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Sex differences in risk factors, treatment and mortality after acute myocardial infarction: an observational study
B Hanratty1, D A Lawlor, M B Robinson
1Department of Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB. B.hanratty@liverpool.ac.uk
Insights
Women experience worse short-term outcomes after acute myocardial infarction (AMI). Under-treatment with aspirin and thrombolysis may contribute to poorer prognosis, highlighting the need for optimal care regardless of sex.
Area of Science:
- Cardiology
- Public Health
- Sex Differences in Medicine
Background:
- Coronary heart disease is a leading cause of death in postmenopausal women.
- Acute myocardial infarction (AMI) has worse short-term outcomes for women, despite affecting men in greater numbers.
- Previous studies on long-term outcomes and sex differences in AMI have varied in follow-up length and adjustment for confounders, with treatment associations underexamined.
Purpose of the Study:
- To investigate sex differences in risk factors, hospital treatment, and mortality following acute myocardial infarction (AMI).
- To examine the impact of treatment disparities on outcomes after AMI in men and women.
Main Methods:
- Prospective observational study in Yorkshire, England, collecting demographic and clinical data.
- Inclusion of 3684 patients with suspected AMI admitted between September and November 1995.
- Primary outcome measures included in-hospital mortality and mortality at two-year follow-up.
Main Results:
- Confirmed AMI in 2196 patients (850 women, 1303 men); women were older and had fewer traditional risk factors.
- Higher crude in-hospital mortality for women (30% vs. 19%), persisting after adjustment for age and risk factors (aOR 1.29).
- Women received less thrombolysis, aspirin, and were less likely to be discharged with beta-blockers or undergo revascularization procedures; age adjustment reduced treatment disparities.
Conclusions:
- Women have a worse prognosis after AMI, potentially due to under-treatment with aspirin and thrombolysis.
- Optimal treatment should be offered to all patients with AMI, irrespective of age or sex.
- Addressing treatment disparities is crucial for improving outcomes in women following acute myocardial infarction.
Background:
Coronary heart disease is the major cause of death of postmenopausal women in industrialised countries. Although acute myocardial infarction (AMI) affects men in greater numbers, the short-term outcomes for women are worse. In the longer term, studies suggest that mortality risk for women is lower or similar to that of men. However, length of follow up and adjustment for confounding factors have varied and more importantly, the association between treatment and outcomes has not been examined.
Study Objective:
To investigate the association between sex differences in risk factors and hospital treatment and mortality after AMI.
Design:
A prospective observational study collecting demographic and clinical data on cases of AMI admitted to hospitals in Yorkshire. The main outcome measures were mortality status at discharge from hospital and two years later.
Setting:
All district and university hospitals accepting emergency admissions in the former Yorkshire National Health Service (NHS) region of northern England.
Participants:
3684 consecutive patients with a possible diagnosis of AMI admitted to hospitals in Yorkshire between 1 September and 30 November 1995.
Main Results:
AMI was confirmed by the attending consultant for 2196 admissions (2153 people, 850 women and 1303 men). Women were older and less likely than men to be smokers or have a history of ischaemic heart disease. Crude inhospital mortality was higher for women (30% versus 19% for men, crude odds ratio of death before discharge for women 1.78, 95% confidence intervals 1.46, 2.18, p=0.00). This difference persisted after adjustment for age, risk factors and comorbidities (adjusted OR 1.29, 95% CI 1.04, 1.63, p=0.02), but was not significant when treatment was taken into account. Women were less likely to be given thrombolysis (37% versus 46%, p<0.01) and aspirin (83% versus 90%, p<0.01), discharged with beta blockers (33% versus 47%, p<0.01) and aspirin (82% versus 88% p<0.01) or be scheduled for angiography, exercise testing or revascularisation. Adjustment for age removed much of the disparity in treatment. Crude mortality rate at two years was higher for women (OR 1.81, 95%CI 1.41, 2.31, p=0.00). Age, existing risk factors and acute treatment accounted for most of this difference, with treatment on discharge having little additional influence.
Conclusions:
Patients admitted to hospital with AMI should be offered optimal treatment irrespective of age or sex. Women have a worse prognosis after AMI and under-treatment of older people with aspirin and thrombolysis may be contributing to this.