Gender Gaps in Care Following Heart Attack Still Persist

This article was originally published on Practical Cardiology.

Padma Kaul, PhD

A new study from the University of Alberta is detailing the significant disparities in outcomes among men and women after their first heart attack.

Results of the study, which included data from more than 45,000 patients hospitalized between 2002-2016, concluded women were at a 20% higher risk of heart failure or dying within 5 years of their first myocardial infarction.

"Close enough is not good enough," said study investigator Padma Kaul, PhD, co-director of the Canadian VIGOUR Centre at the University of Alberta and Sex and Gender Science Chair from the Canadian Institutes of Health Research, in a statement from the American Heart Association. "There are gaps across diagnosis, access, quality of care and follow-up for all patients, so we need to be vigilant, pay attention to our own biases and to those most vulnerable to ensure that we have done everything possible in providing the best treatment."

With an interest in assessing how disparities in management of myocardial infarction may have changed over time, Kaul and a team of colleagues sought to compare prognoses after incident myocardial infarction in men and women using administrative databases available from Alberta’s ministry of health, which represents a population of 4.3 million people. Using a study period lasting from April 1, 2002-March 31, 2016, investigators identified a cohort of 45,064 patients aged 20 years and older with data related to incidence, angiographic findings, treatment, and clinical outcomes of patients with a first-time myocardial infarction.

Instances of myocardial infarction were identified through the use of ICD-9 and ICD-10 codes. Of note, the original search returned information related to 77,363 hospitalizations for myocardial infarction but after exclusion of those with missing data and those with a history of recurrent events or previous diagnosis, 45,064 remained.

Of the 45,064 patients included in the study, 30.8% were women, 54.9% of events were considered non–ST-segment–elevation myocardial infarction (NSTEMI), and 45.1% were considered ST-segment–elevation myocardial infarction (STEMI). In comparison to men, women in the cohort were older (median age, 72 vs 61 years), had more comorbidities, and had lower rates of diagnostic angiography (74% vs 87%). Among those who underwent angiography, women had a lower proportion of left main, 2-vessel disease with proximal left anterior descending or 3-vessel disease compared with men (33.4% vs 40.9%, P <.0001), and a higher frequency of 1-vessel disease or nonobstructive coronary artery disease (39.6% vs 29.1%, P <.0001).

Upon analysis, investigators found women had a higher unadjusted rate of in-hospital mortality than men in patients with STEMI (9.4% vs 4.5%) and patients with NSTEMI (4.7% vs 2.9%). In adjusted analyses, results indicated this difference remained significant for STEMI (aOR, 1.42; 95% CI, 1.24– 1.64) but not for NSTEMI (aOR, 0.97; 95% CI, 0.83–1.13). Further analysis suggested women were more likely to develop heart failure after STEMI (22.5% vs 14.9%) and NSTEMI (23.2% vs 15.7%) when compared to their male counterparts.

When assessing change in risk over time, results indicated the adjusted relative risk for women versus men for developing heart failure or dying was similar across study years. However, investigators pointed out the differences were nonsignificantly attenuated over 5 years of follow-up.

“Identifying when and how women may be at higher risk for heart failure after a heart attack can help providers develop more effective approaches for prevention,” said lead investigator Justin A. Ezekowitz, MBBCh, MSc, a cardiologist and co-director of the Canadian VIGOUR Centre, in the aforementioned statement. “Better adherence to reducing cholesterol, controlling high blood pressure, getting more exercise, eating a healthy diet and stopping smoking, combined with recognition of these problems earlier in life would save thousands of lives of women—and men.”

This study, “Is There a Sex Gap in Surviving an Acute Coronary Syndrome or Subsequent Development of Heart Failure?,” was published in Circulation.