk score but also had increased in-hospital mortality, 1.75 times that of men. This mortality difference persisted after adjusting for all confounders (odds ratios 1.76, 95% confidence interval 1.1 to 2.8, p <0.01). In conclusion, in addition to presentation with higher risk factors, female gender also independently predicted poorer outcomes in patients with ST elevation myocardial infarction.

The Role of Aspirin in Cardiovascular Disease Prevention in Women

Cardiovascular disease is the nation's number one killer of women. Through its actions on platelet inhibition, aspirin is an effective agent for primary and secondary cardiovascular disease prevention and for use with cardiac interventions. However, the evidence for aspirin's effectiveness in women differs by age and indication compared to men. As primary prevention, low dose aspirin is recommended for women over age 65 to reduce the risk of myocardial infarction and stroke while younger women at high risk for stroke may benefit from aspirin. Aspirin has benefits in other selected patient groups, including diabetics and patients presenting with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction acute coronary syndrome (NSTEMI/ACS), peripheral arterial disease, stroke, coronary artery bypass graft (CABG), and percutaneous coronary intervention (PCI). Alternative platelet therapy using dipyridamole or clopidogrel, alone or with aspirin, provides some improved efficacy for reduction in recurrent events for NSTEMI, ASC and PCI, although bleeding risks may be greater. However, dual antiplatelet therapy is not currently recommended for primary prevention in even high risk subjects. Despite the evidence base and guidelines, the use of aspirin in women remains suboptimal and warrants improved provider and patient awareness.

Does health status differ between men and women in early recovery after myocardial infarction?

BACKGROUND

Although much attention has been given to survival after myocardial infarction (MI), little is known about sex differences in health status (symptoms, function, and quality of life). A particularly critical moment to assess health status following an MI is early after discharge when patients have resumed routine activities and when additional treatments may be offered to those with residual angina or quality of life limitations.

METHODS

We used multivariable Poisson and linear regression models to examine differences in 30-day health status by sex in a cohort of 2096 MI patients enrolled in a 19-center Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER).

RESULTS

Women (32% of the cohort) were older and less likely to be white, married, or treated with coronary revascularization. They were more likely to have had a non-ST segment elevation MI, diabetes, hypertension, heart failure, chronic lung disease, and worse health status at admission. Risk-adjusted multivariable models suggest women were slightly more likely to have angina (RR 1.06, 95% CI 1.0, 1.14, p = 0.06), worse quality of life (difference in SAQ score = -4.36 points, 95% CI -5.44, -3.27 points, p = <0.001) and poorer physical functioning (difference in SF-12 PCS = -2.55 points, 95%CI = -3.62, -1.48 points, p = <0.001) at 30 days than men.

CONCLUSIONS

One in four patients experienced angina 1 month after their MI, and women had a slightly greater prevalence than men. The physical function and quality of life of women 30 days after an MI is similar to or worse than that of men.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies

Despite a dramatic decline in mortality over the past three decades, coronary heart disease is the leading cause of death and disability in the U.S. Importantly, recent advances in the field of cardiovascular medicine have not led to significant declines in case fatality rates for women when compared to the dramatic declines realized for men. The current review highlights gender-specific issues in ischemic heart disease presentation, evaluation, and outcomes with a special focus on the results published from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We will present recent evidence on traditional and novel risk markers (e.g., high sensitivity C-reactive protein) as well as gender-specific differences in symptoms and diagnostic approaches. An overview of currently available diagnostic test evidence (including exercise electrocardiography and stress echocardiography and single-photon emission computed tomographic imaging) in symptomatic women will be presented as well as data using innovative imaging techniques such as magnetic resonance subendocardial perfusion, and spectroscopic imaging will also be discussed.

Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease

Coronary heart disease is the leading cause of death and disability in the U.S., but recent advances have not led to declines in case fatality rates for women. The current review highlights gender-specific issues in ischemic heart disease (IHD) presentation, evaluation, and outcomes with a special focus on the results derived from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. In the second part of this review, we will assess new evidence on gender-based differences in vascular wall or metabolic alterations, atherosclerotic plaque deposition, and functional expression on worsening outcomes of women. Additionally, innovative cardiovascular imaging techniques will be discussed. Finally, we identify critical areas of further inquiry needed to advance this new gender-specific IHD understanding into improved outcomes for women.

The Anti-Ischemic Effect of Metoprolol in Patients with Chronic Angina Pectoris Is Gender-Specific

Several gender-specific differences in cardiovascular diseases are known and pharmacokinetics of beta-blockers shows relevant sex-specific differences. The plasma levels of metoprolol, for example, are higher in women compared to men. However, randomized studies have shown that metoprolol has little or no greater reduction in the mortality of women following myocardial infarction. We tested the hypothesis that metoprolol might have significant gender-specific effects in patients with chronic angina pectoris. Body weight of women was slightly (-9%) less than that of men and the daily dose of metoprolol was similar in both groups. Thus, according to pharmacokinetics women should have obtained higher plasma levels of this drug and the ensuing pharmacologic effects of metoprolol should have been greater. Our results do not confirm this assumption. Metoprolol reduced the frequency of angina episodes and the consumption of nitroglycerin tablets to a similar extent in both sexes. However, the pretreatment hemodynamic profiles confirmed the existence of gender-specific differences: women had significantly higher heart rate and blood pressure both at rest and during exercise. Since both groups were comparable in age, comorbidities, and medications, the existing difference is likely to be due to gender-specificity. The hemodynamic differences persisted during therapy with metoprolol: resting heart rate, blood pressure and rate pressure product were reduced to a greater extent in men. During cycloergometry, there was a slight difference in the time of onset of ST depression and time of onset of angina, which were slightly higher in men, but probably because of the limited number of cases, the difference between men and women did not reach significance. On the other hand, with metoprolol the duration of exercise and, in parallel, the number of metabolic equivalents was significantly greater in males than in females. Thus in spite of a presumed greater plasma concentration of metoprolol in women, we found a significant difference in anti-ischemic effect in favor of men. We conclude that metoprolol might exert a significantly greater therapeutic effect on stress-induced angina pectoris in men than in women and this difference should be taken into account when prescribing this beta-blocker.

Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes

OBJECTIVE

To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control.

DESIGN

Retrospective cohort study.

SETTING

Primary care clinics affiliated with an academic medical center.

PARTICIPANTS

Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl.

MEASUREMENTS AND MAIN RESULTS

The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender.

CONCLUSIONS

In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.

The Influence of Gender on Arrhythmias

It is becoming increasingly apparent that there are important gender differences in normal cardiac physiology. These, in turn, could be associated with differences in the type and severity of cardiac arrhythmias. Women have higher resting heart rates than men, probably as a result of a combination of autonomic and intrinsic factors. The clinical significance of this observation is unclear at the present time. Women have a lower incidence of sudden cardiac death, which could be related to the delayed onset of coronary artery disease in women, presumably as a result of the protective effects of female hormones during gestational years. In survivors of sudden cardiac death, there are major gender differences, with fewer women having underlying coronary artery disease and a greater percentage of women having structurally normal hearts. QT interval prolongation and Torsade de Pointes are more common in women, probably on the basis of differences in ion channels between genders. Women appear especially susceptible to Torsades from QT-prolonging drugs such as quinidine or tricyclic antidepressant medications. The mechanisms of paroxysmal supraventricular tachycardia differ between the genders, although therapy seems to be equally efficacious in men and women. Lastly, atrial fibrillation is considerably more common in men. There is also some evidence that it is better tolerated by men.

Mental health issues associated with cardiovascular disease in women

Cardiovascular disease is the leading cause of death in women and men. However, cardiovascular disease and its treatment affect women differently. Much data is emerging regarding the role that mood and anxiety disorders play in the development and prognosis of cardiovascular disease. Pharmacologic treatment of psychiatric disorders can also have direct cardiac effects. The good news is that many more studies are exploring this. However, further research is clearly needed, especially in the area of reproductive hormones and their impact on cardiac disease.

Gender differences in post-infarction hypertrophy in end-stage failing hearts

OBJECTIVES

We explored whether there are gender differences in cardiac remodeling and whether etiology influences organ and cellular remodeling in advanced heart failure (HF).

BACKGROUND

Several studies have shown a survival benefit for women compared to men with symptomatic HF. This observation may be related to gender differences in cardiac remodeling.

METHODS

We studied hearts from 100 patients (72 men and 28 women) receiving cardiac transplantation at our institution. Cardiac morphology was assessed with echocardiography and direct measurement of cardiac mass. Cardiac myocyte volume, length, width, cross-sectional area, and contraction were measured using previously validated techniques.

RESULTS

Among 50 patients with idiopathic cardiomyopathy (CM), we observed no gender-based differences in cardiac or cellular remodeling. In contrast, among 50 patients with ischemic cardiomyopathy (ICM), the heart weight index was significantly greater in men, and there was a strong trend toward an increased left ventricular (LV) mass index as well. These gender differences in cardiac and LV mass were paralleled by marked gender differences in myocyte volume, such that average myocyte volume was 36% greater in men than in women, in association with a 14% increase in resting cell length.

CONCLUSIONS

Our studies demonstrate a multilevel gender difference in post-infarction remodeling, with women exhibiting reduced hypertrophy. Our studies further demonstrate that gender differences in cardiac remodeling in ICM are largely related to fundamental differences in cellular remodeling rather than simply differences in infarct size or expansion. Distinctions observed between ischemic and idiopathic CM suggest that gender may influence local myocardial responses to injury.

Gender differences in the management and survival of patients with acute myocardial infarction

Coronary heart disease (CHD) and specifically acute myocardial infarction (AMI) are the most common causes of death among both men and women throughout the world. Although CHD mortality rates have been halved in many developed countries in recent decades, some studies have pointed out significant differences regarding time-related tendencies of mortality between the sexes. This paper briefly reviews factors related to post-AMI survival and possible reasons for inequalities in survival benefit between men and women after AMI. Presentation of AMI also exhibits differences with regard to sex, and this has some effect on patient care and on mortality from the disease. CHD morbidity and mortality rates vary with socioeconomic deprivation and social patterning in most industrialized countries. Several studies have indicated that women sustaining AMI have a higher mortality than men. Although AMI affects men in greater numbers, the short-term outcomes for women are worse. Studies suggest that, over the longer term, the mortality risk for women is lower than, or similar to, that for men. It is still a major problem that in-hospital case fatality and morbidity rates in the post-infarction period are higher for women, despite lower rates of administration of thrombolytics and catheterization. Patients admitted to the hospital with an AMI should be offered optimal treatment, irrespective of age or sex.

Dissociation of hospitalization and mortality trends for myocardial infarction in the United States from 1988 to 1997

PURPOSE

Although age-adjusted mortality from myocardial infarction in the United States has declined during the past few decades, changes in the incidence of myocardial infarction are less certain. To address this issue, we evaluated trends in hospitalization for, and in-hospital mortality from, myocardial infarction from 1988 to 1997.

METHODS

Hospitalization rates were determined by age and sex using data from the National Hospital Discharge Survey and the Current Population Survey. Comorbid conditions, complications, use of cardiac procedures, and in-hospital mortality were measured. In-hospital mortality was estimated after adjusting for associated risk factors, complications, use of invasive diagnostic and therapeutic procedures, and length of stay.

RESULTS

Age-adjusted rates of hospitalization for myocardial infarction were 525 per 100,000 in 1988 and 482 per 100,000 in 1997, with a mean annual decline of 0.8% (P = 0.32). Mortality declined from 58 per 100,000 in 1988 to 40 per 100,000 in 1997, a mean annual decline of 4.2% (P = 0.01). During these 10 years, although the median hospital stay for myocardial infarction decreased from 8 to 5 days, the intensity of hospital care increased, including use of angiography from 20% to 31% (P = 0.04) and revascularization from 16% to 31% (P = 0.004). Age-adjusted in-hospital mortality decreased by nearly half, from 7.6% in 1988 to 3.9% in 1997 (P = 0.006).

CONCLUSION

During the past decade, the decline in mortality from myocardial infarction in the United States has not been accompanied by a decline in hospitalization rate. At the same time, there has been a marked increased in the use of cardiac revascularization.

Biology or bias: practice patterns and long-term outcomes for men and women with acute myocardial infarction

OBJECTIVES

The goal of our study was to examine how age and gender affect the use of coronary angiography and the intensity of cardiac follow-up care within the first year after acute myocardial infarction (AMI). Another objective was to evaluate the association of age, gender and treatment intensity with five-year survival after AMI.

BACKGROUND

Utilization rates of specialized cardiac services inversely correlate with age. Gender-specific practice patterns may also vary with age in a manner similar to known age-gender survival differences after AMI.

METHODS

Using linked population-based administrative data, we examined the association of age and gender with treatment intensity and long-term survival among 25,697 patients hospitalized with AMI in Ontario between April 1, 1992, and December 31, 1993. A Cox proportional hazards model was used to adjust for socioeconomic status, illness severity, attending physician specialty and admitting hospital characteristics.

RESULTS

After adjusting for baseline differences, the relative rates of angiography and follow-up specialist care for women relative to men, respectively, fell 17.5% (95% confidence interval [CI], 13.6 to 21.3, p < 0.001) and 10.2% (95% CI, 7.1 to 13.2, p < 0.001) for every 10-year increase in age. Conversely, long-term AMI survival rates in women relative to men improved with increasing age, such that the relative survival in women rose 14.2% (95% CI, 10.1 to 17.5, p < 0.001) for every 10-year age increase.

CONCLUSIONS

Gender differences in the intensity of invasive testing and follow-up care are strongly age-specific. While care becomes progressively less aggressive among older women relative to men, survival advantages track in the opposite direction, with older women clearly favored. These findings suggest that biology is likely to remain the main determinant of long-term survival after AMI for women.

Cardiovascular drug utilization and its determinants in unselected medical patients with ischemic heart disease

Background: In patients with ischemic heart disease (IHD), secondary preventive drug therapy improves overall prognosis. Therefore, this study evaluated cardiovascular drug utilization in patients suffering from IHD, identified factors influencing drug utilization, and determined the prevalence of shortfalls of antithrombotic, beta-blocker, and lipid-lowering drug use. Methods: This study is based on data recorded prospectively between 1996 and 1998 in two Swiss teaching hospitals for the SAS/CHDM pharmacoepidemiologic database project. Drug utilization was evaluated in all 987 monitored medical inpatients with IHD. Results: At discharge, only 64% of patients with IHD received platelet aggregation inhibitors, 42% beta-blockers, and 26% lipid-lowering drugs. Secondary preventive drugs were more frequently administered to patients with acute myocardial infarction and less frequently in the elderly. After including other co-factors, no gender difference could be detected. Shortfalls of antithrombotic therapy occurred in 6.5--8.3% of patients and shortfalls in beta-blocker use in 9.9--23.3%. Only about half of all patients with IHD and elevated cholesterol received lipid-lowering drugs. Conclusions: Drugs for secondary prevention are prescribed to the majority of patients with IHD. However, their use could be further increased, especially in the elderly and in patients with IHD who are admitted to the hospital for reasons other than acute myocardial infarction. Lipid-lowering drugs should also be prescribed more often for patients with hypercholesterolemia.

Psychosocial characteristics after acute myocardial infarction: the ENRICHD pilot study. Enhancing Recovery in Coronary Heart Disease

PURPOSE

Psychosocial factors, such as emotional distress and social isolation, have been increasingly recognized as important risk factors for patients' recovery from acute myocardial infarction (AMI). This study examined age, gender, and ethnic differences in depression and general distress, social support, and health-related quality of life after AMI.

METHODS

Data came from a series of 88 patients aged 62.1 +/- 14.2 years (46% female) who were hospitalized for AMI at eight different US clinical centers participating in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Pilot Study. Standardized psychometric measures were administered to assess three psychosocial domains: (1) depression and general distress (mental health functioning), (2) social support, and (3) health-related quality of life. Multivariate analysis of variance was used to examine the effects of age, gender, and ethnic differences in each of the three psychosocial domains.

RESULTS

Female patients reported higher levels of depression and distress compared with male patients (P = .040). Gender differences in mental health functioning differed by age (P = .046), with the greatest differences observed among younger female patients. Older patients (P = .014) and female patients (P = .025) reported lower levels of social support compared with younger and male patients, respectively. Minority patients did not differ from nonminority patients in mental health functioning or social support, and there were no significant differences in post-AMI quality of life on the basis of age, gender, or ethnicity.

CONCLUSIONS

The psychosocial risk profile after AMI may be different for male and female patients, and interventions may need to take account of each gender's specific needs.

Excess mortality in women with hospital-acquired bloodstream infection

PURPOSE

We examined the outcomes of bloodstream infection in men and in women and whether any sex-related differences were explained by underlying disorders, severity of disease, or clinical management.

SUBJECTS AND METHODS

Using a prospectively collected database, we compared in-hospital mortality in men and women. We used multivariable logistic regression analysis to test whether sex-related differences could be due to potential confounders.

RESULTS

Of 4250 patients with bloodstream infections, 1750 (41%) had hospital-acquired infections. The overall case fatality was 31% (625 of 2032) in women and 29% (631 of 2218, P = 0.1) in men. However, 43% (325/758) of the women with hospital-acquired infections died, compared with 33% (327/992) of the men (P = 0.0001). In a multivariate analysis, female sex was associated with greater mortality in patients with hospital-acquired infections (odds ratio = 1.7; 95% confidence interval: 1.1 to 2.6). The excess mortality in women was mainly seen in patients with major underlying disorders (fatality rate of 45% [234 of 525] in women vs. 32% in men [234 of 743, P = 0.0001).

CONCLUSIONS

Mortality in women with hospital-acquired bloodstream infections is substantially greater than in men. The excess mortality was concentrated in women with severe underlying disorders, suggesting that sepsis might have accentuated differences in the outcome of underlying disorders in women.

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

STUDY OBJECTIVE

The objective of this study was to analyse whether the risk of death within 28 days and three years after a first Q wave myocardial infarction was higher in hospitalised women than in men.

DESIGN

Follow up study.

PATIENTS AND SETTING

All consecutive first Q wave myocardial infarction patients aged 25 to 74 years (447 women and 2322 men) admitted to a tertiary hospital in Gerona, Spain, from 1978 to 1997 were registered and followed up for three years.

MAIN RESULTS

Women were older, presented more comorbidity and developed more severe myocardial infarctions than men. A significant interaction was found between sex and age. Women aged 65-74 had higher early mortality risk than men of the same age (OR 1.62; 95% CI 1.01, 2.66) after adjusting for age, comorbidity and acute complications including heart failure. Women under 65 tended to be at lower risk of early mortality than men (0.45 (95% CI 0.19, 1.04). Three year mortality of 28 day survivors did not differ between sexes.

CONCLUSIONS

These data support the idea that the higher 28 day mortality in hospitalised women with a first Q wave myocardial infarction is mainly attributable to the large number of patients aged 65 to 74 years in whom the risk is higher than that in men. Women under 65 with myocardial infarction do not seem to be a special group of risk.

Gender and psychosomatic aspects of ischemic heart disease

While women and their doctors have traditionally worried about mortality from breast and gynecological malignancies, over the past 5 years they have come to realize that ischemic cardiac disease (IHD) is the number one killer of women in most Western countries. This has led to public and professional education campaigns and a new emphasis on gender and gender-specific research in IHD. Unfortunately, this literature remains poorly developed and much work remains to be done. Even in samples in which there may be sufficient numbers to allow for the evaluation of gender and gender differences, these important analyses have often been overlooked. This article provides a review of what is known about gender and gender differences in psychosocial and behavioral issues in IHD.

Death and readmission in the year after hospital admission with cardiovascular disease: the Hunter Area Heart and Stroke Register

OBJECTIVES

To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke.

DESIGN

Cohort study.

SETTING

Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales.

PATIENTS

4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year.

MAIN OUTCOME MEASURES

Death from any cause or emergency hospital readmission for cardiovascular disease.

RESULTS

In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission.

CONCLUSIONS

Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

Coronary heart disease: sexual bias in referral for coronary angiogram. How does it work in a state-run health system?

This study examined the effects of a state-run health system on the gender-specific differences in cardiology worldwide, taking coronary angiography as an example. In a prospective study, 476 angiographed patients (155 female, 321 male) were enrolled in consecutive order over a study period of 9 months and asked to answer a standardized questionnaire. The responses showed a discrepancy in the heart death statistics (52.7% female, 47.3% male) and the demographic statistics (51.8% female, 48.2% male). This was true for all age groups. The duration of complaints before undergoing a coronary angiogram was reported to be acute for 4.5% of the women and 13.7% of the men, <1 year for 27.1% of the women and 34% of the men, and >1 year for 68.4% of the women and 52.3% of the men. Women take longer to access coronary angiogram. This is confirmed by New York Heart Association (NYHA) classes I (1.9% female, 7.8% male), II (46.5% female, 65.4% male), III (41.9% female, 21.8% male), and IV (9.7% female, 5.0% male). Prior to angiogram, all of the women and most of the men (98.4%) were under treatment for heart complaints, more women (87.1%) than men (78.8%) took heart medication, but fewer women (29.7%) than men (37.1%) had been referred to a cardiologist. Major differences were seen in the social situation; that is, 68.4% of the women but 93.5% of the men lived with their family, 30.3% of the women but only 5% of the men lived alone, and 1.3% of the women together with 1.6% of the men lived in a care-giving facility. The results of our study show that even in a state-run health system with free access to high-tech medicine at no charge and no age limits, there is a marked gender bias in access to high-tech medicine.

Sex differences in the clinical care and outcomes of congestive heart failure in the elderly

BACKGROUND

There is evidence for sex differences in treatment and outcome of ischemic heart disease. However, little and conflicting data exist about sex differences in the care and outcome of elderly patients with heart failure.

METHODS

We compared mortality rate, readmission, and use of selected treatments and procedures between women and men in a database of 2445 patients (1426 women) aged >/=65 admitted for heart failure to 18 Connecticut hospitals in 1994 and 1995. Demographic and clinical data were abstracted from the medical records.

RESULTS

Women were older and more likely to have a history of hypertension whereas men more often had previous coronary heart disease. Women had more preserved left ventricular systolic function and higher systolic blood pressure on presentation than men. Treatments on day 1 (aspirin, angiotensin-converting enzyme [ACE] inhibitors, and diuretics), procedures during admission (assessment of left ventricular function, coronary angiography, and revascularization), and use of ACE inhibitors among ideal candidates at discharge were similar in men and women. Six-month rehospitalization rates were also similar. Although 30-day mortality rate did not differ between men and women, 6-month and 1-year mortality rates were lower in women after age adjustment (relative risk for 6-month death 0.81, 95% confidence interval, 0.68-0.95). In multivariable analysis, sex differences in mortality rate were reduced (relative risk 0.90, 95% confidence intervals, 0.75-1.08). History of hypertension, systolic blood pressure on admission, and left ventricular function mostly explained the observed sex differences in mortality rate.

CONCLUSIONS

Female and male patients hospitalized for heart failure have a similar hospital course, treatment pattern, and readmission rates, but women live longer than men. When baseline differences are accounted for, the mortality risk of women and men becomes very similar.

Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants

BACKGROUND

There is conflicting information about whether short-term mortality after myocardial infarction is higher among women than among men after adjustment for age and other prognostic factors. We hypothesized that younger, but not older, women have higher mortality rates during hospitalization than their male peers.

METHODS

We analyzed data on 384,878 patients (155,565 women and 229,313 men) who were 30 to 89 years of age and who had been enrolled in the National Registry of Myocardial Infarction 2 between June 1994 and January 1998. Patients who had been transferred from or to other hospitals were excluded.

RESULTS

The overall mortality rate during hospitalization was 16.7 percent among the women and 11.5 percent among the men. Sex-based differences in the rates varied according to age. Among patients less than 50 years of age, the mortality rate for the women was more than twice that for the men. The difference in the rates decreased with increasing age and was no longer significant after the age of 74 (P< 0.001 for the interaction between sex and age). Logistic-regression analysis showed that the odds of death were 11.1 percent greater for women than for men with every five-year decrease in age (95 percent confidence interval, 10.1 to 12.1 percent). Differences in medical history, the clinical severity of the infarction, and early management accounted for only about one third of the difference in the risk. After adjustment for these factors, women still had a higher risk of death for every five years of decreasing age (increase in the odds of death, 7.0 percent; 95 percent confidence interval, 5.9 to 8.1 percent).

CONCLUSIONS

After myocardial infarction, younger women, but not older women, have higher rates of death during hospitalization than men of the same age. The younger the age of the patients, the higher the risk of death among women relative to men. Younger women with myocardial infarction represent a high-risk group deserving of special study.