A gender perspective on short- and long term mortality in ST-elevation myocardial infarction — A report from the SWEDEHEART register
Introduction
Increased attention has been paid to gender differences in outcomes for patients who have experienced myocardial infarction [MI] in the period 2000–2010. Many studies have indicated higher mortality in women [1], [2], [3], [4], [5], [6], [7], [8], [9] especially during the time when they are in the hospital. Existing studies have not been able to establish if this period of higher mortality might be due to differences in background characteristics, a possible difference in treatment regime for women compared with men, or if it might be related to sex per se. Gender differences in outcome have been reported in some [5], [7], [9], [10] but not all of the published studies even after the researchers had made multivariable adjustments [4], [6]. Discrepancies may be due to differences in patient selection, study population size, covariates in multivariable adjustments and a case mix of ST- and non ST-elevation myocardial infarctions (STEMI and NSTEMI) [3], [7], [8], [11]. The prevalence of both STEMI and NSTEMI differs between men and women [2], [12], and a significant interaction between type of myocardial infarction and gender regarding outcome has been shown [2], [13], [14] with the same or better prognosis in women in NSTEMI [15] but worse in STEMI [14]. STEMI cohorts have often been selected from groups participating in randomised controlled trials [9], [10], so these cohorts may not be representative of an unselected population. There are limited data regarding gender differences in outcome in STEMI based on unselected cohorts, and gender-specific data on long-term prognosis after STEMI are virtually lacking. Thus larger studies with unselected study populations and with more complete adjustments for confounding factors are needed if we are to be able to determine if there are differences in risk between males and females in particular age groups. The main objective of the present study was to evaluate possible gender differences in short and long term outcomes in a large unselected STEMI cohort.
Section snippets
Patients
Data for this study came from the prospective observational register the full name of which is The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) [16], which includes the following registers that previously were kept separately: The Registry of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), the Swedish Coronary Angiography and Angioplasty Registry (SCAAR),
Baseline characteristics
A total of 54,146 patients were included in the analyses of which 18,876 (35%) were women. The average age of women on admission was 73.2 and of men 66.3. The median length of the time interval between symptom onset and arrival at CCU was 30 min longer for women than for men. After adjustment for age, female sex was associated with a history of smoking, diabetes mellitus, hypertension, heart failure, chronic obstructive pulmonary disease and dementia, whereas male sex was associated with a
Discussion
Data on the relationship between gender and the long-term prognosis after MI are very limited, especially for STEMI. In this long-term follow-up study covering almost all Swedish STEMI patients hospitalised between 1995 and 2006, we had complete mortality data for these patients for up to a maximum of 13 years and a mean of 4.6 years after admission. To our knowledge this is the first study of possible gender differences in the long term prognosis for re-infarction and death in a multicentre
Conclusion
In the long-term follow-up of STEMI, female gender is correlated with better prognosis after multivariable adjustments. On the other hand, women have approximately a 20% higher multivariable adjusted risk of in-hospital mortality, and this risk is possibly even higher in the youngest age group. Thus there is a need for more studies in the current primary PCI era that are designed to help us understand why women, and perhaps especially young women, fare worse than men after STEMI during the
Acknowledgements
We thank all the participating hospitals for their help and co-operation to contribute with data to the SWEDEHEART register.
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