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ST-elevation myocardial infarction: a significant survival disadvantage for womente

A new study on a Swedish population of more than 180,000 patients with AMI shows that women are less likely than males to receive reperfusion and revascularization treatments and prescribed guideline-indicated therapies.

21 January Jan 2018 0000 5 months ago
  • Elena Tremoli

A new nationwide swedish study has recently assessed sex differences in treatments, all-cause mortality, relative survival, and excess mortality following acute myocardial infarction. The study was a population-based cohort of all hospitals providing acute myocardial infarction care in Sweden from 2003 to 2013, designed to estimate excess mortality rate ratios (EMRR), adjusted for clinical characteristics and guideline-indicated treatments after matching by age, sex, and year to background mortality data. The study examined a population of >180,000 patients with AMI, and contains several novel and important findings relevant to clinical practice.

First of all, the study has found that women after AMI, despite similar adjusted all-cause mortality, had much worse relative survival and higher excess mortality than men. This was most evident for patients with STEMI. The study also founds that excess mortality increased with increasing age. In line with results of previous studies, women were older than men and more likely to have comorbidities.

Despite the international recommendations for equal treatment of women and men presenting with AMI, the Authors have found that women are less likely to receive reperfusion and revascularization therapies and to be prescribed guideline-indicated pharmacological therapies at the time of discharge from the hospital.

In particular, women with AMI (mostly with ST segment–elevation) have:

  • – 34% chance than males to be subjected to procedures such as bypass and stents in the conditions in which these interventions would serve;
  • – 24% chance than males to be prescribed statins to control cholesterol levels;
  • –16% likely to receive aspirin prescription, to prevent thrombus.

Clinical implications

There are therefore evidences of a survival disadvantage for women with myocardial infarction who were followed for 10 years after acute myocardial infarction. These sex differences in excess mortality persisted after adjusting for age and comorbidities (see figure 1).

However, the differences in excess mortality decreased or disappeared after adjusting for the use of evidence-based treatments. In other words, if treatments for acute myocardial infarction were provided equally between sexes, – the study concludes, – the differences in deaths between men and women would be smaller and premature cardiovascular deaths among women would be reduced.

This study, very significant because it analyzes an extended sample of people who have had myocardial infarction or acute coronary syndrome, shows that in the presence of appropriate therapy, care in women can be as effective as in men. But we must also stress the fact that women generally tend to underestimate the importance of therapies once they have had the cardiovascular event, thus neglecting their disease.

Prof. Elena Tremoli, Monzino’ Scientific Director

The Centro Cardiologico Monzino recently launched an ambitious clinical, scientific and cultural project, within which clinical trials will be started to evaluate the efficacy of both therapies already established for men, but less applied to women, and innovative therapies. and new lines of research dedicated to women's specific risk factors.

In addition, “Monzino Women”, a new specific diagnostic clinical path, has been activated for women between 35 and 60 (and for women presenting cardiovascular risk factors), a real check-up, with specialist examination, targeted instrumental diagnosis and second level counselling, to obtain a personalized evaluation based on age, previous history, lifestyles and risk factors of every single woman.


Figure 1. Adjusted cumulative excess mortality (model 3) by age group stratified by sex for (A) ST-segment–elevation myocardial infarction.


Reference

  1. Alabas, OA, Gale CP, Hall M et al. Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry. Am Heart Assoc. 2017;6:e007123. DOI: 10.1161/JAHA.117.007123.