Sex Differences in Survival Rates after Acute Myocardial Infarction

Tunstall-Pedoe H Kuulasmaa K Amouyel P Arveiler D Rajakangas AM Pajak A . WHO MONICA. Project. Myocardial infarction and coronary deaths in the World Health Organization MONICA Project. Registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 1994; 90: 583–612.

The event-case, mortality and case-fatality of myocardial infarction in the late 1980s in 38 populations participating in the WHO-MONICA project are reported. This major effort to set up sound, standard methods to obtain comparable data allows the scientific community to firmly establish the magnitude of coronary heart diseases in the world for the first time.

McGovern PG, Pankow JS, Shahar E, Doliszny KM, Folsom AR, Blackburn H, Luepker RV, for the Minnesota Heart Survey Investigators. Recent trends in acute coronary heart disease. N Engl J Med 1996; 334: 884–890.

Pérez G, Pena A, Sala J, Roset P, Masiá R, Marrugat J, and the REGICOR Investigators. Acute myocardial infarction case-fatality, incidence and mortality rates in a population registry in the province of Gerona, Spain 1990 to 1992. Int J Epidemiol 1998; 27: 599–604.

Kannel WB Abbot RD . Incidence and prognosis of myocardial infarction in women: The Framingham Study. In: Eaker ED Packard B Wenger MK Clarkson TB Tyroler HA . (editors): Coronary heart disease in women: Proc NIH Workshop. New York: Haymarket Doyma; 1987. pp. 208–214.

The cohort study in the Framingham study shows that women fare worse than men after a myocardial infarction as a result of early case fatality. Angina was also a more frequent presentation of coronary heart disease in women than in men, in whom it usually followed myocardial infarction.

Chambless L Keil U Dobson A Mähonen M Kuulasma K Rajakangas AM , for the MONICA Project. Population versus clinical view of case fatality from acute coronary heart disease. Results from the WHO MONICA Project 1985–1990. Circulation 1997; 96: 3849–3859.

This paper presents and discusses WHO MONICA population case fatality data. Some participating centers showed significantly higher case fatality after myocardial infarction in women than in men. None, however, observed the opposite. The highest imbalance was observed in low-incidence areas.

Vaccarino V Krumholz HM Berkman LF Horwitz RI . Sex differences in mortality after myocardial infarction. Is there evidence for an increased risk for women?. Circulation 1995; 91: 1861–1871.

This revision of 27 studies showed that most of the increase in early mortality observed in women is explained by their age and higher comorbidity. In short-term survivors, mortality was similar at 1 year but better in women thereafter. The authors highlight the great variability of methods and adjustment variables among studies.

Eaker ED Chesebro JH Sacks FM Wenger NK Whisnant Winston M . Cardiovascular disease in women. Circulation 1993; 88: 1999–2009.

Murray CJL Lopez AD . Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet 1997; 349: 1498–1504.

Greenland P Reicher-Reiss H Goldbourt U , Behar S, and the Israeli SPRINT Investigators. In-hospital and 1-year mortality in 1524 women after myocardial infarction. Comparison with 4315 men. Circulation 1991; 83: 484–491.

Short-term survival after myocardial infarction was shown to be worse in the female sex in a large cohort of myocardial infarction patients. Fully adjusted analysis which included severity permitted determination of the independent effect of female sex on worse prognosis. Diabetic women are identified as a particularly high-risk group once myocardial infarction has occurred.

Becker RC Terrin M Rose R Knatterud GL . Desvigne-Nickens P, Gore JM, Braunwald E. Comparison of clinical outcomes for men and women after acute myocardial infarction. Ann Intern Med 1994; 120: 638–645.

Jenkins JS Flaker GC Nolte B Prince LA Morris D Kurz J Petrosky GF . Causes of higher in-hospital mortality in women than in men after acute myocardial infarction: the Framingham study. Am J Cardiol 1994; 73: 319–322.

Marrugat J, Antó JM, Sala J, Masiá R, and the REGICOR Investigators. Influence of gender in acute and long-term cardiac mortality after a first myocardial infarction. J Clin Epidemiol 1994; 47: 111–118.

Women had greater myocardial infarction 28-day case-fatality than men although differences were only marginally significant. Severity in terms of heart failure in the acute phase of myocardial infarction accounted for a large part of the sex case-fatality differences.

Marrugat J, Sala J, Masiá R, Pavesi M, Sanz G, Valle V, Molina L, and the RESCATE Investigators. Differences in acute and six-month mortality between men and women hospitalized for a first myocardial infarction. J Am Med Assoc 1998; 280: 1405–1409.

Women showed worse 28-day and 6-month case fatality, and 6-month case fatality or readmission after myocardial infarction than men after adjustment for all confounding factors. Severity explained the sex differences in 28-day and 6-month case fatality, but not 6-month case fatality or readmission.

Rozalén I Ceniceros Simeón R Gastaldo O'Callaghan A Cabadés Doménech J Cebrián . The female sex is an independent prognosis factor for mortality in the acute phase of myocardial infarction [in Spanish]. Med Clin (Barc) 1997; 109: 171–174.

Ferriz JA Vera A Suarez G Torrado E Rodriguez JJ Alvarez JM Gender and mortality in acute myocardial infarction [in Spanish]. Rev Esp Cardiol 1993; 46: 796–801.

Tofler GH , Stone PH , Muller JE , Willich S , Davis VG , Poole WK , and the MILIS Study Group. Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women. J Am Coll Cardiol 1987; 9: 476–482.

Puletti M Sunseri L Curione M Erba SM Borgia C . Acute myocardial infarction: sex-related differences in prognosis. Am Heart J 1984; 108: 63–66.

Malacrida R , Genoni M , Maggioni AP , Spataro V , Parich S , Palmer A , for the Third International Study of Infarct Survival (ISIS-3) Collaborative Group. A comparison of the early outcome of acute myocardial infarction in women and men. N Engl J Med 1998; 338: 8–13.

This is a study with great statistical power which used the patients included in ISIS-3 trial. Besides early mortality, sex differences in other major clinical events during hospitalization were checked. After adjusting for potential confounding variables, women were at higher risk of early mortality, cardiogenic shock, heart failure, cardiac rupture, reinfarction and major bleeding than men.

White HD , Barbash GI , Modam M , Simes J , Diaz R , Hampton JR , for the Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Study. After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. Circulation 1993; 88: 2097–2103.

Demirovic J Blackburn H McGovern PG Luepker R Sprafka JM Gilbertson D . Sex differences in early mortality after acute myocardial infarction (The Minnesota Heart Survey). Am J Cardiol 1995; 75: 1096–1101.

This study demonstrated a significant interaction between sex and age. Adjusted early mortality was higher in women, but only among those aged < 65 years. In those older than 65 years there were no sex differences in early mortality after adjusting for confounding variables.

Sonke GS Beaglehole R Steward AW Jackson R Steward FM . Sex differences in case fatality and after admission to hospital after acute cardiac events: analysis of community-based coronary heart disease register. Br Med J 1996; 313: 853–855.

This study reported adjusted analysis of early mortality before and after admission to hospital. The higher case fatality after AMI in women admitted to hospital is explained by differences in living status, previous AMI and medical treatment and is balanced by a lower case fatality before admission.

Bueno H Vidán T Almazán A López-Sendón JL Delcán JL . Influence of sex on the short-term outcome of elderly patients with first acute myocardial infarction. Circulation 1995; 92: 1133–1140.

Tunstall-Pedoe H Morrison C Woodward M Fitzpatrick B Watt G . Sex differences in myocardial infarction and coronary deaths in the Scottish MONICA population of Glasgow 1985–91: presentation, diagnosis, treatment, and 28-day case fatality of 3991 events in men and women. Circulation 1996; 93: 1981–1992.

Similar population 28-day age-adjusted case fatality was found in both sexes after myocardial infarction in the Scottish MONICA Collaborating Center.

Weaver WD White HD Wilcox RG Aylward PE Morris D , Guerci A for the GUSTO-I Investigators. Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy. J Am Med Assoc 1996; 275: 777–782.

Herman B Greiser E Polabeln H . A sex difference in short-term survival after initial myocardial infarction: the MONICA-Bremen acute myocardial infarction register 1985–90. Eur Heart J 1997; 18: 963–970.

This is one of the few studies that examined patients previous treatments. Women with an acute myocardial infarction had significantly higher percentages of pre-infarction use of diuretics, antihypertensive and inotropic medications than men. Moreover, during acute events women received fewer medications and procedures than men. After adjusting for these differences and age, sex was no longer an independent predictor of early case fatality.

Herman B Greiser E Polabeln H . A reply [letter]. Eur Heart J 1998; 19: 354.

In this letter, age-adjusted 28-day population case fatality differences between sexes are presented as complementary information to reference [25].

Coronado BE Griffith JL Beshansky JR Selker JT . Hospital mortality in women and men with acute cardiac ischemia: a prospective multicenter study. J Am Coll Cardiol 1997; 29: 1490–1496.

This study found that in-hospital case fatality in women did not differ from that in men when Killip class was taken into account. Since Killip class can be considered a mechanism of death, this finding suggests that women die from congestive heart failure after myocardial infarction.

Fiebach NH Viscoli CM Horwitz RI . Differences between women and men in survival after myocardial infarction. Biology or Methodology?. J Am Med Assoc 1990; 263: 1092–1096.

He J Klag MJ Whelthon PK Yuchang Z Xinzhi W . Short- and long-term prognosis after acute myocardial infarction in Chinese men and women. Am J Epidemiol 1994; 139: 693–703.

Goldberg RJ Gorak EJ Yarzebski J Hosmer DW Dalen P Gore JM A community wide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease. Circulation 1993; 87: 1947–1953.

Both pre- and in-hospital myocardial infarction deaths were analyzed between 1975 and 1988. No conclusive results were reached regarding in-hospital case fatality trends, but a clear declining trend in pre-hospital deaths was observed in men and in women. There were no differences in the multivariate adjusted analysis between men and women in in-hospital mortality. Conversely, men had a worse long-term prognosis (14 years).

Kober L Torp-Pedersen C Ottesen M Rasmussen S Lessing M , Skagen K, on behalf of the TRACE Study Group. Influence of gender on short- and long-term mortality after acute myocardial infarction. Am J Cardiol 1996; 77: 1052–1056.

Maynard C Every NR Martin JS Kudenchuk PJ Weaver D . Association of gender and survival in patients with acute myocardial infarction. Arch Intern Med 1997; 157: 1379–1384.

This paper showed that, during hospitalization, women with acute myocardial infarction were less likely to undergo coronary angiography, thrombolytic therapy, coronary angioplasty or bypass surgery. After adjusting for confounders, women had worse early prognosis than men but no differences in long-term follow-up were found.

Galatius-Jensen S Launbjerg J Mortensen LS Spange Hansen JF . Sex-related differences in short- and long-term prognosis after acute myocardial infarction: 10-year follow-up of 3073 patients in database of first Danish verapamil infarction trial. Br Med J 1996; 313: 137–140.

Dittrich H Gilpin E Nicod P Cali G Henning H Ross JR Jr . Acute myocardial infarction in women: influence of gender on mortality and prognostic variables. Am J Cardiol 1988; 62: 1–7.

Benderly M, Behar S, Reicher-Reiss H, Boyko V, Goldbourt U, for the SPRINT Investigators. Long-term prognosis of women after myocardial infarction. Am J Epidemiol 1997; 146: 153–160.

This is one of the few studies reporting a statistically significant worse prognosis in women with myocardial infarction than in men after a long-term follow up (12 years), even after adjusting for potential confounding variables including severity at hospitalization.

Wong DN Cupples LA Ostfeld AM Levy D Kannel WB . Risk factors for long-term coronary prognosis after initial myocardial infarction: the Framingham Study. Am J Epidemiol 1989; 130: 469–480.

Brett KM Madans JH . Long-term survival after coronary heart disease. Comparisons between men and women in a national sample. Ann Epidemiol 1995; 5: 25–32.

Martin CA Thompson PL Armstrong BK Hobbs MST de Clerk N . Long term prognosis after recovery from myocardial infarction: a nine-year follow-up of the Perth Coronary Register. Circulation 1983; 68: 961–969.

Nine-year follow-up of myocardial infarction patients showed that male sex was an independent risk factor for mortality after adjustment for other clinical, comorbidity and severity factors.

Johansson S Bergstrand R Ulvenstam G Vedin A Wilhemsson C Wedel H Sex differences in preinfarction characteristics and long-term survival among patients with myocardial infarction. Am J Epidemiol 1984; 119: 610–623.

Robinson K Conroy RM Mulcahy R Hickey N . The 15-year prognosis of a first acute coronary episode in women. Eur Heart J 1992; 13: 67–69.

Weinblatt E Shapiro S Frank CW . Prognosis of women with newly diagnosed coronary disease: a comparison with causes of disease among men. Am J Public Health 1973; 63: 577–593.

Pohjola S Siltanen P Romo M . Five-year survival of 728 patients after myocardial infarction: a community study. Br Heart J 1980; 43: 176–183.

In this study, a 5-year follow-up of a sample of 728 28-day consecutive myocardial infarction patient survivors younger than 66 years showed that mortality among women was lower than among men. The study was conducted in an area having a high incidence of myocardial infarction in Finland.

Gottlieb S Moss A McDermott M Eberly S . Comparison of posthospital survival after acute myocardial infarction in women and men. Am J Cardiol 1994; 74: 727–730.

The analysis included important variables of left ventricular ejection fraction, arrhythmias and heart rate variability, factors generally not included in other studies on gender and prognosis after AMI. Post-hospital cardiac mortality after AMI was influenced primarily by the degree of cardiac dysfunction and known risk factors and was independent of gender.

Kostis J Wilson A O'Dowd K Gregory P Chelton S , Cosgrove N for the MIDAS study group. Sex differences in the management and long-term outcome of acute myocardial infarction. Circulation 1994; 90: 1715–1729.

A detailed analysis of sex differences in management and long-term outcome after myocardial infarction is presented. Women were less likely to have invasive cardiac procedures. Adjusted 3-year mortality risk was significantly greater in women only in patients older than 70 years.

Rothman KJ Greenland S . Precision and validity of studies. In: Rothman KJ Greenland S (editors): Modern Epidemiology. Philadelphia: Lippincott-Raven; 1998. pp. 123–125.

Killip T Kimball JT . Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients. Am J Cardiol 1967; 20: 457–464.

Luepker RV . Population versus clinical views in coronary disease: can epidemiological data be useful to clinicians? Circulation 1997; 96: 3836–3837.

Maynard C Litwin PE Martin JS Weaver WD . Gender differences in the treatment and outcome of acute myocardial infarction. Results from the myocardial infarction triage and intervention registry. Arch Intern Med 1992; 152: 972–976.

Although in patients who underwent coronary angiography there were no sex differences in the use of coronary angioplasty or bypass, women received less coronary angiography than men. Clinical decision-making for coronary angiography seems to differ between sexes.

Mendelson MA Hendel RC . Myocardial infarction in women. Cardiology 1995; 86: 272–285.

Masiá R , Pena A , Marrugat J , Sala J , Vila J , Pavesi M , and the REGICOR Investigators. High prevalence of cardiovascular risk factors in Gerona, Spain, a region with low myocardial infarction incidence. J Epidemiol Commun Health 1998; 52: 707–715.

Ayanian JZ Epstein AM . Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991; 325: 221–225.

Fewer diagnostic procedures were shown to be used among women with myocardial infarction than men. Underuse in women and overuse in men are discussed as possibilities to explain such differences.

Hussain KM Estrada AQ Kogan A Dadkhah S Foschi A . Trends in success rate after percutaneous transluminal coronary angioplasty in men and women with coronary artery disease. Am Heart J 1997; 134: 719–727.

The authors show that PTCA has at least the same benefits in women as in men, provided appropriate catheter diameters are used.

Kahn SS Nesim S Gray R Czer LS Chaux A Matloff J . Increased mortality of women in coronary artery bypass surgery: evidence for referral bias. Ann Intern Med 1990; 11: 561–567.

This report showed that when women did worse than men after coronary artery bypass surgery; outcome seemed to be accounted for by women being older and more severely diseased than male patients.

King KB Clark PC Hicks GL Jr Patterns of referral and recovery in women and men undergoing coronary artery bypass surgery. Am J Cardiol 1992; 69: 179–182.