Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002

The UK National Health Service: delivering equitable treatment across the spectrum of coronary disease

BACKGROUND

Social gradients in cardiovascular mortality across the United Kingdom may reflect differences in incidence, disease severity, or treatment. It is unknown whether a universal healthcare system delivers equitable lifesaving medical therapy for coronary heart disease. We therefore examined secular trends in the use of key medical therapies stratified by socioeconomic circumstances across a broad spectrum of coronary disease presentations, including acute coronary syndromes, secondary prevention, and clinical angina.

METHODS AND RESULTS

This was a cross-sectional observational analysis of nationally representative primary and secondary care data from the United Kingdom. Data on treatments for all myocardial infarction patients in 2003 and 2007 were derived from the Myocardial Ischemia National Audit Project (n=51 755). Data on treatments for patients with chronic angina (n=33 211) or requiring secondary prevention (n=32 976) in 1999 and 2007 were extracted from the General Practice Research Database. Socioeconomic circumstances were defined using a weighted composite of 7 area-level deprivation domains. Treatment estimates were age-standardized. Use of all therapies increased in all patient groups, both men and women. Improvements were most marked in primary care, where use of β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for secondary prevention and treatment of angina doubled, from ≈30% to >60%. Small age gradients persisted for some therapies. No consistent socioeconomic gradients or sex differences were observed for myocardial infarction and postrevascularization (hard diagnoses). However, some sex inequality was apparent in the treatment of younger women with angina.

CONCLUSIONS

Cardiovascular treatment is generally equitable and independent of socioeconomic circumstances. Future strategies should aim to further increase overall treatment levels and to eradicate remaining age and sex inequalities.

Racial disparities in stress test utilization in an emergency department chest pain unit

BACKGROUND

Epidemiological studies have demonstrated racial disparities in the workup of emergency department patients with chest pain and the referral of admitted patients for intervention. However, little is known about possible disparities in stress test utilization in low-risk chest pain patients admitted to emergency department chest pain units.

METHODS

A retrospective observational study of consecutive chest pain unit patients was conducted. Eligibility criteria included age >18 years, American Heart Association low-to-intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Patients aged >75 years with a history of coronary artery heart disease were excluded. On each patient, we calculated a Thrombolysis in Myocardial Infarction (TIMI) risk prediction score and a Diamond and Forrester (D&F) score for likelihood of coronary artery disease. Two separate multivariate analyses were completed, one including the TIMI score and the other including D&F score, using logistic regression to estimate odds ratios (ORs) for receiving testing based on race, controlling for other relevant covariates.

RESULTS

Two thousand four hundred fifty-one patients were enrolled over a planned 1.5-year period. In total, 59.7% [95% confidence interval (CI) 57.8-61.7] of patients were white, 11.6% (95% CI 10.4-12.9) African American, and 28.6% (95% CI 26.9-30.4) "other." The overall stress testing rate was 50.3% (95% CI 48.4-52.3). After controlling for insurance and TIMI or D&F scores, African American patients had significantly decreased odds of stress testing (OR(TIMI) 0.68, 95% CI 0.52-0.89; OR(D&F) 0.67, 95% CI 0.51-0.89).

CONCLUSIONS

Our study confirms racial disparities in the utilization of stress testing in the chest pain unit. Further investigation is needed to identify specific provider or patient-level factors that may contribute to this disparity.

Ethnic variations in unplanned readmissions and excess length of hospital stay: a nationwide record-linked cohort study

Background: Studies in the USA have shown ethnic inequalities in quality of hospital care, but in Europe, this has never been analysed. We explored variations in indicators of quality of hospital care by ethnicity in the Netherlands. Methods: We analysed unplanned readmissions and excess length of stay (LOS) across ethnic groups in a large population of hospitalized patients over an 11-year period by linking information from the national hospital discharge register, the Dutch population register and socio-economic data. Data were analysed with stepwise logistic regression. Results: Ethnic differences were most pronounced in older patients: all non-Western ethnic groups > 45 years had an increased risk for excess LOS compared with ethnic Dutch patients, with odds ratios (ORs) (adjusted for case mix) varying from 1.05 [95% confidence intervals (95% CI) 1.02–1.08] for other non-Western patients to 1.14 (95% CI 1.07–1.22) for Moroccan patients. The risk for unplanned readmission in patients >45 years was increased for Turkish (OR 1.24, 95% CI 1.18–1.30) and Surinamese patients (OR 1.11, 95% CI 1.07–1.16). These differences were explained partially, although not substantially, by differences in socio-economic status. Conclusion: We found significant ethnic variations in unplanned readmissions and excess LOS. These differences may be interpretable as shortcomings in the quality of hospital care delivered to ethnic minority patients, but exclusion of alternative explanations (such as differences in patient- and community-level factors, which are outside hospitals’ control) requires further research. To quantify potential ethnic inequities in hospital care in Europe, we need empirical prospective cohort studies with solid quality outcomes such as adverse event rates.

Temporal trends in medical therapies for ST- and non-ST elevation myocardial infarction: (from the Atherosclerosis Risk in Communities [ARIC] Surveillance Study)

Reports from large studies using administrative data sets and event registries have characterized recent temporal trends and treatment patterns for acute myocardial infarction. However, few were population based, and fewer examined differences in patterns of treatment for patients presenting with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). The aim of this study was to examine 22-year trends in the use of 10 medical therapies and procedures by STEMI and NSTEMI classification in 30,986 definite or probable myocardial infarctions in the Atherosclerosis Risk in Communities (ARIC) Community Surveillance Study from 1987 to 2008. Weighted multivariate Poisson regression, controlling for gender, race and center classification, age, and Predicting Risk of Death in Cardiac Disease Tool score, was used to estimate average annual percentage changes in medical therapy use. From 1987 to 2008, 6,106 hospitalized events (19.7%) were classified as STEMIs and 20,302 (65.5%) as NSTEMIs. Among patients with STEMIs, increases were noted in the use of angiotensin-converting enzyme inhibitors (6.4%, 95% confidence interval [CI] 5.7 to 7.2), antiplatelet agents other than aspirin (5.0%, 95% CI 4.0% to 6.0%), lipid-lowering medications (4.5%, 95% CI 3.1% to 5.8%), β blockers (2.7%, 95% CI 2.4% to 3.0%), aspirin (1.2%, 95% CI 1.0% to 1.3%), and heparin (0.8%, 95% CI 0.4% to 1.3%). Among patients with NSTEMIs, the use of angiotensin-converting enzyme inhibitors (5.5%, 95% CI 5.0% to 6.1%), antiplatelet agents other than aspirin (3.7%, 95% CI 2.7% to 4.7%), lipid-lowering medications (3.0%, 95% CI% 1.9 to 4.1%), β blockers (4.2%, 95% CI 3.9% to 4.4%), aspirin (1.9%, 95% CI 1.6% to 2.1%), and heparin (1.7%, 95% CI 1.3% to 2.1%) increased. Among patients with STEMIs, decreases in the use of thrombolytic agents (-7.2%, 95% CI -7.9% to -6.6%) and coronary artery bypass grafting (-2.4%, 95% CI -3.6% to -1.2%) were observed. Similar increases in percutaneous coronary intervention and decreases in the use of thrombolytic agents and coronary artery bypass grafting were noted among all patients. In conclusion, trends of increasing use of evidence-based therapies were found for patients with STEMIs and those with NSTEMIs over the past 22 years.

Racial/ethnic disparity trends in children's mental health care access and expenditures from 2002 to 2007

OBJECTIVE

To examine trends in disparities in children's mental health care.

DATA

2002-2007 Medical Expenditure Panel Survey.

STUDY DESIGN

We used the Institute of Medicine (IOM) definition of health care disparities and estimated two-part expenditure models to examine disparity trends in any mental health care use, any outpatient care, and psychotropic drug use, as well as expenditures in these three categories, conditional on use. We used 2-year longitudinal panel data to determine disparities in care initiation among children with unmet need.

PRINCIPAL FINDINGS

Assessing trends over time between 2002 and 2007, we identified that disparities persist for blacks and Latinos in receipt of any mental health care, any outpatient care, and any psychotropic drug use. Among those with positive mental health care expenditures, Latino-white disparities in overall mental health care expenditures increased over time. Among children with unmet need, significant disparities in initiation of an episode of mental health care were found, with whites approximately twice as likely as blacks and Latinos to initiate care.

CONCLUSIONS

Disparities in children's mental health care use are persistent and driven by disparities in initiation, suggesting policies to improve detection or increase initial access to care may be critical to reducing disparities.

California hospitals serving large minority populations were more likely than others to employ ambulance diversion

It is well documented that racial and ethnic minority populations disproportionately use hospital emergency departments for safety-net care. But what is not known is whether emergency department crowding is disproportionately affecting minority populations and potentially aggravating existing health care disparities, including poorer outcomes for minorities. We examined ambulance diversion, a proxy measure for crowding, at 202 California hospitals. We found that hospitals serving large minority populations were more likely to divert ambulances than were hospitals with a lower proportion of minorities, even when controlling for hospital ownership, emergency department capacity, and other hospital demographic and structural factors. These findings suggest that establishing more-uniform criteria to regulate diversion may help reduce disparities in access to emergency care.

A gender perspective on short- and long term mortality in ST-elevation myocardial infarction--a report from the SWEDEHEART register

BACKGROUND

Previous studies of patients admitted for ST-elevation myocardial infarction [STEMI] have indicated that women have a higher risk of early mortality than do men. These studies have presented limited information on gender related differences in the short term and almost no information on the long term.

METHODS AND RESULTS

We analysed a prospective, consecutively included STEMI population consisting of 54,146 patients (35% women). This population consists of almost all patients hospitalised in Sweden between January 1, 1995 and December 31, 2006 as recorded in the SWEDEHEART register (formerly RIKS-HIA). Follow-up time ranged from one to 13 years (mean 4.6). Women had a lower probability of being given reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79-0.88). During the time these STEMI patients were in the hospital, 13% of the women and 7% of men died, multivariable adjusted OR 1.21 (95% CI 1.11-1.32). During the follow up period, 46% of the women died as compared with 32% of the men. There was, however, no gender difference in age-adjusted risk of long term mortality (hazard ratio [HR] 0.98, 95% CI 0.95-1.01) whereas the multivariable adjusted risk was lower in women (HR 0.92, 95% CI 0.89-0.96). The long term risk of re-infarction was the same in men and women (HR 0.98, 95% CI 0.93-1.03) whereas men in the youngest group had a higher risk than women in that age group (HR 0.82, 95% CI 0.72-0.94).

CONCLUSION

In STEMI, women had a higher risk of in-hospital mortality but the long-term risk of death was higher in men. More studies are needed in the primary percutaneous coronary intervention (pPCI) era that are designed to determine why women fare worse than men after STEMI during the first phase when they are in hospital.

Younger women have a higher risk of in-hospital mortality due to acute myocardial infarction in Chile

INTRODUCTION AND OBJECTIVES

Coronary heart disease is the second cause of death in Chilean women, with higher mortality among women, especially at younger ages. The objective was to analyze in-hospital case-fatality by sex and age in patients with acute myocardial infarction in Chile and to evaluate associated factors.

METHODS

From the nationwide hospital admissions database and the GEMI registry (a multicenter registry), we selected all cases of acute myocardial infarction (code: I.21) that occurred between 2001 and 2007 in Chile. We estimated odds ratios for in-hospital case-fatality in women by age (crude and adjusted for clinical characteristics and treatment).

RESULTS

In total, 49,287 cases of acute myocardial infarction were hospitalized, 31.3% of them women; 9278 patients were incorporated in the GEMI registry (27.1% women). In-hospital case-fatality was higher (P<.001) in women than men (national database, 20.4% vs 11.3%; GEMI, 14.2% vs 7.3%, irrespective of age. In-hospital case-fatality risk was higher in women aged<45 years: national odds ratio=2.3 (95% confidence interval, 1.5-3.3) and GEMI, odds ratio=2.7 (1.1-6.8). The estimated risk was lower in women aged 75 or more years in both databases, 1.3 (1.2-2.4) and 1.5 (1.2-1.9), respectively. Younger women less often received statins, odds ratio=0.7 (0.6-0.8); acetylsalicylic acid, odds ratio=0.4 (0.2-0.6); betablockers, odds ratio=0.8 (0.6-0.9), and thrombolytics, odds ratio=0.6 (0.5-0.8). An interaction was found between Killip class and sex. After adjusting for covariates, women aged<55 years with ST-segment elevation myocardial infarction and Killip class I-II, had the highest risk, odds ratio=4.3 (2.1-8.9).

CONCLUSIONS

In the context of a Latin American country, women aged<55 years with ST-segment elevation myocardial infarction and Killip class I-II had a higher risk of death. Known risk factors do not completely explain this excess of risk.

Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction

BACKGROUND

Young patients (aged≤45 years) presenting with ST-segment elevation myocardial infarction present unique challenges. The quality of care and in-hospital outcomes may differ from their older counterparts.

METHODS

A total of 31,544 patients presenting with ST-segment elevation myocardial infarction and enrolled in the American Heart Association's Get With the Guidelines Coronary Artery Disease registry were analyzed. The cohort was divided into those aged 45 years or less and those aged more than 45 years.

RESULTS

Young patients accounted for 10.3% of all ST-segment elevation myocardial infarction cases. Compared with older patients, younger patients were less likely to have traditional cardiovascular risk factors and had similar or better quality/performance measures with lower in-hospital mortality (unadjusted rate 1.6 vs 6.5%, P<.0001; adjusted odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29-0.46). Time trend analysis (2002-2008) suggested an increase over time in the "all or none" composite performance measure in both the younger and older patients (68%-97% and 69%-96%, respectively). However, there was significantly lower quality of care and worse outcomes in women (vs men) and in the very young (≤35 vs 36-45 years). Significant interaction was seen between age and gender for in-hospital death, such that the gender difference was greater in the younger cohort. Similar interaction was seen for door-to-thrombolytic time such that the gender delay was greater in the younger cohort (women:men ratio of means=1.73, 95% CI, 1.21-2.45 [younger] vs 1.08, 95% CI, 1.00-1.18 [older]; P(interaction)=.0031).

CONCLUSION

Young patients aged 45 years or less presenting with ST-segment elevation myocardial infarction overall had similar quality of care and in-hospital outcomes as older counterparts. However, quality of care was significantly lower and mortality was higher in young women (vs young men) and the very young (≤35 vs 36-45 years).

Gender differences in pre-hospital time delay and symptom presentation in patients suspected of acute coronary syndrome in primary care

OBJECTIVE

To describe gender differences in pre-hospital delay times and symptom presentation in patients suspected of acute coronary syndrome (ACS) in a primary care setting.

METHODS

Over 150 participating GPs included 298 consecutive patients suspected of ACS (52% female, mean age 66 years, 22% eventually diagnosed with ACS according to international guidelines) in a 28-month time period. Data on time from call for help until GP consultation (doctor delay) were prospectively collected, while the time from onset of symptoms until call for help (patient delay) was recorded by the GP at the time of arrival at the patient, together with patient characteristics, including age, sex, previous medical history, chest pain, radiation of chest pain and nausea/sweating.

RESULTS

Median doctor delay was 45 [interquartile range (IQR) 20-55] minutes in women and 33 (IQR 26-72) minutes in men (P = 0.01). Median patient delay was 108 (IQR 39-348) minutes in women and 180 (IQR 48-396) minutes in men (P = 0.20). Women reported spreading chest pain more often than men (68% versus 57%, P = 0.06). Women diagnosed with ACS were older than men (mean 75 years versus 65 years, P < 0.001).

CONCLUSIONS

In patients suspected of ACS in primary care, no differences were found in patient delay, but doctor delay was longer in women than in men. Symptom presentation was largely similar between men and women, although women tended to report 'spreading' chest pain more often.

GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: From bench to beyond-Premature Acute Coronary SYndrome)

BACKGROUND

Previous research has not adequately addressed the topic of sex and gender differences in occurrence of premature acute coronary syndrome (ACS). This study will investigate the clinical presentation, prognosis, and health care use in young men and women with ACS.

METHODS

We have set up a prospective, multicenter study of 1,576 patients aged 18-55 years and admitted to hospital with ACS. At baseline, questionnaires will be administered, and anthropometric and biological measurements will be performed. The patients will be observed for at least 1 year, with additional questionnaires being administered at 1, 6, and 12 months post-discharge. A review of medical records will be performed both at baseline and during follow-up.

CONCLUSIONS

This study will provide important evidence on the roles that a wide range of behavioral, environmental, and biological factors play in premature ACS and will help determine to what extent these roles depend on the individual's sex and gender. Ultimately, the knowledge derived from this study may facilitate accurate diagnosis and effective prevention and management of ACS in young women and men.

Sex differences in management and mortality of patients with ST-elevation myocardial infarction (from the Korean Acute Myocardial Infarction National Registry)

There has been controversy over the disparity between men and women with regard to the management and prognosis of acute myocardial infarction. Analyzing nationwide multicenter prospective registries in Korea, the aim of this study was to determine whether female gender independently imposes a risk for mortality. Data from 14,253 patients who were hospitalized for ST-segment elevation myocardial infarction from November 2005 to September 2010 were extracted from registries. Compared to men, women were older (mean age 56 ± 12 vs 67 ± 10 years, p < 0.001), and female gender was associated with a higher frequency of co-morbidities, including hypertension, diabetes, and dyslipidemia. Women had longer pain-to-door time and more severe hemodynamic status than men. All-cause mortality rates were 13.6% in women and 7.0% in men at 1 year after the index admission (hazard ratio for women 2.01, 95% confidence interval 1.80 to 2.25, p < 0.001). The risk for death after ST-segment elevation myocardial infarction corresponded highly with age. Although the risk remained high after adjusting for age, further analyses adjusting for medical history, clinical performance, and hemodynamic status diminished the gender effect (hazard ratio 1.00, 95% confidence interval 0.86 to 1.17, p = 0.821). Propensity score matching, as a sensitivity analysis, corroborated the results. In conclusion, this study shows that women have a comparable risk for death after ST-segment elevation myocardial infarction as men. The gender effect was accounted for mostly by the women's older age, complex co-morbidities, and severe hemodynamic conditions at presentation.

Eliminating untimely deaths of women from heart disease: highlights from the Minnesota Women's Heart Summit

Despite national campaigns to increase awareness and reduce cardiovascular disease (CVD) mortality in women, CVD remains their leading cause of death, annually killing more women than men. Although some progress has been made in our understanding and treatment of CVD in women, the causes, extent, and demographic trends of observed sex differences and disparities remain uncertain, and the growing burden of CVD and its risk factors among younger women is concerning. The Minnesota Women's Heart Summit was convened to chart a course to eliminate premature deaths of women from heart disease. The multidisciplinary summit was hosted by the Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, University of Minnesota, and Mayo Clinic. Presentations highlighted sex-based differences in symptoms, treatment, and outcomes, and panel experts provided commentary. Invited faculty and summit participants worked in small-group sessions to identify strategies to dissolve barriers, improve primary and secondary prevention, and enhance women's care and outcomes. This report summarizes strategies identified during the conference to serve as springboards for more substantive future initiatives. These include, for example, standardized data collection and use of existing data sets to inform perspectives on sex-related cardiovascular issues, mandatory reporting of sex-specific data, and increased attention to underserved/high-risk women. Participants acknowledged that implementing these ideas would be challenging and recommended key priorities/next action steps such as providing services close to "point-of-life" rather than "point-of-care" and creation of policies and regulations so that resources and environmental modifications encouraging healthier lifestyle choices are promoted. Additional research is needed to improve identification, treatment, and health behaviors and to address continued lack of awareness, symptom recognition delays, barriers to care, and outcome disparities-especially in diverse populations.

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

Short women with severe sepsis-related acute lung injury receive lung protective ventilation less frequently: an observational cohort study

Introduction

Lung protective ventilation (LPV) has been shown to improve survival and the duration of mechanical ventilation in acute lung injury (ALI) patients. Mortality of ALI may vary by gender, which could result from treatment variability. Whether gender is associated with the use of LPV is not known.

Methods

A total of 421 severe sepsis-related ALI subjects in the Consortium to Evaluate Lung Edema Genetics from seven teaching hospitals between 2002 and 2008 were included in our study. We evaluated patients' tidal volume, plateau pressure and arterial pH to determine whether patients received LPV during the first two days after developing ALI. The odds ratio of receiving LPV was estimated by a logistic regression model with robust and cluster options.

Results

Women had similar characteristics as men with the exception of lower height and higher illness severity, as measured by Acute Physiology and Chronic Health Evaluation (APACHE) II score. 225 (53%) of the subjects received LPV during the first two days after ALI onset; women received LPV less frequently than men (46% versus 59%, P < 0.001). However, after adjustment for height and severity of illness (APACHE II), there was no difference in exposure to LPV between men and women (P = 0.262).

Conclusions

Short people are less likely to receive LPV, which seems to explain the tendency of clinicians to adhere to LPV less strictly in women. Strategies to standardize application of LPV, independent of differences in height and severity of illness, are necessary.

Disparities by race, ethnicity, and sex in treating acute coronary syndromes

BACKGROUND

Disparities in the management of coronary artery disease were consistently documented in blacks and women in the 1980s and 1990s. Our objective was to determine if racial/ethnic and sex differences in the use of coronary revascularization persist in a more recent cohort.

METHODS

We examined all 20,604 Medicare beneficiaries admitted for acute coronary syndrome in 2001 from a random sample of 750,000 enrollees that was oversampled for black and Hispanic subjects to assess any cardiac revascularization.

RESULTS

After controlling for demographics and comorbidities, black men and women (odds ratios [OR] 0.47, 0.40), Hispanic men and women (ORs 0.61, 0.52), and white women (OR 0.67) had lower rates of revascularization compared with white men. Lower revascularization rates persisted for white women (OR 0.67) and black men and women (OR 0.55 and 0.54), controlling for income status and geographic variation, but were no longer present in the Hispanic population.

CONCLUSION

The mechanisms by which disparities operate may differ for Hispanic and black populations.

Racial and ethnic disparities in the quality of diabetes care in a nationally representative sample

INTRODUCTION

Previous studies have consistently documented that racial/ethnic minority patients with diabetes receive lower quality of care, based on various measures of quality of care and care settings. However, 2 recent studies that used data from Medicare or Veterans Administration beneficiaries have shown improvements in racial/ethnic disparities in the quality of diabetes care. These inconsistencies suggest that additional investigation is needed to provide new information about the relationship between racial/ethnic minority patients and the quality of diabetes care.

METHODS

We analyzed 3 years of data (2005-2007) from the Medical Expenditure Panel Survey and used multivariate models that adjusted for sociodemographic characteristics, regional location, insurance status, health behaviors, health status, and comorbidity to examine racial/ethnic disparities in the quality of diabetes care.

RESULTS

We found that Asian patients with diabetes were less likely to have received 2 or more glycated hemoglobin (HbA1c) tests or a foot examination during the past year compared with their white counterparts. Hispanic patients with diabetes were also less likely to have received a foot examination during the past year compared with white patients with diabetes. Conversely, black patients with diabetes were more likely to have received a foot examination during the past year compared with white patients with diabetes. The differences in the quality of diabetes care remained significant even after controlling for socioeconomic status (SES), health insurance status, self-rated health status, comorbid conditions, and lifestyle behavior variables.

CONCLUSION

Although the link between racial/ethnic minority status and the quality of care for patients with diabetes is not completely understood, our results suggest that factors such as SES, health insurance status, self-rated health status, and other health conditions are potential antecedents of quality of diabetes care.

Gender differences in presentation, management, and in-hospital outcomes for patients with AMI in a lower-middle income country: evidence from Egypt

BACKGROUND

Many studies in high-income countries have investigated gender differences in the care and outcomes of patients hospitalized with acute myocardial infarction (AMI). However, little evidence exists on gender differences among patients with AMI in lower-middle-income countries, where the proportion deaths stemming from cardiovascular disease is projected to increase dramatically. This study examines gender differences in patients in the lower-middle-income country of Egypt to determine if female patients with AMI have a different presentation, management, or outcome compared with men.

METHODS AND FINDINGS

Using registry data collected over 18 months from 5 Egyptian hospitals, we considered 1204 patients (253 females, 951 males) with a confirmed diagnosis of AMI. We examined gender differences in initial presentation, clinical management, and in-hospital outcomes using t-tests and χ(2) tests. Additionally, we explored gender differences in in-hospital death using multivariate logistic regression to adjust for age and other differences in initial presentation. We found that women were older than men, had higher BMI, and were more likely to have hypertension, diabetes mellitus, dyslipidemia, heart failure, and atrial fibrillation. Women were less likely to receive aspirin upon admission (p<0.01) or aspirin or statins at discharge (p = 0.001 and p<0.05, respectively), although the magnitude of these differences was small. While unadjusted in-hospital mortality was significantly higher for women (OR: 2.10; 95% CI: 1.54 to 2.87), this difference did not persist in the fully adjusted model (OR: 1.18; 95% CI: 0.55 to 2.55).

CONCLUSIONS

We found that female patients had a different profile than men at the time of presentation. Clinical management of men and women with AMI was similar, though there are small but significant differences in some areas. These gender differences did not translate into differences in in-hospital outcome, but highlight differences in quality of care and represent important opportunities for improvement.

Ethnic differences in cardiovascular risks and mortality in atherothrombotic disease: insights from the Reduction of Atherothrombosis for Continued Health (REACH) registry

OBJECTIVE

To determine whether ethnic-specific differences in the prevalence of cardiovascular risk factors and outcomes exist worldwide among individuals with stable arterial disease.

PATIENTS AND METHODS

From December 1, 2003, to June 30, 2004, the prospective, observational REduction of Atherothrombosis for Continued Health (REACH) Registry enrolled 49,602 out-patients with coronary artery disease, cerebrovascular disease, and/or peripheral arterial disease from 7 predefined ethnic/racial groups: white, Hispanic, East Asian, South Asian, Other Asian, black, and Other (comprising any race distinct from those specified). The baseline demographic and risk factor profiles, medication use, and 2-year cardiovascular outcomes were assessed among these groups.

RESULTS

The prevalence of traditional atherothrombotic risk factors varied significantly among the ethnic/racial groups. The use of medical therapies to reduce risk was comparable among all groups. At 2-year follow-up, the rate of cardiovascular death was significantly higher in blacks (6.1%) compared with all other ethnic/racial groups (3.9%; P=.01). Cardiovascular death rates were significantly lower in all 3 Asian ethnic/racial groups (overall, 2.1%) compared with the other groups (4.5%; P<.001).

CONCLUSION

The REACH Registry, a large international study of individuals with atherothrombotic disease, documents the important ethnic-specific differences in cardiovascular risk factors and variations in cardiovascular mortality that currently exist worldwide.

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.

Women and heart disease: knowledge, worry, and motivation

BACKGROUND

Heart disease remains the number one killer of women. Epidemiologic data show a persisting failure to raise the perception of heart disease risk in women despite massive campaigning efforts. We sought to describe the psychosocial barriers preventing women from recognizing this risk and actively preventing heart disease.

METHODS

We obtained access to data from the 534 participants of a random sampling of U.S. women from a commercial telephone survey commissioned by a nonprofit advocacy organization, the Society for Women's Health Research, in 2007. The survey was designed to test women's general knowledge of cardiac risk factors. We grouped the questions into five psychosocial/knowledge categories: worry, motivation, personal cardiovascular risk awareness, general cardiac knowledge, and general cholesterol knowledge. Univariate and multivariate modeling of the relationships of these psychosocial/knowledge categories-along with five baseline demographic variables, age, ethnicity, income, education, and geographic location-to the motivation score were performed.

RESULTS

Univariate modeling revealed that higher motivation scores were associated with greater personal risk factor knowledge/awareness and more worry about cardiovascular disease (CVD) (R(2)=0.43, 95% confidence interval [CI] 0.35-0.50 for both scores). Younger age, Asian ethnicity, and lower education levels were associated with less motivation to modify their cardiovascular risk factors (p<0.05). Multivariate modeling revealed a persistent significant relationship of motivation to worry, personal cardiovascular risk awareness, age <45 years, and nonblack, non-Hispanic ethnic minority (p<0.001).

CONCLUSIONS

Worried and knowledgeable women over the age of 45 are motivated to modify their risk factors. Heart health education targeting the subgroups of less motivated women may be of benefit to raise awareness of heart disease.

Sex-based disparities in liver transplant rates in the United States

We sought to characterize sex-based differences in access to deceased donor liver transplantation. Scientific Registry of Transplant Recipients data were used to analyze n = 78 998 adult candidates listed before (8/1997-2/2002) or after (2/2002-2/2007) implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation. The primary outcome was deceased donor liver transplantation. Cox regression was used to estimate covariate-adjusted differences in transplant rates by sex. Females represented 38% of listed patients in the pre-MELD era and 35% in the MELD era. Females had significantly lower covariate-adjusted transplant rates in the pre-MELD era (by 9%; p < 0.0001) and in the MELD era (by 14%; p < 0.0001). In the MELD era, the disparity in transplant rate for females increased as waiting list mortality risk increased, particularly for MELD scores ≥15. Substantial geographic variation in sex-based differences in transplant rates was observed. Some areas of the United States had more than a 30% lower covariate-adjusted transplant rate for females compared to males in the MELD era. In conclusion, the disparity in liver transplant rates between females and males has increased in the MELD era. It is especially troubling that the disparity is magnified among patients with high MELD scores and in certain regions of the United States.

Ethnicity and thrombolysis in ischemic stroke: a hospital based study in Amsterdam

Background

Ethnic differences have been reported with regard to several medical therapies. The aim of this study was to investigate the relation between ethnicity and thrombolysis in stroke patients.

Methods

Retrospective single-centre study. Patients admitted with an ischemic stroke between 2003 and 2008 were included. Ethnicity was determined by self-identification and stratified into white and non-white (all other ethnicities). The main outcome measure was the difference in thrombolysis rate between white and non-white patients. Logistic regression analysis was used to identify potential confounders of the relation between ethnicity and thrombolysis.

Results

510 patients were included, 392 (77%) white and 118 (23%) non-white. Non-white patients were younger (median 69 vs. 60 years, p < 0.001), had a higher blood pressure at admission (median systolic 150 vs. 160 mmHg, p = 0.02) and a lower stroke severity (median NIHSS 5 vs. 4, p = 0.04). Non-white patients were significantly less often treated with thrombolysis compared to white patients (odds ratio 0.34, 95% CI 0.17-0.71), which was partly explained by a later arrival at the hospital. After adjustment for potential confounders (late arrival, age, blood pressure above upper limit for thrombolysis, and oral anticoagulation use), a trend towards a lower thrombolysis rate in non-whites remained (adjusted odds ratio 0.38, 95% CI 0.13 to 1.16).

Conclusions

Non-white stroke patients less often received thrombolysis than white patients, partly as a result of a delay in presentation. In this single centre study, potential bias due to hospital differences or insurance status could be ruled out as a cause. The magnitude of the difference is worrisome and requires further investigation. Modifiable causes, such as patient delay, awareness of stroke symptoms, language barriers and treatment of cardiovascular risk factors, should be addressed specifically in these ethnic groups in future stroke campaigns.

Effect of gender on treatment and outcomes in severe aortic stenosis

The aim of this study was to evaluate the effect of gender on operative rates and outcomes in men and women with severe aortic stenosis. An institutional echocardiographic database was used to identify all adult patients with severe aortic stenosis from 2004 through 2005. Only patients with class I indication for aortic valve replacement (AVR) during the period of follow-up were included in the study. Three hundred sixty-two patients were identified with severe aortic stenosis and class I indication for AVR (52% women). Overall operative rate for the cohort was 72%. In patients who underwent AVR, Kaplan-Meier survival rates were the same for men and women. Sixty-four percent of women versus 81% of men underwent AVR (p <0.001). After adjusting for multiple covariates, women had a 2.1-fold lower odds of undergoing AVR compared to men (p = 0.02). After matching for age and Society of Thoracic Surgery risk score, women underwent AVR at a 19% lower relative rate compared to men (p = 0.03); when stratified by gender, there was no difference in reasons for not undergoing AVR. In conclusion, despite similar outcomes after surgery, women with severe aortic stenosis are less likely than men to undergo AVR.

Trends in postacute myocardial infarction management and mortality in patients with diabetes. A population-based study from 1995 to 2001

OBJECTIVE

To compare trends in coronary revascularization use and case fatality rate (CFR) following acute myocardial infarction in patients with and without diabetes.

METHODS

A retrospective study of 77,552 patients, 20 years of age or older (25% with diabetes), who were hospitalized for a first acute myocardial infarction in the province of Quebec between April 1995 and December 2001 was conducted. Administrative databases were used to identify patients and assess outcomes.

RESULTS

Compared with patients without diabetes, patients with diabetes underwent more coronary artery bypass graft (CABG) surgeries (11.1% versus 8.3%; P<0.0001) but fewer percutaneous coronary interventions (17.1% versus 20.2%; P<0.0001). The use of percutaneous coronary intervention increased substantially over time in both populations, driven mainly by an increase during the index admission (20.6% versus 16.6% per year; P=0.1144 in patients with and without diabetes, respectively). The use of CABG during the index admission increased markedly among patients with diabetes compared with those without (10.3% versus 5.3% per year; P=0.0072); however, at one-year following discharge, CABG use remained stable in patients with diabetes and fell in those without (-0.7% versus -5.3% per year; P=0.2046). Concomitantly, patients with diabetes presented a similar decline in CFR compared with patients without diabetes. The decline was more pronounced during the index admission (-5.0% versus -4.1% per year; P=0.282) than at one-year following discharge (-2.5% versus -2.5% per year; P=0.629) in patients with and without diabetes, respectively. However, fatal outcome remained higher in patients with diabetes than without, with an adjusted RR of 1.21 (95% CI 1.18 to 1.24) at one-year follow-up.

CONCLUSION

Overall, coronary revascularization use and CFR improved over time in patients with diabetes. Nevertheless, the mortality rate in patients with diabetes remains higher than in patients without diabetes, indicating that additional progress is required to improve the poorer prognosis in this population.

The implications of using adjusted versus unadjusted methods to measure health care disparities at the practice level

Reducing disparities in care requires that health care providers identify populations at risk for suboptimal quality of care. Stratified analyses are often used to examine disparities (eg, by race or sex). However, stratified analyses can be misleading if the variables are confounded. The authors examined disparities in quality within a large ambulatory care practice using both unadjusted and adjusted methods for 18 measures. In unadjusted analyses, differences in quality were identified for 9 measures by race. However, in analyses adjusted simultaneously for race, sex, age, socioeconomic status, and chronic medical conditions, racial differences were apparent for only 4 measures. Women received lower quality care for 4 measures in both unadjusted and adjusted analyses. The pattern of observed disparities can differ significantly based on whether unadjusted or adjusted methods are applied. Health care organizations should consider the routine use of adjusted methods to measure disparities in order to better inform disparity reduction initiatives.

Another treatment gap: restarting secondary prevention medications: the Women's Health Initiative

BACKGROUND

Women's long-term patterns of evidence-based preventive medication utilization following a coronary heart disease (CHD) diagnosis have not been sufficiently studied.

METHODS

Postmenopausal women 50-79 years were eligible for randomization in the Women's Health Initiative's (WHI) hormone trials if they met inclusion and exclusion criteria and were >80% adherent during a placebo-lead-in period and in the dietary modification trial if they were willing to follow a 20% fat diet. Those with adjudicated myocardial infarction or coronary revascularization after the baseline visit were included in the analysis (n=2627). Baseline visits occurred between 1993 and 1998, then annually until the trials ended in 2002 through 2005; medication inventories were obtained at baseline and years 1, 3, 6 and 9.

RESULTS

Utilization at the first WHI visit following a CHD diagnosis increased over time for statins (49% to 72%; p<0.0001), beta-blockers (49% to 62%; p=0.003), and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers (ACEI/ARBs ) [26 to 43%; p<0.0001]. Aspirin use remained stable at 76% (p=0.09). Once women reported using a statin, aspirin, or beta-blocker, 84-89% reported use at 1 or more subsequent visits, with slightly lower rates for ACEI/ARBS (76%). Statin, aspirin, beta-blocker, or ACEI/ARB use was reported at 2 or more consecutive visits by 57%, 66%, 48%, and 28% respectively. These drugs were initiated or resumed at a later visit by 24%, 17%, 15%, and 17%, respectively, and were never used during the period of follow-up by 19%, 10%, 33%, and 49% respectively.

CONCLUSIONS

Efforts to improve secondary prevention medication utilization should target both drug initiation and restarting drugs in patients who have discontinued them.

Persistent racial disparities in survival after heart transplantation

BACKGROUND

Racial and ethnic disparities are well documented in many areas of health care, but have not been comprehensively evaluated among recipients of heart transplants.

METHODS AND RESULTS

We performed a retrospective cohort study of 39075 adult primary heart transplant recipients from 1987 to 2009 using national data from the United Network of Organ Sharing and compared mortality for nonwhite and white patients using the Cox proportional hazards model. During the study period, 8082 nonwhite and 30 993 white patients underwent heart transplantation. Nonwhite heart transplant recipients increased over time, comprising nearly 30% of transplantations since 2005. Nonwhite recipients had a higher clinical risk profile than white recipients at the time of transplantation, but had significantly higher posttransplantation mortality even after adjustment for baseline risk. Among the nonwhite group, only black recipients had an increased risk of death compared with white recipients after multivariable adjustment for recipient, transplant, and socioeconomic factors (hazard ratio, 1.34; 95% confidence interval, 1.21 to 1.47; P<0.001). Five-year mortality was 35.7% (95% confidence interval, 35.2 to 38.3) among black and 26.5% (95% confidence interval, 26.0 to 27.0) among white recipients. Black patients were more likely to die of graft failure or a cardiovascular cause than white patients, but less likely to die of infection or malignancy. Although mortality decreased over time for all transplant recipients, the disparity in mortality between blacks and whites remained essentially unchanged.

CONCLUSIONS

Black heart transplant recipients have had persistently higher mortality than whites recipients over the past 2 decades, perhaps because of a higher rate of graft failure.

Clinical characteristics and outcomes of Japanese women undergoing coronary revascularization therapy

BACKGROUND

Limited data are available for gender-based differences in patients undergoing coronary revascularization. This study aimed to identify gender-based differences in risk factor profiles and outcomes among Japanese patients undergoing coronary revascularization.

METHODS AND RESULTS

The subjects consisted of 2,845 women and 6,843 men who underwent first percutaneous coronary intervention or coronary artery bypass grafting in 2000-2002. The outcome measures were all-cause death, major adverse cardiovascular events (MACE) as the composite of cardiovascular death, myocardial infarction and stroke, and any coronary revascularization. The females were older than the males and more frequently had histories of heart failure, diabetes, hypertension, chronic kidney disease, anemia, and dyslipidemia. Unadjusted survival analysis revealed a significantly lower incidence of any revascularization in women (at 3 years: 28.2% vs. 31.2%, P = 0.0037), although no significant gender-based differences were shown in the incidence of all-cause death (at 3 years: 8.8% vs. 8.5%, P = 0.37) or MACE (at 3 years: 12.0% vs. 11.5%, P = 0.61). Multivariate analysis revealed that female gender was associated with significantly lower risks of any revascularization (relative risk = 0.93, 95% confidence interval [CI] = 0.88-0.99, P = 0.014) and all-cause death (relative risk = 0.86, 95%CI = 0.77-0.96, P = 0.005).

CONCLUSIONS

In Japanese patients undergoing first coronary revascularization, the coronary risk factor burden appeared greater in women than in men. Despite the greater modifiable risk factor accumulation, female gender was associated with a lower incidence of repeated revascularization relative to male gender.

Recent US Patterns and Predictors of Prevalent Diabetes among Acute Myocardial Infarction Patients

Background. Diabetes mellitus (DM) confers high vascular risk and is a growing national epidemic. We assessed clinical characteristics and prevalence of diagnosed DM among patients hospitalized with acute myocardial infarction (AMI) in the US over the last decade. Methods. Data were obtained from all states within the US that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 2006 with a primary discharge diagnosis of AMI were included. Time trends in the proportion of these patients with DM diagnosis were computed. Results. The portion of patients with comorbid diabetes among AMI hospitalizations increased substantially from 18% in 1997 to 30% in 2006 (P < .0001). Absolute numbers of AMI hospitalizations in the US decreased 8% (from 729, 412 to 672, 243), while absolute numbers of AMI hospitalizations with coexisting DM rose 51% ((131, 189 to 198, 044), both (P < .0001). Women with AMI were significantly more likely to have DM than similarly aged men, but these differences diminished with increasing age. Conclusion. Although overall hospitalizations for AMI in the US diminished over the last decade, prevalence of diabetes rose substantially. This may have important consequences for the future societal vascular disease burden.

Racial and gender disparities in implantable cardioverter-defibrillator placement: are they due to overuse or underuse?

Previous studies documented racial and gender disparities in implantable cardioverter-defibrillator (ICD) placement. The authors examined whether racial and gender disparities in ICD placement are due to underutilization or overutilization. Among 1,054 adults hospitalized from 2001 to 2004 with ventricular arrhythmias in a large academic hospital, the study found that 17% of patients had clinical indicators concordant with ICD placement criteria. Among those, Blacks were less likely than Whites to receive an ICD (adjusted odds ratio [OR] = 0.24; 95% CI = 0.08-0.71). Among the 83% who were discordant with ICD placement criteria, Blacks (adjusted OR = 0.30; 95% CI = 0.18-0.52) and Hispanics (adjusted OR = 0.24, 95% CI = 0.10-0.57) were less likely than Whites, and women less likely than men, to receive an ICD (adjusted OR = 0.48; 95% CI = 0.34-0.67). In this cohort, these differences appear related to overutilization among men and Whites who are discordant with ICD placement criteria in addition to underutilization among Blacks concordant with placement criteria.

Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention

BACKGROUND

Despite the known benefits of cardiac rehabilitation in patients with coronary artery disease, referral rates to rehabilitation programs remain low. We determined the incidence and determinants of cardiac rehabilitation referral rates for patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

The incidence and predictors of referral to cardiac rehabilitation were assessed among 145,661 consecutive patients undergoing PCI and surviving to hospital discharge across 31 hospitals in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium between 2003 and 2008. The 6-year cardiac rehabilitation referral rate was 60.2%. Younger age, male gender, white race, and presentation with acute or severe disease (ie, acute myocardial infarction [AMI] in the previous 24 hours and ST-elevation myocardial infarction) were associated with increased referral to rehabilitation (all P < .0001). Most medical comorbidities were associated with decreased referral. Referral rates for cardiac rehabilitation were below the rates of other AMI quality-of-care indicators and more variable across hospital sites. Race-specific referral rates differed significantly in the lowest referring hospitals (P < .0001) but not in the highest referring hospitals (P = .16). Women had a 0.7% relative decrease in referral as compared to men (P = .0188) in the highest referring hospitals but a 26.7% relative decrease in referral in the lowest referring hospitals (P = .02).

CONCLUSIONS

Over one third of patients undergoing PCI are not referred for cardiac rehabilitation. Referral rates are below the rates of other AMI quality-of-care performance measures and more variable across sites. Racial and gender disparities in referral to rehabilitation exist but are concentrated at the lowest referring hospitals.

Racial disparities in survival after lung transplantation

CONTEXT

Racial disparities have not been comprehensively evaluated among recipients of lung transplantation.

OBJECTIVES

To describe the association between race and lung transplant survival and to determine whether racial disparities have changed in the modern (2001-2009) compared with the historical (1987-2000) transplant eras.

DESIGN, SETTING, AND PATIENTS

A retrospective cohort study of 16 875 adults who received primary lung transplants from October 16, 1987, to February 19, 2009, was conducted using data from the United Network of Organ Sharing.

MAIN OUTCOME MEASURES

We measured the risk of death after lung transplant for nonwhites compared with whites using time-to-event analysis.

RESULTS

During the study period, 14 858 white and 2017 nonwhite patients underwent a lung transplant; they differed significantly at baseline. The percentage of nonwhite transplant recipients increased from 8.8% (before 1996) to 15.0% (2005-2009). In the historical era, 5-year survival was lower for nonwhites than whites (40.9% vs 46.9%). Nonwhites were at an increased risk of death independent of age, health and socioeconomic status, diagnosis, geographic region, donor organ characteristics, and operative factors (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30). In subgroup analysis of the historical era, blacks had worsened 5-year survival compared with whites (39.0% vs 46.9%) and black women had worsened survival compared with white women (36.9% vs 48.9%). In the modern transplant era, survival improved for all patients. However, a greater improvement among nonwhites has eliminated the disparities in survival between the races (5-year survival, 52.5% vs 51.6%).

CONCLUSION

In contrast to the historical era, there was no significant difference in lung transplant survival in the modern era between whites and nonwhites.

Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics

Younger women use both internal medicine and obstetrics-gynecology (OBGYN) clinics as primary sources of health care. However, the role of OBGYN clinics in cardiovascular disease prevention is largely unexplored. The objective of this study was to examine rates of hypertension recognition in women<50 years of age who presented with elevated blood pressures in family practice and internal medicine (medicine) OBGYN clinics and to compare these rates across clinic type. The study's population consisted of 34 627 nonpregnant women ages 18 to 49 years with new-onset hypertension (defined as 2 consecutive visits with elevated blood pressures of systolic blood pressure≥140 mm Hg or diastolic blood pressure≥90 mm Hg with no previous hypertension history) from 2002 to 2006. Multivariate logistic regressions predicting the clinical recognition of hypertension (a recorded diagnosis of hypertension and/or an antihypertensive prescription by any provider within 1 year of the second elevated blood pressure) assessed the association between hypertension recognition and the clinic where the second elevated blood pressure was recorded. Analysis showed that hypertension was recognized in <33% of women with new-onset hypertension. Women whose second consecutive elevated blood pressure was recorded in OBGYN clinics were less likely to be recognized as having hypertension within 12 months by any provider compared with women whose second consecutive elevated blood pressure was recorded in a medicine clinic (odds ratio: 0.51 [95% CI: 0.48 to 0.54]). This study suggests that further attention be paid to identifying and treating cardiovascular disease risk factors in women<50 years of age presenting in both medicine and OBGYN clinics and that improved coordination across care settings has the potential to improve cardiovascular disease prevention in young women.

Gender differences in clinical presentation and management of patients with acute coronary syndrome in Southwest of Saudi Arabia

OBJECTIVE

Gender differences in the clinical presentation and management of patients with acute coronary syndrome (ACS) have been reported in different parts of the world with contradicting results. We aimed at investigating the presence of gender bias in patients admitted with ACS to Aseer Central Hospital (ACH).

METHODS

A retrospective cohort of all consecutive patients admitted to ACH with the diagnosis of ACS, during the period between the 1st of June 2007 and the 31st of May 2009 was studied. Data on demographic and clinical profiles, management and outcomes of ACS patients were collected and compared for both genders.

RESULTS

The present study included 148 females and 397 males. Females were significantly older than males (62.9 ± 14.2 vs. 60 ± 13.4, respectively, P < 0.03), were less likely ever to have smoked (0.7% vs. 26.2%, respectively, P < 0.001), less likely to have had a history of hyperlipidemia (10.8% vs. 22.2%, respectively, P < 0.003) or family history of ischemic heart disease (10.1% vs. 18.9%, respectively, P < 0.014). Female patients presented more with atypical presentation (42.6% vs. 28.9%, respectively, P < 0.003), more with unstable angina (72.3% vs. 50.4%, respectively, P < 0.001), and less with ST-elevation myocardial infarction (18.9% vs. 40.8%, respectively, P < 0.001). Furthermore, they had significantly lower levels of hemoglobin compared to males (12.9 ± 2.3 vs. 14.5 ± 2.2 g/L, respectively, P < 0.001), and higher levels of high density lipoprotein (1.1 ± 0.4 vs. 0.98 ± 0.4 mmol/L, respectively, P < 0.008). Left ventricular ejection fraction was significantly higher in female patients compared to males (50.9 ± 14 vs. 45.8 ± 14, respectively, P < 0.003). Coronary angiography showed a higher rate of normal findings (29.3% vs. 8.9%, respectively, P < 0.001) and less severe disease (46.7% vs. 60.3%, respectively, P < 0.027) in women, however, they were less likely to undergo invasive revascularization procedures (31% vs. 42.8%, respectively, P < 0.013). No significant differences were found between both sexes regarding in-hospital mortality or re-infarction rates.

CONCLUSION

We documented gender differences in both clinical presentation as well as management of patients admitted with ACS to ACH. However, there were no significant differences between both genders regarding the clinical in-hospital outcomes. Emphasis should be made to avoid such bias in the future.

The concentration of hospital care for black veterans in Veterans Affairs hospitals: implications for clinical outcomes

Where minorities receive their care may contribute to disparities in care, yet, the racial concentration of care in the Veterans Health Administration is largely unknown. We sought to better understand which Veterans Affairs (VA) hospitals treat Black veterans and whether location of care impacted disparities. We assessed differences in mortality rates between Black and White veterans across 150 VA hospitals for any of six conditions (acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal hemorrhage, and pneumonia) between 1996 and 2002. Just 9 out of 150 VA hospitals (6% of all VA hospitals) cared for nearly 30% of Black veterans, and 42 hospitals (28% of all VA hospitals) cared for more than 75% of Black veterans. While our findings show that overall mortality rates were comparable between minority-serving and non-minority-serving hospitals for four conditions, mortality rates were higher in minority-serving hospitals for acute myocardial infarction (AMI) and pneumonia. The ratio of mortality rates for Blacks compared with Whites was comparable across all VA hospitals. In contrast to the private sector, there is little variation in the degree of racial disparities in 30-day mortality across VA hospitals, although higher mortality among patients with AMI and pneumonia requires further investigation.