Causes of higher in-hospital mortality in women than in men after acute myocardial infarction

The SCORE risk model applied to recent population surveys in Norway compared to observed mortality in the general population

AIMS

To compare the predictions of the Systematic Coronary Risk Evaluation (SCORE) high- and low-risk functions applied to a recent population study with observed cardiovascular disease (CVD) mortality estimated from annual official mortality statistics in Norway.

METHODS

Data were obtained from large epidemiological surveys conducted in five Norwegian counties in 2000-2003.

RESULTS

A total of 32 251 men and women were investigated (aged 30-31, 40-41, 45-46, and 59-61). For men aged >or=59, more than 75% qualified for preventive treatment by having a 10-year risk >or=5%. Few women and practically no men younger than 46 years can be considered at high risk according to the SCORE risk prediction models. For men, the high-risk function overestimated and the low-risk model underestimated the CVD mortality as compared to the 10-year risks calculated from official mortality statistics (1999-2003). For women, however, both functions underestimated mortality in young individuals, whereas in the elderly an overestimation was observed.

CONCLUSIONS

The risk predictions depended strongly on age and gender. The SCORE high-risk function overestimates the risk of fatal CVD for men in Norway, and before implementation in clinical practice, proper adjustments to national levels are required.

Comparison of left ventricular function following first ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention in men versus women

Previous data reported worse outcomes in female patients after acute ST elevation myocardial infarction (STEMI), related at least in part to less aggressive and nonparallel treatment. We investigated the presence of gender differences in left ventricular (LV) systolic and diastolic function in patients presenting with first STEMI, treated with primary percutaneous coronary intervention (PCI). Study population included 187 consecutive patients (81% men) presenting with STEMI and treated by primary PCI and guideline-based medications. Their mean age was 58 ± 10 years. All patients underwent a comprehensive echocardiographic evaluation within 3 days of admission. Female patients were older (62 ± 11 vs 59 ± 10 years, p = 0.006), with more co-morbidities and longer symptom duration (490 ± 436 vs 365 ± 437 minutes, p = 0.013). Echocardiography demonstrated that female patients had significantly lower LV systolic function (47 ± 8% vs 45 ± 8%, p = 0.03), lower septal and lateral e' velocities, higher average E/e' ratio (all p <0.001), elevated systolic pulmonary artery pressure (p = 0.03), and worse diastolic dysfunction (p = 0.007). No significant changes were present in left atrial volumes. In a logistic multivariate analysis model, female gender emerged as an independent predictor of septal e' <8 cm/s (odds ratio 10.11, 95% confidence interval 1.23 to 82.32, p = 0.002) and E/average e' ratio >15 (odds ratio 6.47, 95% confidence interval 1.63 to 25.61, p = 0.008). In conclusion, female patients undergoing primary PCI for first STEMI demonstrated worse systolic and diastolic LV function, despite receiving similar treatment as male patients.

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Gender differences in mortality after acute myocardial infarction with mild to moderate heart failure

BACKGROUND

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.

AIM

To compare the prognosis of men and women with AMI and mild-moderate HF.

METHODS

We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.

RESULTS

Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.

CONCLUSIONS

Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Coronary revascularisation in women

Coronary heart disease is the leading cause of death in men and women worldwide. It is still considered a disease of men and there has been little recognition of its importance in women. Gender differences exist in acute and chronic ischaemia in terms of clinical manifestations, investigations and treatment. There are clear gender differences in coronary revascularisation with a higher mortality seen in women. At the time a woman presents with coronary artery disease she is older and has more co-morbid factors. Furthermore, women have smaller coronary arteries making them more difficult to revascularise. In recent years there has been a general trend towards improved outcomes in women undergoing both surgical and percutaneous coronary intervention. The increasing use of drug eluting stents and adjunctive medical treatment as well as the use of off-pump bypass surgery needs further evaluation in terms of gender differences. This article reviews the current literature on coronary revascularisation in women.

Factores asociados a la mortalidad intrahospitalaria del infarto de miocardio. Resultados de un estudio observacional

BACKGROUND AND OBJECTIVE

Myocardial infarction is one of the leading causes of death in Spain. This study assesses in-hospital mortality and associated factors.

PATIENTS AND METHOD

Mortality of episodes of initial attention of myocardial infarction attended in hospitals was analyzed using the 2001 Minimum Basic Group of Data corresponding to the Community of Madrid in relation with sociodemographic, hospitals, procedures, risk factors and comorbidities. Statistical descriptive techniques and logistic regression analyses were employed to analyze the data.

RESULTS

5,306 cases of myocardial infarction were studied. 71% were men and the mean age was 68 year. 73% were admitted in high technology hospitals, 49% received coronary angiography and 29% received a stent. Mortality rate was 10.8%. Multivariable analysis showed that increase in age, presence of arrhythmias, congestive heart failure, renal failure, cardiogenic shock and cerebrovascular disease were associated with in-hospital mortality, while admission in centers attending between 100 and 300 myocardial infarction cases, use of coronary angiography and stent, and previous history of arterial hypertension, smoking and high lipid levels, appeared to be protective factors.

CONCLUSIONS

Mortality estimated with an administrative data-base is similar than the mortality estimated in studies based on clinical data sets. Mortality is associated with several variables; although some of them have been previously reported, others need further investigations to confirm their relevance.

Influence of age on gender differences in the management of acute inferior or posterior myocardial infarction

STUDY OBJECTIVES

To assess the effect of gender on the in-hospital management of patients with acute inferior or posterior myocardial infarction (MI).

DESIGN

Retrospective analysis of clinical records. Gender differences in management and prognosis were assessed by stepwise multiple logistic regression analysis.

SETTING

University, large-volume, tertiary hospital.

PATIENTS

We studied 1,178 consecutive patients admitted to our coronary care unit with an acute inferior or posterior MI, and evaluated the influence of gender on clinical management and outcome.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Women were older (73 years vs 66 years), had a higher prevalence of diabetes and hypertension, presented later (8 h vs 6 h after symptom onset), and had a higher in-hospital mortality rate (26% vs 9%) [all p values < 0.01]. Women underwent reperfusion therapy (45% vs 61%, p < 0.01), noninvasive studies (30% vs 62%, p < 0.001), and coronary angiography (34% vs 48%, p < 0.01) less often than men. Multivariable analysis revealed that female gender was an independent predictor of a lower use of noninvasive studies (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.24 to 0.63; p < 0.005) and coronary angiography (OR, 0.59; 95% CI, 0.37 to 0.93; p = 0.02). A significant interaction between age and gender was found (p = 0.002); therefore, women > or = 75 years old had a much lower probability of undergoing noninvasive tests and coronary angiography than men of the same age.

CONCLUSION

Despite their worse prognosis, women undergo noninvasive studies and coronary angiography less frequently than men after an acute inferior or posterior MI. The gender gap increases in patients > or = 75 years old.

Ethnic variations in female vulnerability after an acute coronary event

OBJECTIVE

To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays.

DESIGN

Population based registry.

PATIENTS

Residents of Singapore between the ages of 20-64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project.

MAIN OUTCOME MEASURES

Adjusted 28 day case fatality and long term mortality.

RESULTS

From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51.5% v 38.6%, p < 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1.43 to 1.88) and 1.50 (95% CI 1.37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p = 0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age.

CONCLUSION

In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups.

Coronary heart disease: the female heart is vulnerable

During the past decade, an overall theme has emerged, validating the exploration of gender-based differences in coronary heart disease (CHD) as a basis for clinical strategies to improve outcomes for women. Underrepresentation of women in most of CHD and lack of gender-specific reporting in many clinical trials continue to limit the available knowledge and evidence-based medicine needed to devise optimal managements for women with CHD. Control of conventional coronary risk factors provides comparable cardioprotection for men and women. Current evidence fails to show cardiac protection from menopausal hormone therapy. Clinical presentations of coronary heart disease (CHD) and management strategies differ between the sexes. Underutilization of proven beneficial therapies is a contributor to less-favorable outcomes in women. The contemporary increased application of appropriate diagnostic, therapeutic, and interventional managements has favorably altered the prognosis for women, particularly when the data are adjusted for baseline characteristics. Better education of women during office visits, earlier and more aggressive control of coronary risk factors, and a greater index of suspicion regarding chest pain and its appropriate evaluation may help to reverse the trend of late referral and late intervention. Research indicates that behavioral changes on the part of women and reshaping of practice patterns by their health care providers may dramatically reduce the number of women disabled and killed by CHD each year.

Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B) Angioplasty Substudy

BACKGROUND

Direct angioplasty (PTCA) and thrombolytic therapy are the chief therapies for treating an ST-segment elevation myocardial infarction (MI).

OBJECTIVE

This study was designed to evaluate sex differences in the relative benefit of direct PTCA versus thrombolytic therapy among patients enrolled in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B PTCA) Substudy.

METHODS

Women and men presenting with an acute ST-segment elevation MI were randomized to receive either direct PTCA or accelerated tissue plasminogen activator (t-PA). Patients were then randomized to treatment with either heparin or bivalirudin. A gender analysis of outcome was performed.

RESULTS

Women were older than men (68.6 +/- 11.5 vs 59.5 +/- 12.0 years, P <.001) and were more likely to have diabetes (22.5% vs 13.5%, P <.0001) and hypertension (53.3% vs 34.8%, P =.001). After adjusting for differences in baseline variables, the odds ratio (OR) for reaching a 30-day clinical end point (death, nonfatal infarction, or nonfatal disabling stroke) was similar for women and men (1.35, 95% CI 0.88-2.08). The OR for reaching a clinical end point at 30 days for the PTCA-treated women compared with the t-PA-treated women was 0.685 (95% CI 0.36-1.32) and similar to the OR in men, 0.565 (95% CI 0.35-0.91), P for interaction =.535. Because women had a higher event rate than men, the absolute number of major events prevented when treating women with direct PTCA was higher than men (56 events/1000 women treated with PTCA vs 42 events per 1000 men treated with PTCA).

CONCLUSIONS

Although the relative benefit of direct PTCA to t-PA for the treatment of an acute MI appears to be similar in women and men, women may derive a larger absolute benefit from direct PTCA.

Gender differences in clinical status at time of coronary revascularisation in Spain

OBJECTIVE

To study gender differences in clinical status at the time of coronary revascularisation.

DESIGN

Retrospective study of clinical records. Two stage stratified cluster sampling was used to select a nationally representative sample of patients receiving a coronary revascularisation procedure in 1997.

SETTING

All of Spain.

MAIN OUTCOME MEASURES

Odds ratios (OR) in men and women for different clinical and diagnostic variables related with coronary disease. A logistic regression model was developed to estimate the association between coronary symptoms and gender.

RESULTS

In the univariate analysis the prevalence of the following risk factors for coronary heart disease was higher in women than in men: obesity (OR=1.8), hypertension (OR=2.9) and diabetes (OR=2.1). High surgical risk was also more prevalent among women (OR=2.6). In the logistic regression analysis women's risk of being symptomatic at the time of revascularisation was more than double that of men (OR=2.4).

CONCLUSIONS

Women have more severe coronary symptoms at the time of coronary revascularisation than do men. These results suggest that women receive revascularisation at a more advanced stage of coronary disease. Further research is needed to clarify what social, cultural or biological factors may be implicated in the gender differences observed.

Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry)

There is conflicting information about gender differences in presentation, treatment, and outcome after acute ST elevation myocardial infarction (STEMI) in the era of thrombolytic therapy and primary percutaneous coronary intervention. From June 1994 to January 1997, we enrolled 6,067 consecutive patients with STEMI admitted to 54 hospitals in southwest Germany in the Maximal Individual TheRapy of Acute myocardial infarction (MITRA), a community-based registry. Women were 9 years older than men, more often had hypertension, diabetes mellitus, and congestive heart failure, and had a history of previous myocardial infarction less often. Women had a longer prehospital delay (45 minutes), had anterior wall infarction more often (odds ratio [OR] 1.21; 95% confidence interval [CI] 1.08 to 1.36), and received reperfusion therapy less often (OR 0.83; 95% CI 0.74 to 0.94). The percentage of patients who were eligible for thrombolysis and received no reperfusion was higher in women (OR 1.7; 95% CI 1.56 to 1.89). Women had recurrent angina (OR 1.45; 95% CI 1.23 to 1.71) and congestive heart failure (OR 1.26; 95% CI 1.01 to 1.56) more often. There was a trend toward a higher hospital mortality in women (age-adjusted OR 1.16, 95% CI 0.99 to 1.35; multivariate OR 1.21, 95% CI 0.96 to 1.51), but there was no gender difference in long-term mortality after multivariate analysis (age-adjusted OR 0.95, 95% CI 0.78 to 1.15; multivariate OR 0.93, 95% CI 0.72 to 1.19). Thus, women with STEMI receive reperfusion therapy less often than men. They experience recurrent angina and congestive heart failure more often during their hospital stay. The age-adjusted long-term mortality is not different between men and women, but there is a trend for a higher short-term mortality in women.

Sex-based differences in early mortality of patients undergoing primary angioplasty for first acute myocardial infarction

BACKGROUND

Morbidity and mortality after an acute myocardial infarction (AMI) has been reported to be higher in women than men. However, in some prior reports, women were not treated as aggressively as men, suggesting a treatment bias. We sought to determine whether sex influenced short-term outcomes in a cohort of AMI patients, all of whom underwent primary angioplasty.

METHODS AND RESULTS

We conducted a retrospective cohort study of all patients undergoing primary angioplasty for a first AMI in New York State in 1995. A total of 1044 patients, 317 women and 727 men, were identified. Mean age was 59+/-12 years in men and 65+/-12 years in women (P<0.05). Women had a higher prevalence of hypertension (59% versus 44%, P<0.05), diabetes (19% versus 14%, P<0.05), and peripheral vascular or carotid disease (9.5% versus 5.5%, P<0.05) than men. Men were more likely to be treated earlier (within 6 hours) from the time of symptom onset than women (74% versus 63%, P<0.05). Women had a higher incidence of shock or hemodynamic instability than men (25% versus 17%, P<0.05). The unadjusted in-hospital mortality rate was 7.9% in women and 2.3% in men (P<0.05). After multivariate logistic regression analysis, women maintained a 2.3-fold higher risk of in-hospital death compared with their male counterparts (95% confidence interval [CI], 1.2 to 4.6, P=0.016).

CONCLUSIONS

After correcting for age and baseline risk differences, women undergoing primary angioplasty for AMI have a significantly higher in-hospital mortality rate than men.

Differences in thrombolytic treatment and in-hospital mortality between women and men after acute myocardial infarction

There is evidence for gender differences in the treatment and outcome of acute myocardial infarction (AMI). However, little data exist about these differences in patients from the Arab Middle East. Therefore, we studied the influence of patient gender on the presentation, the use of thrombolytic therapy, and in-hospital mortality after AMI in Kuwaiti nationals. This is a retrospective study of all consecutive Kuwaiti patients admitted to the coronary care unit of a university hospital with the diagnosis of AMI between June 1994 and May 1997. A total of 89 women and 267 men were included. Women were older than men and had significantly higher rates of diabetes (72% vs 46%), hypertension (58% vs 33%) and hypercholesterolemia (80% vs 53%). Women were less likely to receive thrombolytic therapy (40% vs 62%, p=0.001). Fewer women were eligible for thrombolytic therapy (50% vs 66%, p<0.05). Of those who were eligible for thrombolysis there was no sex difference in receiving such treatment. The in-hospital mortality among women younger than 70 years was 2.5 times higher than among men in the same age group, while there was no difference in mortality between women and men aged 70 years and older. We conclude that women and men with AMI have different clinical characteristics and outcomes following AMI. There was no gender bias for the use of thrombolytic therapy. The higher in-hospital mortality in younger women, i.e. less than 70 years, compared to younger men, indicates that younger women with AMI should be considered as a high-risk group.

Absence of gender differences in clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction. A report from the SHOCK Trial Registry

OBJECTIVES

The aim of this study was to assess the impact of gender on clinical course and in-hospital mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI).

BACKGROUND

Previous studies have demonstrated higher mortality for women compared with men with ST elevation myocardial infarctions and higher rates of CS after AMI. The influence of gender and its interaction with various treatment strategies on clinical outcomes once CS develops is unclear.

METHODS

Using the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) Registry database of 1,190 patients with suspected CS in the setting of AMI, we examined shock etiologies by gender. Among the 884 patients with predominant left ventricular (LV) failure, we compared the patient demographics, angiographic and hemodynamic findings, treatment approaches as well as the clinical outcomes of women versus men. This study had a 97% power to detect a 10% absolute difference in mortality by gender.

RESULTS

Left ventricular failure was the most frequent cause of CS for both gender groups. Women in the SHOCK Registry had a significantly higher incidence of mechanical complications including ventricular septal rupture and acute severe mitral regurgitation. Among patients with predominant LV failure, women were, on average, 4.6 years older, had a higher incidence of hypertension, diabetes and a lower cardiac index. The overall mortality rate for the entire cohort was high (61%). After adjustment for differences in patient demographics and treatment approaches, there was no significant difference in in-hospital mortality between the two gender groups (odds ratio = 1.03, 95% confidence interval of 0.73 to 1.43, p = 0.88). Mortality was also similar for women and men who were selected for revascularization (44% vs. 38%, p = 0.244).

CONCLUSIONS

Women with CS complicating AMI had more frequent adverse clinical characteristics and mechanical complications. Women derived the same benefit as men from revascularization, and gender was not independently associated with in-hospital mortality in the SHOCK Registry.

Mortalidade por diabetes mellitus e outras causas no município do Rio de Janeiro: diferenças por sexo e idade

Objetivo: O diabetes mellitus (DM) é considerado um problema de saúde pública em razão de sua alta prevalência e pelo fato de que a maioria dos seus portadores não está em tratamento adequado e, portanto, exposta ao risco de desenvolver altas taxas de morbidade e mortalidade. A análise dos registros contidos nas declarações de óbito é uma das formas de se avaliar o impacto desta síndrome na sociedade. Este estudo objetiva analisar comparativamente óbitos por DM e outras causas na população geral do Rio de Janeiro (RJ). Materiais, métodos e desenho da pesquisa: Os dados foram obtidos do banco de dados de Mortalidade da Secretaria Municipal de Saúde do RJ. Compararam-se os óbitos por DM como causa básica ocorridos no município do RJ nos anos de 1994, 1995 e 1996 com os óbitos ocorridos na população geral em relação aos critérios de sexo e grupo etário. Resultados: Até os 50 anos as mulheres com DM e aquelas sem DM apresentam mortalidade proporcional semelhante. Após os 50 anos, as mulheres com DM têm valores percentuais mais elevados do que as sem DM. Já entre os homens, os sem DM têm percentuais de mortalidade maiores até os 60 anos, quando então são ultrapassados pelos portadores de DM. Conclusão: No conjunto dos óbitos nos três anos entre os diabéticos, as mulheres apresentam percentual de mortalidade superior ao dos homens. Já entre as demais causas de óbitos nos três anos, o predomínio foi do sexo masculino. Portanto, sugerindo menor sobrevida das mulheres entre os diabéticos e dos homens entre as outras causas de óbitos.

Gender differences and temporal trends in clinical characteristics, stress test results and use of invasive procedures in patients undergoing evaluation for coronary artery disease

OBJECTIVES

This study examined gender differences and temporal changes in the clinical characteristics of patients referred for nuclear stress imaging, their imaging results and subsequent utilization of coronary angiography and revascularization.

BACKGROUND

Gender bias may influence resource utilization in patients with coronary artery disease (CAD). No study has analyzed gender differences and time trends in patients referred for noninvasive testing and subsequent use of invasive procedures.

METHODS

Between January 1986 and December 1995, 14,499 patients (5,910 women and 8,589 men) without established CAD underwent stress myocardial perfusion imaging. The clinical characteristics, imaging results, coronary angiograms and revascularization outcomes were compared in women and men over time.

RESULTS

The mean pretest probability of CAD was lower in women (45%) than in men (70%) (p < 0.001). More women (69%) than men (42%) had normal nuclear images (p < 0.001). Men (17%) were more likely than women (8%) to undergo coronary angiography (p < 0.001). Male gender was independently associated with referral for coronary angiography (multivariate model: chi-square = 16, p < 0.001) but was considerably weaker than the imaging variables (summed reversibility score: chi-square = 273, p < 0.001). Revascularization was performed in more men (46% of the population undergoing angiography) than women (39%) (p = 0.01), but gender was not independently associated with referral to revascularization. There were no significant differences in clinical, imaging or invasive variables between the genders over time.

CONCLUSIONS

There was little evidence for a bias against women in this study. Women were somewhat less likely to undergo coronary angiography but were referred for stress perfusion imaging more liberally. Practice patterns remained constant over this 10-year period.

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.

Myocardial infarction in men and women under 65 years of age: no evidence of gender bias

We examined short and long term outcomes of MI in a consecutive series of 169 men and 50 women who were followed for an average of 3.5 years. Similar percentages of men and women were admitted to medical intensive care, received in-patient cardiac rehabilitation, quit smoking at one year, were still smoking, were taking a lipid lowering drug or had returned to work at one year, underwent coronary angiography at 3.5 years or had died by 3.5 years. The lack of gender difference in outcome may reflect an absence of gender bias in the management of men and women with MI in southwest Scotland.

Do race and gender influence the use of invasive procedures?

OBJECTIVE

To assess the influence of race and gender influence on the use of invasive procedures in patients with acute myocardial infarction (AMI) in community hospitals.

DESIGN

Prospective, observational.

SETTING

Five mid-Michigan community hospitals.

PATIENTS

All patients (838) identified with AMI between January 1994 and April 1995 in 1 of these hospitals.

MEASUREMENTS AND MAIN RESULTS

After adjusting for age, hospital of admission, insurance type, severity of AMI, and comorbidity, using white men as the reference group, the rate of being offered cardiac catheterization (CC) was 0.88 (95% confidence interval [95% CI], 0.60 to 1.29) for white women; 0.79 (95% CI, 0.41 to 1.50) for black men; and 1.14 (95% CI, 0.53 to 2.45)for black women. Among patients who underwent CC, after also adjusting for coronary artery anatomy, the rate of being offered angioplasty, using white men as the reference group, was 1.22 (95% CI, 0.75 to 1.98) for white women; 0.61 (5% CI, 0.29 to 1.28, P =.192) for black men; and 0.40 (95% CI, 0.14 to 1.13) for black women The adjusted rate of being offered bypass surgery was 0.47 (95% CI, 0.24 to 0.89) for white women; 0.36 (95% CI, 0.12 to 1.06) for black men; and 0.37 (95% CI, 0.11 to 1.28)for black women.

CONCLUSIONS

Our study shows that white women are less likely than white men to be offered bypass surgery after AMI. Although black men and women with AMI are less likely than white men to be offered percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in both unadjusted and adjusted analyses, these findings did not reach statistical significance. Our study is limited in power due to the small number of blacks in the sample.

Characterization and clinical course of patients not receiving aspirin for acute myocardial infarction: results from the MITRA and MIR studies

BACKGROUND

Clinical trials have shown the efficacy of aspirin for acute myocardial infarction (AMI). However, not all patients receive aspirin for AMI. The aim of this study was to provide information on characteristics and clinical course of patients not treated with aspirin for AMI.

METHODS

We analyzed the data of the Myocardial Infarction Registry (MIR) and the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) registry. MITRA and MIR were prospective multicenter registries of patients with ST segment elevation myocardial infarction in Germany.

RESULTS

Of 22,572 patients registered from 1994 to 1998, 1767 (7.8%) did not receive aspirin within the first 48 hours after admission. Multivariate analysis revealed two main factors associated with withholding aspirin for AMI: relative contraindications to aspirin (gastric ulcer [odds ratio (OR) 4.9, 95% confidence interval (CI) 3.7-5.7], renal insufficiency [OR 1.4, 95% CI 1.1-1.8]), and critical clinical state at admission (cardiogenic shock [OR 1.5, 95% CI 1.2-2.1] and prehospital resuscitation [OR 1.8, 95% CI 1.4-2.2]). In addition, these patients were significantly less likely to receive reperfusion therapy and adjunctive medical therapy such as beta-blockers and angiotensin-converting enzyme inhibitors. In-hospital mortality after adjustment for baseline characteristics was 27.2% in patients without aspirin compared with 11.1% in patients treated with aspirin.

CONCLUSIONS

Only a minority of AMI patients (7.8%) did not receive aspirin. Relative contraindications to aspirin and a critical clinical state at admission were the main factors associated with withholding aspirin for AMI. Even after adjustment for patient characteristics, the mortality of patients without aspirin was almost three times higher.

Sex differences in risk factors, treatment and mortality after acute myocardial infarction: an observational study

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.

Heart disease in women

Women face a disparity in the evaluation and treatment of coronary artery disease, even though coronary artery disease is the leading cause of death for women in the United States. Primary care physicians play an important role in the identification and treatment of risk factors and comorbidities. It is their obligation to ensure that women receive equal and appropriate care, and to advocate for their patients.

Myocardial infarction in women: a critical appraisal of gender differences in outcomes

In every year since 1984, cardiovascular disease has claimed the lives of more women than men. Data from randomized trials indicate that gender contributes to increased mortality after myocardial infarction independent of other risk factors, but additional confounding variables cannot be discounted. Data from registry databases indicate that women are less likely to receive medically proven therapies for myocardial infarction. Women experience more vague symptoms, which may account for underuse of effective therapies. In addition, they may benefit less from thrombolytic therapy than men. Increased use of thrombolytic therapy has resulted in a continued decrease in cardiovascular deaths for men, but not for women. It is unclear if this disparity is a result of inequitable access to therapy or decreased efficacy of these agents in women.

Treatment of acute myocardial infarction and 30-day mortality among women and men

BACKGROUND

Previous studies have suggested that women with acute myocardial infarction receive less aggressive therapy than men. We used data from the Cooperative Cardiovascular Project to determine whether women and men who were ideal candidates for therapy after acute myocardial infarction were treated differently.

METHODS

Information was abstracted from the charts of 138,956 Medicare beneficiaries (49 percent of them women) who had an acute myocardial infarction in 1994 or 1995. Multivariate analysis was used to assess differences between women and men in the medications administered, the procedures used, the assignment of do-not-resuscitate status, and 30-day mortality.

RESULTS

Among ideal candidates for therapy, women in all age groups were less likely to undergo diagnostic catheterization than men. The difference was especially pronounced among older women; for a woman 85 years of age or older, the adjusted relative risk was 0.75 (95 percent confidence interval, 0.68 to 0.83). Women were somewhat less likely than men to receive thrombolytic therapy within 60 minutes (adjusted relative risk, 0.93; 95 percent confidence interval, 0.90 to 0.96) or to receive aspirin within 24 hours after arrival at the hospital (adjusted relative risk, 0.96; 95 percent confidence interval, 0.95 to 0.97), but they were equally likely to receive beta-blockers (adjusted relative risk, 0.99; 95 percent confidence interval, 0.95 to 1.03) and somewhat more likely to receive angiotensin-converting-enzyme inhibitors (adjusted relative risk, 1.05; 95 percent confidence interval, 1.02 to 1.08). Women were more likely than men to have a do-not-resuscitate order in their records (adjusted relative risk, 1.26; 95 percent confidence interval, 1.22 to 1.29). After adjustment, women and men had similar 30-day mortality rates (hazard ratio, 1.02; 95 percent confidence interval, 0.99 to 1.04).

CONCLUSIONS

As compared with men, women receive somewhat less aggressive treatment during the early management of acute myocardial infarction. However, many of these differences are small, and there is no apparent effect on early mortality.

Gender differences in the management and outcome of acute myocardial infarction in unselected patients in the thrombolytic era

This study compares the clinical features, management, and outcome in men and women from a consecutive, unselected series of patients with acute myocardial infarction (AMI) who were admitted to a university cardiac center over a 3-year period. It is a retrospective observational study of 1,059 admissions with AMI identified through the Hospital In-Patient Enquiry (HIPE) registry, validated according to Minnesota Manual criteria, and followed for a period of up to 5 years (median 36 months). Women comprised 40% of all admissions, had a higher hospital mortality (24% vs. 16%, p<0.001), and were less likely to receive thrombolysis (23% vs. 33%, p<0.01), admission to coronary care (65% vs. 77%, p<0.001), or subsequent invasive or noninvasive investigations (55% vs. 63%, p<0.01). However, women with AMI were older than men with AMI (71 vs. 65 years, p<0.001). After adjusting for age, differences that remained significant were prevalence of hypertension (odds ratio [OR] 2.12, 95% confidence intervals [CI] 1.56 to 2.88) and cigarette smoking (OR 0.47, 95% CI 0.35 to 0.65), management in coronary care (OR 0.66, 95% CI 0.49 to 0.88), and hospital mortality (OR 1.48, 95% CI 1.07 to 2.04). Excess mortality occurred predominantly in women <65 years old (18% vs. 8%, OR [multivariate] 2.35, 95% CI 1.19 to 4.56), among whom multivariate analysis demonstrated a significantly lower thrombolysis rate (OR 0.48, 95% CI 0.27 to 0.86). In this group, lack of thrombolysis independently predicted hospital mortality (OR 5.37, 95% CI 1.45 to 19.82). Female gender was not an independent predictor of mortality following AMI (OR 1.42, 95% CI 0.90 to 2.26). Thus, among unselected patients, female gender is associated with, but not an independent predictor of, reduced survival after AMI. Gender differences in mortality are greatest in younger patients, who are less likely to receive thrombolysis and in whom lack of thrombolysis is independently associated with mortality after AMI.

Short- and medium-term outcome differences in women and men after primary percutaneous transluminal mechanical revascularization for acute myocardial infarction

Women presenting with acute myocardial infarction (AMI) have a higher mortality with conventional medical and thrombolytic therapy when compared with men. The outcome after primary percutaneous transluminal mechanical revascularization has not yet been fully investigated. This study was performed to compare the characteristics and the short- and medium-term outcomes of women and men with AMI treated with primary percutaneous revascularization. A total of 182 consecutive patients (62 women and 120 men) were included. Baseline clinical characteristics were similar except that women were older than men, presented more often in cardiogenic shock, and had smaller reference vessel diameters. Stents and abciximab were used equally, but abciximab was stopped more often in women before completion of the 12-hour infusion because of higher bleeding rates. Acute procedural success rates were similar (92% and 97%) but mortality was much higher in women, both at 30-day follow-up (100% vs 0.9%; p <0.05) and during a mean follow-up of 6.9 +/- 4.1 months (15% vs 4.4%; p <0.05). Women also experienced more unfavorable cardiovascular events (recurrent unstable angina or AMI, target vessel revascularization) than men. However, after control for baseline clinical differences in a multivariate analysis, gender was not an independent predictor of survival, whereas age, cardiogenic shock, and completion of a 12-hour abciximab infusion were.

Is There a Gender Difference in Infarct Size and Arrhythmias Following Experimental Coronary Occlusion and Reperfusion?

It has been suggested that there may be gender differences in the outcome of myocardial infarction and therapies. However, there is a lack of knowledge regarding the basic science of gender difference in the setting of experimental myocadial infarction. Therefore, we performed a randomized study to determine whether there is a gender-related difference in infarct size as well as arrhythmias in an experimental model of myocardial infarction. Eleven male and 10 female adult rats were studied. All rats underwent 90 minutes of left main coronary occlusion and 4 hours of reperfusion. After 4 hours of reperfusion, the area at risk (AR) was delineated by dye injection and the area of necrosis (AN) was assessed by triphenyltetrazolium chloride staining. The electrocardiogram was recorded for the incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF). The area at risk was similar between the two groups. Myocardial infarct size, expressed as a percentage of the area at risk, averaged 57.3 +/- 4.9% in male and 58.2 +/- 3.5% in female rats (p = NS). The incidences of VT and VF were similar between male and female rats during 90 minutes of ischemia. Thus, gender had no effect on the extent of myocardial injury in this model of ischemia/reperfusion. To the best of our knowledge this is the first prospective randomized experimental trial that has shown no effect of gender on myocardial infarct size.

Saruplase is a safe and effective thrombolytic agent; observations in 1,698 patients: results of the PASS study. Practical Applications of Saruplase Study

Saruplase (unglycosylated human-type high molecular weight single-chain urokinase-type plasminogen activator) was given to 1698 patients in the open-label Practical Applicability of Saruplase Study (PASS), which assessed the safety and efficacy of saruplase in the treatment of acute myocardial infarction. Thirty-seven hospitals in Europe participated in the study. All patients received 20 mg saruplase as a bolus followed by an infusion of 60 mg saruplase over 1 hour. Prior to the infusion of saruplase, 62% of the patients received a bolus of 5000 U of heparin, and after saruplase a 24-hour intravenous infusion of heparin was given to 95% of patients. The mean age of the patients was 59 years and 80.1% were male. The median delay from the onset of chest pain to the start of saruplase infusion was 145 minutes. Acute angiography was performed in 8 of the participating 37 centers in 350 patients (20.6%), on average 85 minutes (median) after the start of the saruplase infusion. TIMI 3 flow was obtained in 186 patients (53.1%) and TIMI 2 flow in 61 patients (17.4%). Patency rates were similar for patients with anterior and inferior infarction. ECG signs suggestive of reperfusion were seen in 63% of the patients. In-hospital mortality was low (92 patients; 5.4%), and nonfatal recurrent myocardial infarction was seen in 60 patients (3.5%). Severe bleeding complications occurred in 92 patients (5.4%), 21 of whom (1.2%) needed a blood transfusion. An intracerebral hemorrhage was observed in eight patients (0.5%), and seven patients (0.4%) suffered from a thromboembolic stroke. At discharge 85.9% of the patients were in NYHA functional class I. One-year mortality was low (142 patients; 8. 4%). Mortality was high in patients with TIMI 0 or 1 flow at the acute angiography who did not undergo rescue PTCA (9/39; 23.1%), lower in patients with TIMI 0 or 1 flow followed by successful rescue PTCA (7/64; 10.9%), and low in patients with TIMI 2 flow (1/61; 1.6%) or with TIMI 3 flow (2/186; 1.1%). Patency rates and (bleeding) complications did not differ between patients with a body weight greater than or less than 70 kilograms. No antibodies against saruplase were detected in samples from 455 patients. In conclusion, it can be stated that saruplase, given in combination with aspirin and intravenous heparin, can be given safely and effectively to patients with acute myocardial infarction.

Clinical and prognostic characteristics associated with age and gender in acute myocardial infarction: a multihospital perspective in the Murcia region of Spain

Age and female gender have been associated with poor prognosis in acute myocardial infarction (AMI). Data currently available about the prognostic significance of gender in AMI might well have led to inappropriate/incomplete conclusions. A multicenter, prospective study on 1239 patients with AMI was conducted. Clinical characteristics, complications during the acute phase and one-year follow-up were monitored. Women constituted 24.1% of all patients. Female patients were older with more prevalence of diabetes, hypertension, and previous congestive heart failure. Compared with men, the following complications were more frequently found in women: heart failure, 43% vs. 22% (p < 0.001); reinfarction, 5% vs. 2% (p < 0.05); use of pacemaker, 7% vs. 4% (p < 0.05). Women had higher mortality: early, during the first 24 hours post-admission, 10.7 vs. 3.1%; in-hospital, 23% vs. 8.1%; and 1-year, 33.7% vs. 16% (p < 0.001 for all the 3 cases of mortality). In the age-groups considered (<65, 65-74, and > or =75 years), 1-year mortality increased exponentially with ageing in men: 7.8%, 21.3%, and 38.9%, whereas in women the figures were: 15.3%, 41.5%, and 38.8%. Multivariate analysis showed that, among other variables, age and female gender had independent prognostic value for in-hospital mortality whereas gender lost its prognostic significantly for 1-year mortality. Multivariate analysis restricted to those patients aged over 75 years showed that age but not gender had independent prognostic value. In conclusion, age and female sex have independent prognostic value for predicting mortality in patients with AMI. Mortality increases exponentially with ageing in men whereas it stabilises in the case of women over 65 years. Female gender loses its independent value for predicting mortality in patients over 75 years.

Prognostic significance of diabetes in acute myocardial infarction. Are the differences linked to female gender?

A prospective study of acute myocardial infarction was carried out in 1239 patients in order to assess both the prognostic significance of diabetes mellitus and the clinical characteristics associated with age and gender. Diabetes mellitus (DM) was found in 386 cases, often associated with old age, female gender, and more prevalent history of angina, heart failure, and hypertension. DM patients were admitted later and they were less likely to receive thrombolytic therapy, 47.9 vs. 58.1% (P<0.001). Complications more often associated with DM were: heart failure, 45 vs. 24.5% (P<0.01), and early, in-hospital and 1-year mortalities, 7.2 vs. 3.9% (P<0.05), 17.6 vs. 9.1% (P<0.001), and 29.2 vs. 16.2% (P<0.001), respectively. Compared with diabetic men, diabetic women were older and had a more prevalent history of hypertension and congestive heart failure. Diabetic women also had a higher rate of heart failure during hospitalisation, and of mortality, than diabetic men: early: 11.7 vs. 4.5% (P<0.01); in-hospital: 29.6 vs. 10.3% (P<0.001); and 1-year: 42.7 vs. 21.1% (P>0.001). DM was not selected by the multivariate analysis as a variable with independent prognostic value for mortality. In separate multivariate analysis for diabetic and non-diabetic patients, female gender had independent prognostic value for mortality only in the case of the diabetic population.

Management and outcome of acute myocardial infarction in older patients in the thrombolytic era

OBJECTIVE

Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group.

DESIGN

An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI.

SETTING

An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center.

RESULTS

Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short- and long-term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta-blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care.

CONCLUSION

Patients more than age 75 comprise almost one-third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.

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

Several studies have indicated that women sustaining a myocardial infarction have a higher unadjusted short-term (i.e., in-hospital or 30-day) mortality than men. The advanced age of women at the time of presentation appears to be the major factor contributing to their worse prognosis relative to men. Controlling for age eliminates the association between female gender and increased mortality in most, but not all studies. This article reviews the data on age and other factors that might explain why women with a myocardial infarction fare worse then men.

[Analysis of causes of excessive prehospital delay of patients with acute myocardial infarction in the province of Teruel]

BACKGROUND

To analyze the delay of patients who come to the hospital and are diagnosed with acute myocardial infarction, its causes and the variables with determine it.

PATIENTS, MATERIAL AND METHODS

Prospective study of 115 patients (79 male and 36 female). The pre-hospital delay time was measured as the time which passed from the moment when the patient feels the first symptoms "chest pain", until his arrival and registration at the Emergency Service. This time was divided into three subdivisions: decision time, medical time and transport time. We determined: place of origin, indications and means of transport used to reach the hospital, diagnosis and treatment given by the general practitioner before arrival at the hospital, the cardiovascular risk factors, location of patients pain, the time of day and the delay at the Emergency Service.

RESULTS

The mean pre-hospital delay was 364 +/- 534 min (median of 195 min). Most of the patients (73.7%) came to hospital during the first six hours. The major part of total delay corresponded to the decision delay (202 +/- 363 min with a median of 75), which occupied 50.1% of the whole (confidence interval 95% [CI 95%], 44.6-55.6%), while the transport time occupied 34.6% (CI 95%, of 30.1-39%) with a median of 50 min. Major pre-hospital delay corresponded to the patients coming from rural areas (p = 0.007), to those asked for medical assistance (p = 0.0029), to diabetics (p = 0.01) and to those who felt the pain during their night sleep (p = 0.0023). Transport time was negatively influenced by old age (p = 0.0012), rural origin (p = 0.0001), the appearance of the night sleep pain (p = 0.031) and calling the general practitioner for first aid (p = 0.0001), but it was not influenced by the form of transport used to get to the hospital. The intra-hospital delay time had an median of 60 min, being longer for older people (p = 0.007), for patients with hypertension (p = 0.014) and those who were admitted from the Intensive Care Unit (p = 0.0001).

CONCLUSIONS

The pre-hospital delay detected in our environment is longer than other studies and confirms that half of it is not due to the intrinsic functioning of our health system, even through it should get involved as much as possible to diminish the delay time.

[Clinical prediction of the early prognosis in acute myocardial infarct]

Several clinical factors can influence the pathophysiology, clinical course and prognosis of acute myocardial by different means. Some of them may be easily detected through the history, physical examination or ECG in an early phase. The knowledge of these factors may help the therapeutic decision making of patients with myocardial infarction. The influence for the main clinical factors (age, sex, risk factors, cardiologic antecedents and evolutive findings) on the short-term prognosis of acute myocardial infarction is reviewed. An analysis of the likely mechanisms of the influence of these factors on infarct prognosis is also performed.

Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction

OBJECTIVES

Women and men enrolled in the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial of unstable angina and non-Q wave myocardial infarction (MI) were evaluated to determine gender differences in characteristics and outcome.

BACKGROUND

Coronary heart disease is the leading cause of death for women and men. However, the characteristics and outcome of women compared with men with unstable angina and non-Q wave MI have not been extensively studied.

METHODS

The characteristics, outcomes and proportion of 497 women and 976 men with unstable angina and non-Q wave MI at the time of enrollment were compared. When these proportions were noted to be significantly different, we compared them with the 7,731-patient TIMI IIIB Registry, which represents the non-trial, screened population with these syndromes at these centers.

RESULTS

For both coronary syndromes, women were older, were less frequently white, had a higher incidence of diabetes and hypertension and were receiving more cardiac medications. The 42-day rate of death and MI in TIMI IIIB was similar for women and men (7.4% vs. 7.5%). Coronary angiography revealed less severe coronary artery disease for women than for men, with absence of critical obstructions in 25% versus 16% and mean ejection fractions 62 +/- 12% versus 57 +/- 13% for women versus men (p < 0.01). Medical management failed in women as often as in men, and rates of cardiac catheterization and percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery were similar for women and men in the conservative strategy arm as well as in the invasive strategy arm. Women in the TIMI IIIB trial had proportionately more unstable angina than did men. The proportion of unstable angina and non-Q wave MI for women was similar in the trial and Registry. However, proportionately more men in the trial had non-Q wave MI than men in the Registry.

CONCLUSIONS

1) Women with each acute coronary syndrome are older than men and have more comorbidity. 2) The outcome with unstable angina and non-Q wave MI is related to severity of illness and not gender. 3) Mortality associated with revascularization for unstable angina and non-Q wave MI was similar for women and men. 4) The proportion of women and men enrolled with each acute coronary syndrome is different. These rates reflect both the prevalence of disease and selection bias owing to trial eligibility criteria and other identified factors.

Hospital mortality in women and men with acute cardiac ischemia: a prospective multicenter study

OBJECTIVES

This study sought to determine gender differences in hospital mortality in patients with acute cardiac ischemia.

BACKGROUND

It is unclear why women experience higher mortality from acute myocardial infarction (AMI) than men and whether this applies to all patients with acute ischemia.

METHODS

We analyzed data from a prospective multicenter study involving patients presenting to the emergency department (ED) with symptoms suggestive of acute ischemia.

RESULTS

Of 10,783 patients, 5,221 (48.4%) were women. Mean age was 60.5 years for women and 56.9 for men (p < 0.001). Women had more hypertension (54.6% vs. 45.9%, p < 0.001) and diabetes (23.3% vs. 17.0%, p < 0.001) than men but fewer previous AMIs (21.1% vs. 28.9%, p < 0.001). Acute ischemia was confirmed in 1,090 women (20.8%) and 1,451 men (26.1%, p < 0.001), including AMI in 322 women (6.2%) and 572 men (10.3%, p < 0.001). Women with an AMI were in a higher Killip class than men: class I in 60.3% versus 72.2%, class II in 19.3% versus 16%, class III in 15.5% versus 8.7% and class IV in 5% versus 3.1%, respectively (p = 0.001). There was no significant difference in mortality from acute ischemia between genders (4.0% vs. 3.5%, p = 0.6), but there was a trend for higher AMI mortality in women (10.3% vs. 7.4%, p = 0.1). After controlling for age, diabetes, heart failure and presenting blood pressure, gender did not predict mortality from acute ischemia (odds ratio 0.9, 95% confidence interval 0.5 to 1.4, p = 0.5).

CONCLUSIONS

Among patients presenting to the ED with acute cardiac ischemia, gender does not appear to be an independent predictor of hospital mortality. The trend for higher mortality in women from AMI can be explained by their older age, greater frequency of diabetes and higher Killip class on presentation.

Sex differences in survival after myocardial infarction in older adults: a community-based approach

OBJECTIVE

To determine sex differences in survival after myocardial infarction in older individuals.

DESIGN

Prospective cohort study based on a community sample of older individuals. All patients were followed for 1 year after hospital admission.

SETTING

Two hospitals in New Haven, Connecticut.

PARTICIPANTS

The study included 103 women and 120 men who were participants in the New Haven, CT cohort of the Established Populations for the Epidemiologic Study of the Elderly (EPESE) program and who were diagnosed with myocardial infarction between the inception of the community study in 1982 and December 31, 1992. The mean age of women was 79.3 and of men, 77.3.

MEASUREMENTS

Data on clinical characteristics were abstracted from medical records. Sociodemographic, psychosocial, and physical function information was derived from the EPESE interview preceding the infarction. The main outcome measure was all-cause mortality, for which three end points were used: early mortality (first 30 days), late mortality (1-year mortality among survivors of the first 30 days), and overall mortality (1-year mortality from admission in the whole sample).

RESULTS

Mortality in the first 30 days did not differ significantly in the two sexes. The relative risk (RR) of death in women compared with men was 0.85 (95% confidence interval [CI], 0.49-1.47) before multivariable adjustment; this was unchanged after adjustment for demographic factors, comorbidity, functional status, psychosocial factors, and clinical severity (RR, 0.85, 95% CI, 0.41-1.76). Among survivors of 30 days, women were almost two times more likely to survive at 1 year compared with men, both before multivariable adjustment (RR, 0.56, 95% CI, 0.31-1.02) and after controlling for demographic factors, comorbidity, physical function, psychosocial factors, clinical severity on admission, and hospital complications (RR, 0.44 ; 95% CI, 0.20-0.99). Analyses involving 1-year follow-up from admission for the entire sample yielded intermediate results.

CONCLUSION

There was little difference in mortality in the first 30 days after myocardial infarction between older men and women, but when the early deaths were excluded, women showed an increased survival compared with men in the first year after the myocardial infarction.

Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry)

This study compared the presentation (symptoms and signs), treatment, and outcome of 1,097 consecutive patients (851 men and 246 women) from the Myocardial Infarction Triage and Intervention (MITI) Project Registry with confirmed acute myocardial infarction (AMI), all of whom were initially evaluated in the prehospital setting, met clinical criteria for possible thrombolysis, and were followed throughout their hospital course. Women were older than men and had a higher prevalence of known cardiovascular risk factors, including systemic hypertension and congestive heart failure. The presentation of AMI with respect to symptoms, delay, and hemodynamic and electrocardiographic findings was for the most part indistinguishable between mean and women. Women appeared "undertreated" early in the course of AMI and were half as likely as men to undergo acute catheterization, angioplasty, thrombolysis, or coronary bypass surgery (odds ratio 0.5 [0.3 to 0.7]). The risk for hospital mortality in women was almost twice that for men (odds ratio 1.95 [1.01 to 3.8]). Hospital mortality after AMI was also independently predicted by older age, early evidence of hemodynamic instability, and an intraventricular conduction abnormality on the initial electrocardiogram. Although similar in its presentation, AMI in women is not as aggressively treated, and results in a less favorable outcome than in men. Gender as well as nongender-specific risk factors are important in assessing risk and the likelihood of early intervention after AMI.