Eleven-Year Trends in Gender Differences of Treatments and Mortality in ST-Elevation Acute Myocardial Infarction in Northern Italy, 2000 to 2010

doi:10.1016/j.amjcard.2014.05.007

The American Journal of Cardiology

Volume 114, Issue 3, 1 August 2014, Pages 336-341

https://doi.org/10.1016/j.amjcard.2014.05.007 Get rights and content

The aim of this study was to assess recent trends in hospital mortality and in the treatment techniques for patients with ST-segment elevation myocardial infarction according to gender. Data on hospitalizations for ST-segment elevation myocardial infarction from 2000 to 2010 were extracted from hospital discharge record databases (International Classification of Diseases, Ninth Revision, Clinical Modification, codes) in the Lombardy Region of Italy. The impact of female gender on in-hospital mortality was assessed by multivariable regression after adjusting for invasive approach use (i.e., coronary angiography, angioplasty or coronary artery bypass graft), age, and co-morbidities. A total of 89,562 patients, men (66.5%) and women (33.5%), were enrolled. The use of an invasive approach increased over time in both sexes although it was higher in men (from 54.9% in 2000 to 91.9% in 2010 in men; from 36.8% in 2000 to 72.0% in 2010 in women). This pattern was driven by the subgroup of patients aged ≥75 years, whereas differences between sexes were not observed in patients <65 years and were small in patients aged 65 to 74 years. In-hospital mortality presented a small decrease from 7.6% in 2000 to 6.2% in 2010 in men (p for trend = 0.004), whereas it remained higher and substantially constant over time in women (16.6% in 2000, 15.5% in 2010, p for trend = 0.09). At multivariable regression, female gender did not emerge as an independent predictor of mortality (p = 0.13). However, a significant gender-age interaction was found, with female gender being a significant predictor of increased mortality in patients aged ≥75 years (odds ratio [OR] 1.33) while predicting a reduced mortality in patients aged <75 years (OR 0.93, p for interaction <0.0001). The use of an invasive approach was an independent predictor of mortality (OR 0.23, p <0.0001), the magnitude of mortality reduction being higher in men than in women and in patients aged <75 years than in those aged ≥75 years. In conclusion, a weak temporal trend in mortality reduction is observed in men only, which is driven by patients aged ≥75 years. In-hospital mortality remains higher in women than in men, although female gender is not a significant predictor of mortality. Despite temporal increases in the use of an invasive approach, women are more often treated conservatively.

Section snippets

Methods

Cross-sectional data on all hospitalizations in Lombardy, a large Northern Italy region with >9.5 million subjects, during 2000 to 2010 were extracted from the regional hospital discharge record (HDR) database that covers all patient admissions to hospitals connected to the network of Italian National Health System. Briefly, all HDRs that belonged to major diagnostic category groups 1, 4, and 5, corresponding to neurologic, respiratory, and cardiovascular diseases, respectively, were extracted

Results

Between 2000 and 2010, a total of 89,562 patients, men (66.5%) and women (33.5%), have been admitted to the hospital. Baseline clinical characteristics according to sex are listed in Table 1. Briefly, women were older than men. The gap in mean admission patient age between sexes tended even to slightly increase over time. Women presented a higher prevalence of chronic renal failure and a lower prevalence of peripheral vascular disease and neoplasms (Table 1). First admission ward was more

Discussion

The main findings of this study that enrolled a broad unselected population of all-comer STEMI patients from a high-density population region are as follow: (1) despite improvement in the use of an invasive approach and in particular of PCI for the treatment of STEMI in both sexes over time, women still receive less frequently an invasive treatment and such gender-treatment gap persists over time; (2) a small decline in in-hospital mortality over time was observed in men only, while women

Disclosures

The authors have no conflict of interest to disclose.

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SCAI Expert Consensus Statement on Sex-Specific Considerations in Myocardial Revascularization
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Impact of the Admission Pathway on the Gender-Related Mortality of Patients With ST-Elevation Myocardial Infarction
2022, American Journal of Cardiology
The mortality of women with ST-elevation myocardial infarction (STEMI) exceeds that of men, supposedly the result of older age and co-morbidities. Patients with STEMI can be transported directly to the catherization lab by the emergency medical service (EMS) or to the emergency department (ED) by the EMS, a regular ambulance, or independently. This raises the question whether gender disparity in the transport of patients with STEMI may affect time to therapy and consequently explain the disparate outcome in men and women with STEMI. We analyzed a large nationwide registry of prospectively-recorded patients with acute coronary syndromes in order to determine if there is a survival gap between men and women with STEMI, and to assess the gender-related effect of admission pathway on time intervals and 5-year mortality. Study population included 2,740 patients with STEMI who underwent primary percutaneous coronary interventions, comprising 464 women (17%, median-70 years) and 2,276 men (83%, median-58 years). The unadjusted 5-year mortality of women was higher compared with men (26.4% vs 15.6%, p = 0.001) but adjustment abrogated this survival difference. Regardless of adjustment, the 5-year mortality of patients with STEMI admitted directly to the catherization lab or to the ED by EMS was similar for men and women but significantly lower in the directly admitted patients (p <0.028). In contrast, admission to the ED by non-EMS was associated with markedly worse survival among women. These results indicate that women suspected of STEMI benefit from transportation by the EMS and should use this pathway exclusively to reach the hospital.
No significant gender difference in hospitalizations for acute coronary syndrome in Switzerland over the time period of 2001 to 2010
2017, International Journal of Cardiology
Citation Excerpt :
Only the increase in the oldest age group (80 +) was significant and can be explained by the increasing practice of invasive procedures in the very elderly, parallel to the higher life expectancy. As shown in a large Italian cohort study consisting of 89.562 patients, the use of an invasive approach increased markedly over time in both sexes (from 54.9% in 2000 to 91.9% in 2010 in men; from 36.8% in 2000 to 72.0% in 2010 in women), while the change was mainly driven by the subgroup of patients aged 75 + years [41]. Similar in Switzerland, where the procedure of coronary angiography and PCI in ACS gained importance during the 1990s and rapidly replaced systemic thrombolysis.
Morbidity and mortality from cardiovascular diseases have decreased since the 1970s in most Western societies. However, it is unclear if this positive trend can also be found in younger women suffering from acute coronary syndrome (ACS).
This is a prospective single center registry study including 11.015 women and men hospitalized for a first ACS between the years 2001 and 2010. We analyzed ACS rates according to sex and age group using Poisson regression in order to assess temporal trends.
Overall ACS hospitalization rates per 100.000 inhabitants increased by 31% between 2001 and 2010 (Rate Ratio (RR) of 1.31, 95% CI 1.20–1.43; p < 0.001) with a similar increase in men (RR 1.29, p < 0.00001) and women (RR 1.35, p < 0.0001). Analyses of age-specific ACS rates showed a significant increase in ACS hospitalization rates only for the age groups 70–79 years (p = 0.003) and 80 + years (p < 0.00001). None of the age matched subgroups showed a sex related significant difference in trend for ACS hospitalization rates. Temporal trends for recorded risk factors showed a significant increase in smoking (p = 0.03), and a trend to increased obesity prevalence (p = 0.06) in females in the age group 60–69 years.
In contrast to other studies, we found no evidence for a particular increase in the number of younger women referred for a first ACS during the years 2001 and 2010. Potential negative effects of smoking and obesity on ACS incidence may be delayed to women older than 70 years.
Is female gender associated with worse outcome after ST elevation myocardial infarction?
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Citation Excerpt :
There is also a debate on the independent role of gender in clinical outcomes of patients with STEMI.3,9,15 Although female gender was demonstrated as an independent risk factor for mortality after STEMI in some of the studies,7,9,15 others have reported no independent impact of gender on clinical outcomes.2,3 The fact that female patients are generally older with more concurrent diseases, higher mortality in females may result from other confounding factors, rather than gender itself.16,17
To investigate the impact of gender in outcomes of patients with ST segment myocardial infarction in a setting with limited access to primary percutaneous coronary intervention
In 1017 consecutive patients hospitalized with ST segment myocardial infarction during years 2008–2013, distribution of risk factors, therapeutic methods, heart failure and in-hospital mortality were compared between males and females. Association of gender and primary outcomes was determined after adjustment for confounding factors.
Females were significantly older (66 ± 12.1 years vs. 59.5 ± 12.7 years, p < 0.001). Prevalence of hypertension, hyperlipidemia and diabetes was significantly higher in females (72.2% vs. 39%, p < 0.001, 36.1% vs. 20.3%, p < 0.001, 46.5% vs. 32.1%, p < 0.001, respectively). Presentation delay was similar in males and females. Females received reperfusion therapy more than males (63.2%vs. 55.8%, p = 0.032). Development of heart failure and in-hospital mortality were significantly higher in females (36.5% vs. 27.2%, p = 0.003 and 19.4% vs. 12.1%, p = 0.002, respectively).
However in multivariate analysis, female gender was not independently associated with increased rate of heart failure and in-hospital mortality
In a center with low rate of primary percutaneous coronary intervention, crude rates of heart failure and in-hospital mortality are higher in females; however, the association is lost after adjustment for baseline characteristics
End-of-life expenditure on health care for the older population: a scoping review
2024, Health Economics Review
Age and Sex Differences and Temporal Trends in the Use of Invasive and Noninvasive Procedures in Patients Hospitalized With Acute Myocardial Infarction
2022, Journal of the American Heart Association

View all citing articles on Scopus

: EC and GF equally contributed to this article.

: This study has been supported by a grant into the Strategic Research Finalized Ministerial Program by the Lombardy region (RFPS-2007-642981).

: See page 341 for disclosure information.

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Coronary Artery DiseaseEleven-Year Trends in Gender Differences of Treatments and Mortality in ST-Elevation Acute Myocardial Infarction in Northern Italy, 2000 to 2010

Section snippets

Methods

Results

Discussion

Disclosures

Am J Cardiol

Chest

Am Heart J

Am J Cardiol

Am J Cardiol

Int J Cardiol

Can J Cardiol

Am Heart J

Sex differences in management and outcome after acute myocardial infarction in the 1990s: a prospective observational community-based study. Israeli thrombolytic survey group

Circulation

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

Circulation

Gender differences in outcomes after primary angioplasty versus primary stenting with and without abciximab for acute myocardial infarction: results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial

Circulation

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

N Engl J Med

Coronary Artery Disease
Eleven-Year Trends in Gender Differences of Treatments and Mortality in ST-Elevation Acute Myocardial Infarction in Northern Italy, 2000 to 2010