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

Gender differences in vascular aging and in coronary artery disease pathophysiology

Women have a clinical advantage over men in relation to atherosclerotic cardiovascular disease (CVD) (morbidity and mortality). This advantage disappears once women become older, and in their seventh decade, the risk to develop CVD equals men at that age. There have been several theories about this gender difference that were related to hormones, and the different morphology and physiology that characterize the cardiovascular system in women. In this review, the different mechanisms will be reviewed and discussed.

Health care service use and costs for a cohort of high-needs elderly diabetic patients

AIMS

To describe the impact of diabetes comorbidities on the health care services use and costs of a cohort of elderly patients with diabetes and high health care needs (HHCN), based on real-world data.

METHODS

We focused on a cohort of diabetic patients with HHCN belonging to Resource Utilization Bands 4 and 5 according to the Adjusted Clinical Group (ACG) system. Their comorbidities were assessed using the clinical diagnoses that the ACG system assigns to single patients by combining different information flows. Regression models were applied to analyze the associations between comorbidities and health care service use or costs, adjusting for age and sex.

RESULTS

Our analyses showed that all health care service usage measures (e.g. access to emergency care; number of outpatient visits) and the total annual costs and pharmacy costs are associated significantly with comorbidity class. Instead, no differences in hospitalization rates by comorbidity class were revealed.

CONCLUSION

The association between a larger number of comorbidities and higher total health care service usage and costs was seen mainly for primary care services. This underscores the need to strengthen primary care for today's aging and multimorbid population.

Impact of Age on Gender Difference in Long-term Outcome of Patients With Acute Myocardial Infarction (from J-MINUET)

Although gender difference in long-term outcomes after acute myocardial infarction have been shown previously, impact of age on gender difference is still controversial. This study focused on the association between age and gender difference in long-term outcome. We analyzed data from 3,283 consecutive patients who were included in a prospective, nationwide, multicenter registry (Japan Registry of Acute Myocardial Infarction Diagnosed by Universal Definition) from 2012 to 2014. The primary end point was the major adverse cardiovascular event (MACE), which was defined as a composite of death, myocardial infarction, stroke, heart failure, and revascularization for unstable angina during 3 years. Patients were divided into 4 strata according to age: those with age <65 years (group 1: n = 1161), 65 to 74 years (group 2: n = 954), 75 to 84 years (group 3: n = 866) and 84< years (group 4: n = 302). Although the crude incidence of 3-year MACE was significantly higher in women than men (36.4% vs. 28.5%, p <0.001), there was not significant gender difference in each group (group 1, 19.6% vs 19.0%, p = 0.74; group 2, 33.1% vs 28.3%, p = 0.25; group 3, 38.9% vs 39.6%, p = 0.54; and group 4, 54.0% vs 56.8%, p = 0.24). In conclusion, although women had higher crude incidence of 3-year MACE than men, there was no gender difference in each group.

Healthcare Service Usage and Costs for Elderly Patients with Obstructive Lung Disease

Background

The worldwide prevalence of obstructive lung disease (OLD) is increasing, especially among people >65 years old, and nearly three in four adults with OLD have two or more comorbid conditions. This study describes the impact of such comorbidities on the healthcare service usage and related costs in a country with universal health coverage, basing on a large cohort of elderly patients with OLD and employing real-world data.

Methods

We carried out a retrospective cohort study on a large population of elderly (age >64 years) patients with OLD served by a Local Health Unit in northern Italy. Their comorbidities were assessed using the clinical diagnoses assigned by the Adjusted Clinical Group (ACG) system to individual patients by combining different information flows. Correlations between number of comorbidities and total annual healthcare service usage and costs were examined with Spearman's test. Regression models were applied to analyze the associations between the above-mentioned variables, adjusting for age and sex.

Results

All types of healthcare service usage (access to emergency care; number of outpatient visits; number of hospital admissions) and pharmacy costs increased significantly with the number of comorbidities. Average total annual costs increased steadily with the number of comorbidities, ranging from € 1158.84 with no comorbidities up to € 9666.60 with 6 comorbidities or more. Poisson regression analyses showed an independent association between the number of comorbidities and the use of every type of healthcare service.

Conclusion

These results based on real-world data provide evidence that the burden of care for OLD patients related to their comorbidities is independent of and in addition to the burden related to OLD alone and is strongly dependent on the number of comorbidities, suggesting a holistic approach to multimorbid patients with OLD is the most sound public health strategy.

Sex differences in the treatment and outcome of emergency general surgery

Background

Sociodemographic characteristics, such as sex, have been shown to influence health care delivery. Acute care surgery models are effective in decreasing mortality and morbidity after emergency surgeries, but sex-based differences in delivery and outcomes have not been explored. Our objective was to explore sex associated differences in the patient characteristics and clinical outcomes of those admitted to emergency general surgery.

Methods

A post-hoc analysis of 512 emergency general surgical patients admitted consecutively to two tertiary care hospitals in Alberta Canada, between April 1, 2014 and July 31, 2015. We measured associations between sex and patient demographics, pre-, intra- and post-operative delivery of care, as well as post-operative outcomes.

Findings

Of those excluded from the analysis, older females were more likely to undergo conservative management compared to older men (41% vs 34%, p = 0.03). Overall, there were no differences between sexes for time from admission to surgery, time spent in surgery, overall complication rate, mortality, hospital length of stay, or discharge disposition. Women were more likely to have a cancer diagnosis [OR 4.12 (95% CI: 1.61–10.5), p = 0.003, adjusted for age], while men were more likely to receive hernia surgery [OR 2.33 (95% CI 1.35–4.02), p = 0.002, adjusted for age and Charlson Comorbidity Index]. Finally, men were more likely to have a major respiratory complication [OR 2.73 (95% CI: 1.19–6.24), p = 0.02, adjusted for age].

Conclusions

Only two differences in peri and post-operative complications between sexes were noted, which suggests sex-based disparity in quality of care is limited once a decision has been made to operate. Future studies with larger databases are needed to corroborate our findings and investigate potential sex biases in surgical versus conservative management.

Interpreting angina: symptoms along a gender continuum

BACKGROUND

'Typical' angina is often used to describe symptoms common among men, while 'atypical' angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women.

OBJECTIVES

To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach.

METHODS

Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel.

RESULTS

Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a 'gender continuum'. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women.

CONCLUSIONS

The 'gender continuum' offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional 'typical' versus 'atypical' distinction that can misrepresent gendered angina experiences.

Using decision trees for measuring gender equity in the timing of angiography in patients with acute coronary syndrome: a novel approach to equity analysis

BACKGROUND

Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome.

METHODS

Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS.

RESULTS

Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay.

CONCLUSIONS

A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.

Life Expectancy and Years of Potential Life Lost After Acute Myocardial Infarction by Sex and Race: A Cohort-Based Study of Medicare Beneficiaries

BACKGROUND

Most studies of sex and race differences after acute myocardial infarction (AMI) have not taken into account differences in life expectancy in the general population. Years of potential life lost (YPLL) is a metric that takes into account the burden of disease and can be compared by sex and race.

OBJECTIVES

This study sought to determine sex and race differences in long-term survival after AMI using life expectancy and YPLL to account for differences in population-based life expectancy.

METHODS

Using data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized for AMI between 1994 and 1995 (N = 146,743), we calculated life expectancy and YPLL using Cox proportional hazards regression with extrapolation using exponential models.

RESULTS

Of the 146,743 patients with AMI, 48.1% were women and 6.4% were black; the average age was 75.9 years. Post-AMI life expectancy estimates were similar for men and women of the same race but lower for black patients than white patients. On average, women lost 10.5% (SE 0.3%) more of their expected life than men, and black patients lost 6.2% (SE 0.6%) more of their expected life than white patients. After adjustment, women still lost an average of 7.8% (0.3%) more of their expected life than men, but black race became associated with a survival advantage, suggesting that racial differences in YPLL were largely explained by differences in clinical presentation and treatment between black and white patients.

CONCLUSIONS

Women and black patients lost more years of life after AMI, on average, than men and white patients, an effect that was not explained in women by clinical or treatment differences.

The risk and burden of smoking related heart disease mortality among young people in the United States

PURPOSE

Although cigarette smoking remains the most common risk factor for heart disease among the young, few studies have explored the relationship of smoking with heart disease mortality risk among young people. This prospective study assesses the risk and burden of all heart disease (HD) and coronary heart disease (CHD) mortality associated with smoking among younger adults from a nationally representative sample of the United States.

METHOD

National Health Interview Survey respondents' data from 1997-2004 were linked to their death records through 2006. The analyses were restricted to individuals 18 to 44 years of age during follow up (n = 121,284). Cox proportional hazard ratios (HR) were estimated with adjustment for sample weights and design effects. Attributable fractions (AF) of smoking were calculated.

RESULTS

After controlling for age, race, body mass index, history of hypertension and diabetes, and leisure time physical activity, current smoking related CHD mortality HR was 14.6 [95 % confidence interval or CI, 3.3-64.9] for females and 3.6 [95 % CI, 1.2-10.4] for males. The HR for all HD mortality was 3.1 [95 % CI, 1.3-7.6] for females and 2.4 [95 % CI, 1.2-4.7] for males. The AF of smoking for CHD deaths for female and male were 0.58 and 0.54 respectively. The AF of all HD mortality was 0.31 for male and 0.32 for female. The mean estimates of all HD deaths attributable to smoking during 1997-2006 among this age group were 52,214, of which 45,147 were CHD deaths.

CONCLUSION

Even after adjustment for multiple risk factors and without addressing passive smoking, our result showed a strong relationship between smoking and HD and CHD mortality among young adults that is likely causal.

Sex differences in long-term mortality after myocardial infarction: a systematic review

BACKGROUND

Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge.

METHODS AND RESULTS

We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization.

CONCLUSIONS

Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality.

Sex differences in the management and outcomes of Ontario patients with cardiogenic shock complicating acute myocardial infarction

BACKGROUND

Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied.

METHODS

We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization.

RESULTS

The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes.

CONCLUSION

Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.

Gender disparities in AMI management and outcomes among health professionals, their relatives, and non-health professionals in Taiwan from 1997 to 2007

Numerous reports of gender differences in the management and mortality of acute myocardial infarction (AMI) patients have raised concerns on gender inequity in cardiac care. However, no study has explored whether gender disparity exists among health professionals and their relatives. Therefore, this study assesses gender disparity in the management and mortality of AMI patients in Taiwan, and determines whether such disparity exists among health professionals and their relatives. National Health Insurance (NHI) files were used to obtain information on a cohort of 79,360 AMI patients aged 30-85 years in Taiwan from 1997 to 2007. The use of catheterization and revascularization (CATH/RAVS) and one-year mortality were compared between men and women in all adult patients, health professionals and their relatives, and non-health professional patients. Taiwanese women with AMI were significantly less likely than their male counterparts to receive CATH/RAVS, and showed greater one-year mortality. Similarly, women in the professional group were significantly less likely to receive CATH/RAVS. However, they did not have worse survival outcomes (hazard ratio: 1.01; 95% CI: 0.68-1.50) compared to men. Regarding mortality following CATH/RAVS, no gender disparities against women were observed in health professionals and their relatives, whereas significant gender disparities persisted in non-health professional patients. In conclusion, this study shows a substantial gender disparity against women in the management and one-year survival of AMI patients in Taiwan. This research extends earlier studies by showing similar gender gaps in treatment uses among health professionals and their relatives without strong evidence on gender disparities against women in survival.

Effect of use of combination evidence-based medical therapy after acute coronary syndromes on long-term outcomes

Several medications have individually been shown to reduce mortality in patients with acute coronary syndromes (ACS), but data on long-term outcomes related to the use of combinations of these medications are limited. For 2,684 consecutive patients admitted with ACS from January 1999 and January 2007, a composite score was calculated correlating with the use upon discharge of indicated evidence-based medications (EBMs): aspirin, β blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents. Multivariate models were used to examine the impact of EBM score on 2-year events with adjustment for components of the Global Registry of Acute Coronary Events (GRACE) risk score, thienopyridine use, and year of discharge. Women were older, had more co-morbidities, and were less likely to receive all 4 EBMs (53% vs 64%, p < 0.0001) than men. Patients who received all 4 indicated EBMs had a significant 2-year survival benefit compared to patients who received ≤1 EBM (odds ratio 0.25, 95% confidence interval 0.15 to 0.41), which was observed when men and women were examined separately (for men, odds ratio 0.22, 95% confidence interval 0.11 to 0.44; for women, odds ratio 0.3, 95% confidence interval 0.15 to 0.63). A modest benefit, in terms of cardiovascular disease events (myocardial infarction, rehospitalization, stroke, and death), was observed only for men who received all 4 EBMs. In conclusion, a combination of cardiac medications at the time of ACS discharge is strongly associated with 2-year survival in men and women, suggesting that discharge is an important time to prescribe secondary preventative medications.

Role of cigarette smoking and gender in acute coronary syndrome events

Cigarette smoking has been associated with lower mortality after an acute coronary event. We hypothesized that the improved survival in smokers is related to demographic differences and sought to further evaluate the gender disparities in smokers after an acute coronary event. A prospective cohort of 3,588 patients hospitalized at a single center from 1999 to 2006 was identified. Smoking status, in-hospital and 6-month follow-up death, and cardiovascular events (i.e., myocardial infarction, stroke, cardiac-related rehospitalization, and unscheduled revascularization) were assessed. The prevalence of smoking in men increased over time. The smokers were younger at presentation with fewer co-morbidities than nonsmokers. Male smokers had lower mortality (3.2% vs 5.4%, p = 0.04) and fewer cardiovascular events (33.1% vs 42.4%, p = 0.003) at 6 months than nonsmokers. However, after adjusting for age and co-morbidities, smoking was not an independent predictor of events (odds ratio 0.88, 95% confidence interval 0.67 to 1.17). Female smokers had mortality (5.6% vs 8.4%, p = 0.15) and cardiovascular events (54.5% vs 49.7%, p = 0.28) at 6 months similar to that of nonsmokers, with a nonsignificant trend toward increased risk after adjustment (odds ratio 1.31, 95% confidence interval 0.90 to 1.93). Among smokers, female gender remained a significant risk factor for cardiovascular events at 6 months (odds ratio 2.35, 95% confidence interval 1.58 to 3.50), even after adjustment for age and co-morbidities. In conclusion, smokers experienced acute coronary event events earlier than did nonsmokers. Younger age and fewer co-morbidities likely account for most observed survival benefit in smokers, although female smokers are more likely to experience cardiovascular complications by 6 months than male smokers.

Effect of patient age on airway response by paramedics: frailty or futility?

OBJECTIVE

We studied patterns related to patient age and indication for airway interventions delivered by paramedics from 2000 through 2004.

METHODS

The study population included patients ≥ 15 years old managed by paramedics. Outcomes were the frequencies of definitive airway, ventilatory techniques, and oxygenation techniques. Independent variables were patient age, gender, race, hospital drive time, do-not-resuscitate status, and two trauma indicators of the American College of Surgeons Committee on Trauma (anatomic injury and mechanism of injury). Subset analysis was performed with the presence or absence of a set of recorded conditions.

RESULTS

A total of 827,772 paramedic transports were studied; 233,470 were identified with at least one indication for airway intervention. Patients older than 65 years were, when compared with patients 65 years old or younger, 1) less likely to receive ventilatory interventions with any indication; 2) more likely to receive ventilatory intervention without an indication; and 3) more likely to receive oxygenation interventions whether indications were present or not. We considered age in five-year intervals and noted a consistent biphasic pattern for all interventions, regardless of indications. The odds ratios for interventions for patients in each block compared with those for 15- to 29-year-old patients increased with age until about 70 years of age, then gradually declined.

CONCLUSIONS

Patterns of age-related variations in airway interventions cannot be explained by the application of protocols. The reason for the peak rate of interventions at age 70 years is unknown. Explanations need to consider the influence on paramedic behavior of a number of factors, including frailty and futility. Additional paramedic training may be needed to change these patterns.

Significant association of female gender with lower degree of pathological 99mTc-sestamibi scintigraphy results as well as higher cardiac-related deaths free survival in elderly patients

BACKGROUND

The aim of the present study was to assess the impact of female gender on the extent of myocardial perfusion defects as revealed by (99m)Tc-sestamibi myocardial perfusion scintigraphy (MPS) and on emerging cardiac events (CE) in patients aged ≥ 70 years.

PATIENTS AND METHODS

86 patients aged ≥ 70 years with known or suspected CAD undergoing MPS (74.4 ± 3.2 years; women: n = 46; 53.5%) were included in this study. Semiquantitative analysis of MPS was performed and summed stress (SSS), summed difference (SDS), and summed rest scores (SRS) were calculated. Emerging CE comprised myocardial revascularization and -infarction and cardiac-related death. Multivariate regression analysis was performed to assess the independent prognostic impact of several patient related variables on MPS results. Kaplan-Meier- and log rank analyses were calculated for assessment of CE free survival as related to gender.

RESULTS

Normal SSS (87.0% vs. 27.5%; p < 0.0001), SDS (80.4% vs. 27.5%; p < 0.0001), and SRS (97.8% vs. 82.5%; p = 0.023) were significantly more often found in women, whereas incidence of mildly and severely impaired SSS (6.5% vs. 35%; p = 0.001 and 2.2% vs. 25%; p = 0.002, respectively) and SDS (15.2% vs. 52.5%; p < 0.0001 and 2.2% vs. 17.5%; p = 0.023, respectively) were significantly higher in men. Multivariate logistic regression analysis revealed female gender as an independent predictor of normal SSS (odds ratio/OR: 17.6) and SDS (OR: 53.3). Female gender was associated with a significant higher cardiac-death free survival compared to male patients (p = 0.031).

CONCLUSION

Female gender is independently associated with a significantly lower degree of pathological MPS results and a higher cardiac-death free survival in elderly patients.

Referrals in acute coronary events for CARdiac catheterization: The RACE CAR trial

BACKGROUND

Women with acute coronary syndromes have lower rates of cardiac catheterization (CC) than men.

OBJECTIVE

To determine whether sex⁄gender, age, risk level and patient preference influence physician decision making to refer patients for CC.

METHODS

Twelve clinical scenarios controlling for sex⁄gender, age (55 or 75 years of age), Thrombolysis in Myocardial Infarction risk score (low, moderate or high) and patient preference for CC (agreeable or refused⁄no preference expressed) were designed. Scenarios were administered to specialists across Canada using a web-based computerized survey instrument. Questions were standardized using a five-point Likert scale ranging from 1 (very unlikely to benefit from CC) to 5 (very likely to benefit from CC). Outcomes were assessed using a two-tailed mixed linear regression model.

RESULTS

Of 237 scenarios, physicians rated men as more likely to benefit from CC than women (mean [± SE] 4.44±0.07 versus 4.25±0.07, P=0.03), adjusted for age, risk and patient preference. Low-risk men were perceived to benefit more than low-risk women (4.20±0.13 versus 3.54±0.14, P<0.01), and low-risk younger patients were perceived to benefit more than low-risk older patients (4.52±0.17 versus 3.22±0.16, P<0.01). Regardless of risk, patients who agreed to CC were perceived as more likely to benefit from CC than patients who were disagreeable or made no comment at all (5.0±0.23, 3.67±0.21, 2.95±0.14, respectively, P<0.01).

CONCLUSION

Canadian specialists' decisions to refer patients for CC appear to be influenced by sex⁄gender, age and patient preference in clinical scenarios in which cardiac risk is held constant. Future investigation of possible age and sex⁄gender biases as proxies for risk is warranted.

Identifying women with severe angiographic coronary disease

OBJECTIVES

To determine sex/gender differences in the distribution of risk factors according to age and identify factors associated with the presence of severe coronary artery disease (CAD).

DESIGN

We analysed 23,771 consecutive patients referred for coronary angiography from 2000 to 2006.

SUBJECTS

Patients did not have previously diagnosed CAD and were referred for first diagnostic angiography.

OUTCOME MEASURES

Patients were classified according to angiographic disease severity. Severe CAD was defined as left main stenosis > or = 50%, three-vessel disease with > or = 70% stenosis or two-vessel disease including proximal left anterior descending stenosis of > or = 70%. Univariate and multivariate logistic regression was used to assess the association between risk factors and angina symptoms with severe CAD.

RESULTS

Women were less likely to have severe CAD (22.3% vs. 36.5%) compared with men. Women were also significantly older (69.8 +/- 10.6 vs. 66.3 +/- 10.7 years), had higher rates of diabetes (35.0% vs. 26.6%), hypertension (74.8% vs. 63.3%) and Canadian Cardiovascular Society (CCS) class IV angina symptoms (56.7% vs. 47.8%). Men were more likely to be smokers (56.9% vs. 37.9%). Factors independently associated with severe CAD included age (OR = 1.05; 95% CI 1.05-1.05, P < 0.01), male sex (OR = 2.43; CI 2.26-2.62, P < 0.01), diabetes (OR = 2.00; CI 1.86-2.18, P < 0.01), hyperlipidaemia (OR = 1.50; CI 1.39-1.61, P < 0.01), smoking (OR = 1.10; CI 1.03-1.18, P = 0.06) and CCS class IV symptoms (OR = 1.43; CI 1.34-1.53, P < 0.01). CCS Class IV angina was a stronger predictor of severe CAD amongst women compared with men (women OR = 1.82; CI 1.61-2.04 vs. men OR = 1.28; CI 1.18-1.39, P < 0.01).

CONCLUSIONS

Women referred for first diagnostic angiography have lower rates of severe CAD compared with men across all ages. Whilst conventional risk factors, age, sex, diabetes, smoking and hyperlipidaemia are primary determinants of CAD amongst women and men, CCS Class IV angina is more likely to be associated with severe CAD in women than men.

The Effect of Age upon Care and Outcomes in Patients Hospitalized for Congestive Heart Failure in Alberta, Canada

We describe the age-specific outcomes for patients hospitalized with newly diagnosed congestive heart failure using administrative hospital abstracts from Alberta, Canada, from April 1, 1994, to March 31, 2000. Seniors (aged 65 years and older) constituted about 85 per cent of the 16,162 patients. Both co-morbidity and severity of illness tended to increase with age. The use of special care unit admissions, coronary artery diagnostic services (cardiac catheterization), and revascularization procedures (percutanenous transluminal coronary angioplasty/stenting, coronary artery bypass surgery) peaked in the 50-to 64-year age group and decreased with increasing age. Specialist/sub-specialist care, prescriptions of beta blockers and angiotensin-converting enzyme inhibitors / angiotensin receptor blockers decreased with age in seniors. Adjusted in-hospital, 1-year mortality and crude, age-specific 5-year mortality were significantly greater in those 75 years and older. Outcomes and process of care in patients with newly diagnosed congestive heart failure were not uniformly distributed with age. The elderly had greater mortality but received less therapy.

Coronary artery disease: Are men and women created equal?

BACKGROUND

Ischemic heart disease in women is a difficult issue in cardiovascular medicine, mainly because of our lack of understanding of the early-stage mechanisms and symptoms. A better and earlier understanding of the pathophysiology of coronary artery disease (CAD) in women will enable us to detect ischemic heart disease earlier and prevent adverse clinical outcomes.

OBJECTIVES

The aims of this article were to describe the phenomenon of ischemic heart disease in women, increase awareness of the difference between men and women in relation to ischemic heart disease, improve our understanding of the mechanisms that cause this difference, and identify new approaches for better and earlier detection and treatment of CAD in women.

METHODS

We conducted a search of the PubMed database for double-blind studies on the mechanistic pathways of CAD in women published in English within the past 10 years and epidemiologic studies published since 1970. Search terms included women and coronary artery disease and ischemic heart disease in women.

RESULTS

The literature search revealed 30 peer-reviewed articles pertaining to this issue. The incidence of CAD was markedly lower in women <60 years of age than in older women. After 60 years of age, the rate of CAD increased and reached the rate seen among men by the 8th decade of life. The gender difference in atherosclerosis in the coronary tree was particularly large in patients <55 years of age and remained large at older ages. The gender difference in the coronary bed was strikingly larger than in other vascular beds. Intensive risk-factor modification had a similar effect on plaque progression in both men and women. Coronary endothelial dysfunction appeared to be related to cardiovascular morbidity and mortality in women as well as in men, and because endothelial dysfunction could be modified, it appeared that the prognosis could be improved by appropriate management. A strong association was found between body mass index (BMI) and metabolic status, but only the metabolic syndrome was associated with CAD. Physical activity was independently associated with fewer risk factors, less CAD, and fewer adverse events in women; however, obesity was not associated with these outcomes.

CONCLUSIONS

Results of the identified studies suggest that reduction of risk factors is a common approach to fighting heart disease in both sexes. It appears that for women, weight and BMI are not as important as previously thought, but physical exercise and fitness are very important and can change risk factors and clinical outcomes more than any other known intervention. Data suggest that global inflammation may play an important role in women and may predict cardiovascular outcome in women much better than the traditional risk factors that have been used and proved for men.

The impact of statins on health services utilization and mortality in older adults discharged from hospital with ischemic heart disease: a cohort study

BACKGROUND

Cardiovascular disease (CVD) carries a high burden of morbidity and mortality and is associated with significant utilization of health care resources, especially in the elderly. Numerous randomized trials have established the efficacy of cholesterol reduction with statin medications in decreasing mortality in high-risk populations. However, it is not known what the effect of the utilization of these medications in complex older adults has had on mortality and on the utilization of health services, such as physician visits, hospitalizations or cardiovascular procedures.

METHODS

This project linked clinical and hospital data from the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) database with administrative data from the Population Health Research Unit to identify all older adults hospitalized with ischemic heart disease between October 15, 1997 and March 31, 2001. All patients were followed for at least one year or until death. Multiple regression techniques, including Cox proportional hazards models and generalized linear models were employed to compare health services utilization and mortality for statin users and non-statin users.

RESULTS

Of 4232 older adults discharged alive from the hospital, 1629 (38%) received a statin after discharge. In multivariate models after adjustment for demographic and clinical characteristics, and propensity score, statins were associated with a 26% reduction in all- cause mortality (hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.63-0.88). However, statin use was not associated with subsequent reductions in health service utilization, including re-hospitalizations (HR, 0.98, 95% CI 0.91-1.06), physician visits (relative risk (RR) 0.97, 95% CI 0.92-1.02) or coronary revascularization procedures (HR 1.15, 95% CI 0.97-1.36).

CONCLUSION

As the utilization of statins continues to grow, their impact on the health care system will continue to be important. Future studies are needed to continue to ensure that those who would realize significant benefit from the medication receive it.

Impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries

OBJECTIVES

We investigated the impact of sex on outcomes after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

BACKGROUND

Women have a higher risk of adverse outcomes after PCI than do men. However, long-term outcomes of women after contemporary PCI with DES have not been fully investigated.

METHODS

We performed a retrospective cohort study of 4,936 consecutive patients (28.2% women) who underwent PCIs between 2000 and 2004, before and after introduction of DES (bare-metal stent [BMS] group: n = 2,131, DES group: n = 2,805), to assess the impact of sex on long-term PCI outcomes and to compare outcome after PCI of women between the DES and BMS eras.

RESULTS

Compared with men, women undergoing PCIs were 5 years older and more frequently have comorbidities such as diabetes mellitus and hypertension. In patients treated throughout the BMS and DES eras, there were no differences by sex for risk of all-cause death, myocardial infarction, or target vessel revascularization 3 years after procedure. The procedural complexity was higher in the DES era, nevertheless, risk for target vessel revascularization and major adverse cardiac event at 3 years were significantly lower in women treated with DES than in women treated with BMS (adjusted hazard ratio [HR] for target vessel revascularization: 0.52 [95% confidence interval (CI): 0.36 to 0.75], adjusted HR for major adverse cardiac event: 0.63 [95% CI: 0.48 to 0.83]).

CONCLUSIONS

Although women had worse baseline characteristics, no differences in 3-year outcomes were observed between men and women. Compared with BMS use, DES use has decreased revascularization rate equally in women and men.

[Gender bias in women with myocardial infarction: ten years after]

OBJECTIVE

Previous studies show that the women with acute myocardial infarction (AMI) receive less fibrinolitic treatment than the men. The objective of this study is to analyze if it exists any difference in fibrinolysis related to gender and to compare the results with those obtained 10 years ago.

DESIGN

Retrospective descriptive study that compare patients with AMI of less than 24 hours of evolution of studies Analysis of Delay in Acute Infarct of Myocardium (ARIAM) in 2003-2004 and Project of Analysis Epidemiologist of Critical Patient (PAEEC) of 1992-1993.

SETTING

ICUs from 86 hospitals in Spain that participated in the PAEEC study and 120 ICUs in the ARIAM.

PATIENTS

We compared data of 9,981 patients including in study ARIAM in 2003-2004 with 1,668 of the PAEEC of 1992-1993.

RESULTS

Women were less likely to receive thrombolytic therapy than men (odds ratio= 0.82, p < 0.01), after adjusting for age, origin, size of the hospital and antecedents. The probability of fibrynolisis is lower in elderly, patients referred from the general ward, in hospitals of more than 1,000 beds and patients with arterial hypertension, stroke, diabetes or peripheral vascular disease. The probability of fibrinólisis is higher when patient is transferred from another hospital (followed by those of Emergencies Room), in the hospitals by less than 300 beds (followed by those of 300-1,000) and when history of prior ischemic heart disease exists. Comparing the two periods, has increased the frequency of fibrynolisis in both genders, although the increment has been greater in the women.

CONCLUSIONS

The women with AMI continue receiving less fibrynolisis, although exists an increase in the number of treatments superior to register in the men.

Gender biases and discrimination: a review of health care interpersonal interactions

A good interpersonal relationship between a patient and provider, as characterized by mutual respect, openness, and a balance in their respective roles in decision-making, is an important marker of quality of care. This review is undertaken from a gender and health equity perspective and illustrates that gender biases and discrimination occur at many levels in the healthcare delivery environment, and affects the patient-provider interaction which can result in health inequities affecting individual health seeking behaviour, access to good quality healthcare, and, ultimately, health outcomes. Interventions will have to be introduced at multiple levels, from health system legislation and policy and gender sensitive training to the development of women and men centred services and health literacy programmes.

Detection and prevalence of abuse of older males: perspectives from family practice

Family doctors' frequent contact with seniors put them in reasonable positions to detect elder abuse and initiate referral to adult protective services. Since doctor reporting is low, however, this paper explores whether the gender of patient and/or doctor impacts on identification of elder mistreatment, or creates differential detection of one gender over the other. Use of the validated Elder Abuse Suspicion Index (EASI), and a structured social work evaluation, is described to provide some gender-based data from Canadian family practice. Specifically, while the prevalence of elder abuse is estimated to range from 12.0% to 13.3%, the specific prevalence was found for females to be 13.6% to 15.2% and for males 9.1% to 9.7%.

Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes

BACKGROUND

Previous studies examining sex-related differences in the treatment of coronary artery disease have focused on patients in hospital. We sought to examine sex-related differences at an earlier point in care--presentation to the emergency department.

METHODS

We collected data on ambulatory care and hospital admissions for 54,134 patients (44% women) who presented to an emergency department in Alberta between July 1998 and March 2001 because of acute myocardial infarction, unstable angina, stable angina or chest pain. We used logistic regression and Cox regression analyses to determine sex-specific associations between the likelihood of discharge from the emergency department or coronary revascularization within 1 year and 1-year mortality after adjusting for age, comorbidities and socioeconomic factors.

RESULTS

Following the emergency department visit, 91.3% of patients with acute myocardial infarction, 87.4% of those with unstable angina, 40.7% of those with stable angina and 19.8% of those with chest pain were admitted to hospital. Women were more likely than men to be discharged from the emergency department: adjusted odds ratio (and 95% confidence interval [CI]) 2.25 (1.75-2.90) for acute myocardial infarction, 1.71 (1.45-2.01) for unstable angina, 1.33 (1.15-1.53) for stable angina and 1.46 (1.36-1.57) for chest pain. Women were less likely than men to undergo coronary revascularization within 1 year: adjusted odds ratio (and 95% CI) 0.65 (0.57-0.73) for myocardial infarction, 0.39 (0.35-0.44) for unstable angina, 0.35 (0.29-0.42) for stable angina and 0.32 (0.27-0.37) for chest pain. Female sex had no impact on 1-year mortality among patients with acute myocardial infarction; it was associated with a decreased 1-year mortality among patients with unstable angina, stable angina and chest pain: adjusted hazard ratio (and 95% CI) 0.60 (0.46-0.78), 0.60 (0.46-0.78) and 0.74 (0.63-0.87) respectively.

INTERPRETATION

Women presenting to the emergency department with coronary syndromes are less likely than men to be admitted to an acute care hospital and to receive coronary revascularization procedures. These differences do not translate into worse outcomes for women in terms of 1-year mortality.

Coronary heart disease in women: update 2008

Coronary heart disease (CHD) remains the leading cause of mortality for US women, responsible for almost 250,000 deaths annually. Preventive heart-health behavioral changes by women and aggressive coronary risk reduction can decrease the number of women disabled and killed by CHD. Angina is the predominant initial and subsequent presentation of CHD in women; categorization of chest pain and risk stratification of women assume pivotal roles. A robust evidence-based algorithm can guide cardiovascular imaging techniques to evaluate women with suspected myocardial ischemia to detect those with worsened survival. Restricted functional capacity (<5 METs) is a consistent marker of worsened prognosis. Younger women have substantially higher mortality rates than men following myocardial infarction and coronary bypass surgery. Although these women have more comorbidity and risk factors, other issues including biological differences, treatment differences, and psychosocial factors require management strategies tailored to the unique needs of women.

Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20,290 patients from the AMIS Plus Registry

BACKGROUND

Gender differences in management and outcomes have been reported in acute coronary syndrome (ACS).

OBJECTIVES

To assess such gender differences in a Swiss national registry.

METHODS

20 290 patients with ACS enrolled in the AMIS Plus Registry from January 1997 to March 2006 by 68 hospitals were included in a prospective observational study. Data on patients' characteristics, diagnoses, procedures, complications and outcomes were recorded. Odds ratios (ORs) of in-hospital mortality were calculated using logistic regression models.

RESULTS

5633 (28%) patients were female and 14 657 (72%) male. Female patients were older than men (mean (SD) age 70.9 (12.1) vs 63.4 (12.9) years; p<0.001), had more comorbidities and came to hospital later. They underwent percutaneous coronary intervention (PCI) less frequently (OR = 0.65; 95% CI 0.61 to 0.69) and their unadjusted in-hospital mortality was higher overall (10.7% vs 6.3%; p<0.001) and in those who underwent PCI (3.0% vs 4.2%; p = 0.018). Mortality differences between women and men disappeared after adjustments for other predictors (adjusted OR (aOR) for women vs men: 1.09; 95% CI 0.95 to 1.25), except in women aged 51-60 years (aOR = 1.78; 95% CI 1.04 to 3.04). However, even after adjustments, female gender remained significantly associated with a lower probability of undergoing PCI (OR = 0.70; 95% CI 0.64 to 0.76).

CONCLUSIONS

The analysis showed gender differences in baseline characteristics and in the rate of PCI in patients admitted for ACS in Swiss hospitals between 1997 and 2006. Reasons for the significant underuse of PCI in women, and a slightly higher in-hospital mortality in the 51-60 year age group, need to be investigated further.

Sex-and age-based differences in the delivery and outcomes of critical care

BACKGROUND

Previous studies have suggested that a patient's sex may influence the provision and outcomes of critical care. Our objective was to determine whether sex and age are associated with differences in admission practices, processes of care and clinical outcomes for critically ill patients.

METHODS

We used a retrospective cohort of 466,792 patients, including 24,778 critically ill patients, admitted consecutively to adult hospitals in Ontario between Jan. 1, 2001, and Dec. 31, 2002. We measured associations between sex and age and admission to the intensive care unit (ICU); use of mechanical ventilation, dialysis or pulmonary artery catheterization; length of stay in the ICU and hospital; and death in the ICU, hospital and 1 year after admission.

RESULTS

Of the 466,792 patients admitted to hospital, more were women than men (57.0% v. 43.0% for all admissions, p < 0.001; 50.1% v. 49.9% for nonobstetric admissions, p < 0.001). However, fewer women than men were admitted to ICUs (39.9% v. 60.1%, p < 0.001); this difference was most pronounced among older patients (age > or = 50 years). After adjustment for admission diagnoses and comorbidities, older women were less likely than older men to receive care in an ICU setting (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.66-0.71). After adjustment for illness severity, older women were also less likely than older men to receive mechanical ventilation (OR 0.91, 95% CI 0.81-0.97) or pulmonary artery catheterization (OR 0.80, 95% CI 0.73-0.88). Despite older men and women having similar severity of illness on ICU admission, women received ICU care for a slightly shorter duration yet had a longer length of stay in hospital (mean 18.3 v. 16.9 days; p = 0.006). After adjustment for differences in comorbidities, source of admission, ICU admission diagnosis and illness severity, older women had a slightly greater risk of death in the ICU (hazard ratio 1.20, 95% CI 1.10-1.31) and in hospital (hazard ratio 1.08, 95% CI 1.00-1.16) than did older men.

INTERPRETATION

Among patients 50 years or older, women appear less likely than men to be admitted to an ICU and to receive selected life-supporting treatments and more likely than men to die after critical illness. Differences in presentation of critical illness, decision-making or unmeasured confounding factors may contribute to these findings.

Rate of Progression of Coronary Atherosclerotic Plaque in Women

OBJECTIVES

The purpose of this study was to determine the relationship between gender and the extent of coronary atherosclerosis assessed by intravascular ultrasound (IVUS) and its rate of progression in subjects treated with established medical therapies.

BACKGROUND

It is uncertain whether the pathophysiology of coronary artery disease (CAD) differs between genders.

METHODS

A systematic analysis was performed of 978 subjects who participated in serial studies of atheroma progression. Genders were compared with regard to the extent of coronary atheroma at baseline and subsequent change in response to use of established medical therapies.

RESULTS

Women were more likely to have a history of hypertension and higher levels of body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, C-reactive protein, and systolic and diastolic blood pressure. Despite this, women had less plaque in terms of percent atheroma volume (PAV) (33.9 +/- 10.2% vs. 37.8 +/- 10.3%, p < 0.001) and total atheroma volume (TAV) (148.7 +/- 66.6 mm3 vs. 194.7 +/- 84.3 mm3, p < 0.001). With medical therapy, the rate of change of PAV (0.7 +/- 0.6% vs. 0.7 +/- 0.5%, p = 0.92) and TAV (-2.3 +/- 3.2 mm3 vs. -1.9 +/- 2.9 mm3, p = 0.84) did not differ between genders. In the setting of intensive risk factor modification, there was no significant difference between genders with regard to the rates of plaque progression or regression.

CONCLUSIONS

Despite the presence of more risk factors, the extent of atheroma in women with angiographic CAD is less than in men in subjects participating in clinical trials that employed serial assessments with IVUS. The finding that the rate of plaque progression or regression does not differ between genders in the setting of intensive risk factor modification supports the use of established medical therapies in women with CAD.

A comprehensive view of sex-specific issues related to cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of mortality in women. In fact, CVD is responsible for a third of all deaths of women worldwide and half of all deaths of women over 50 years of age in developing countries. The prevalence of CVD risk factor precursors is increasing in children. Retrospective analyses suggest that there are some clinically relevant differences between women and men in terms of prevalence, presentation, management and outcomes of the disease, but little is known about why CVD affects women and men differently. For instance, women with diabetes have a significantly higher CVD mortality rate than men with diabetes. Similarly, women with atrial fibrillation are at greater risk of stroke than men with atrial fibrillation. Historically, women have been underrepresented in clinical trials. The lack of good trial evidence concerning sex-specific outcomes has led to assumptions about CVD treatment in women, which in turn may have resulted in inadequate diagnoses and suboptimal management, greatly affecting outcomes. This knowledge gap may also explain why cardiovascular health in women is not improving as fast as that of men. Over the last decades, mortality rates in men have steadily declined, while those in women remained stable. It is also becoming increasingly evident that gender differences in cultural, behavioural, psychosocial and socioeconomic status are responsible, to various degrees, for the observed differences between women and men. However, the interaction between sex-and gender-related factors and CVD outcomes in women remains largely unknown.

Gender-age interaction in early mortality following primary angioplasty for acute myocardial infarction

Previous studies have demonstrated a significant interaction between gender and age after medically treated acute myocardial infarction (AMI), when younger women were found to have a higher mortality rate than younger men, but the mortality rate for older men and women was similar. The study objective was to determine whether a gender-age interaction exists for AMI treated exclusively with primary angioplasty. This analysis was a retrospective cohort study of 9,015 consecutive patients who underwent primary angioplasty for AMI in New York State from 1997 to 1999. The primary end point of interest was in-hospital mortality. A logistic regression model was constructed to determine the relation between gender and mortality among patients with AMI treated with angioplasty. Additional analyses were performed to test whether a mortality difference existed according to age. In-hospital mortality rate was twofold higher in women than in men (6.7% vs 3.4%, p <0.001). After adjusting for age, co-morbid conditions, and hemodynamic status by multivariable logistic regression analysis, the odds ratio for in-hospital death for women was no longer significant (odds ratio 1.21, 95% confidence interval 0.69 to 2.10, p = 0.51). Among patients <75 years of age, women had a 37% increased risk of in-hospital mortality (adjusted odds ratio 1.37, 95% confidence interval 1.01 to 1.98, p = 0.04), whereas there was no significant difference in mortality between men and women who were >or=75 years of age. In conclusion, female gender was found to be an independent predictor of in-hospital mortality in patients <75 years of age after primary angioplasty for AMI.

Short- and long-term prognosis after acute myocardial infarction in men versus women

The prevailing view is that women have a higher early mortality after acute myocardial infarction (AMI) than men, but several studies have shown no differences. Further, long-term differences have not been addressed widely. The present study examined gender differences in short- and long-term prognoses after AMI in The Netherlands. A nationwide cohort of 21,565 patients with a first hospitalized AMI in 1995 was identified through linkage of the National Hospital Discharge Register and the population register. Crude short- and long-term mortalities were significantly higher in women than in men (28-day hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.58 to 1.82; 5-year HR 1.52, 95% CI 1.46 to 1.59). After adjustment for age, the risk difference was attenuated at 28 days and even reversed at 5 years in favor of women (28-day HR 1.11, 95% CI 1.03 to 1.20; 5-year HR 0.94, 95% CI 0.90 to 0.99). When differences in other covariates were also taken into account, the risk differences remained virtually the same. To account for differences in reperfusion procedures, we repeated the analyses in 1,176 patients who underwent acute reperfusion therapy (angioplasty/thrombolysis). Comparable, but not statistically significant, gender differences were observed (28-day HR 1.06, 95% CI 0.65 to 1.74; 5-year HR 0.82, 95% CI 0.62 to 1.08). In conclusion, our findings in an unselected cohort covering a complete nation indicate that the worse short- and long-term prognoses after an AMI in women compared with men may largely be explained by differences in age, whereas differences in co-morbidity, origin, infarct location, and reperfusion therapy seem to contribute little.

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.

Influence of gender on treatment and short-term mortality of patients with acute myocardial infarction in Berlin

AIMS

Previous studies have shown higher hospital mortality rates in women, especially younger women, than in men. In light of the fact that myocardial infarction therapy is rapidly developing, and since gender-specific aspects have been discussed in detail during recent years, it was our goal to re-evaluate factors influencing hospital mortality rate, especially those involving gender-specific differences, in the city of Berlin, Germany.

METHODS

We prospectively collected data from 5133 patients (3330 men and 1803 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the years 1999 to 2002.

RESULTS

During hospitalization the overall mortality rate was 18.6% among women and 8.4% among men. Women were older (mean age for men 62 years; women 73 years) and less likely to be married (men 74.6%; women 36.9%) than men. Women generally took longer to arrive at the hospital after infarction than did men (median time: men 2.0 h; women 2.6 h). Women furthermore demonstrated a higher proportion of diabetes (men 22.8%; women 36.5%) and hypertension (men 58.0%; women 69.3%). Reperfusion therapy (men 68.8%; women 49.7%) and administration of beta-blockers (men 76.0%; women 66.0%) took place less often for women than for men. A multivariate analysis revealed the following factors to be independent predictors of hospital mortality: age, gender, diabetes mellitus, hypercholesterolemia, pre-existing heart failure, pre-hospital cardiopulmonary resuscitation, cardiogenic shock and pulmonary congestion on admission, admission to a hospital with >600 beds, ST-elevation in the initial ECG, reperfusion therapy, as well as beta-blocker and ACE inhibitor treatment within 48 h of hospitalization.

CONCLUSION

Even after adjustment in multivariate analysis, women with acute myocardial infarction still demonstrate a higher risk for in-hospital death than men.

Gender differences in the management and experience of Chronic Obstructive Pulmonary Disease

Whether women receive the same medical care for COPD as men and if they are at risk of different outcomes as a result, is not known. The Confronting COPD International Survey was performed in the USA, Canada, France, Italy, Germany, The Netherlands, Spain and the UK in 2000 with 3265 COPD participants. Forty-one per cent were women; mean age in women and men was 61.2 (SD 10.5) and 64.4 (11.0) years, mean pack-years of smoking 36 (29) and 46 (35) years, respectively. After adjusting for age, pack-years, country and severe dyspnea (MRC scores 5 and 4), women were less likely to have had spirometry (OR 0.84, 95% C.I. 0.72-0.98) but more likely to get smoking cessation advice (OR 1.57, 1.33-1.86). Despite significantly lower pack-years of smoking, women were more likely to report severe dyspnea than men (OR 1.30, 1.10-1.54), with similar cough (OR 1.08, 0.92-1.27) and less sputum (OR 0.84, 0.72-0.98). There were no differences in the risk of hospitalisation or emergency room visit. This study indicates that gender differences in COPD care and outcomes exist.