Myocardial Infarction

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Prognosis

Women have a worse prognosis following acute myocardial infarction than men, both prior to (116) and following the advent of thrombolytic therapy (117). In the Framing-ham Study cohort, the initial fatality rate was 44% in women and 27% in men, and dur-

Fig. 11. Gender differences in the initial treatment for myocardial infarction. Women with an acute myocardial infarction take longer to seek medical attention compared to men. Once at the emergency room, they are less likely to receive aspirin and b-blockers and take longer to start thrombolytic therapy (120).

Fig. 11. Gender differences in the initial treatment for myocardial infarction. Women with an acute myocardial infarction take longer to seek medical attention compared to men. Once at the emergency room, they are less likely to receive aspirin and b-blockers and take longer to start thrombolytic therapy (120).

ing the first 5 yr following the index event, women had an average annual rate of rein-farction of 9.6% in comparison with 2.9% in men (116). In the Multicenter Investigation of the Limitation of Infarct Size (MILIS) study, in-hospital mortality was 13% in women as compared to 7% in men, and cumulative mortality at 48 mo was 36% in women vs 21% in men (118,119).

The extent to which this increased risk can be attributed to differences in treatment is not well defined; however, review of 1737 patients admitted to a cardiac intensive care unit with an acute myocardial infarction (Fig. 11) revealed that women took longer to seek medical treatment, were less likely to receive aspirin acutely (87.8 vs 91.3%, p < 0.03), and had longer door-to-needle times (90 min [range 60-143.5 min] compared to 78 min [range 50-131 min], p = 0.004) for men. This resulted in an estimated survival at 30 d of only 78.4% (range 74.4-81.9%) for women compared to 88.0% (range 86.1 to 89.7%) for men. Increased risk of an adverse outcome persisted in this cohort of women even after adjustment for age, racial group, and diabetes (HR 1.52; 95% CI: 1.15-2.01). Estimated 30-d survival free of reinfarction and unstable angina was also lower for women than for men (75% [range 71-79%] vs 86% [range 84-88%]). Interestingly, at 12 mo, there was no observed gender-based differences in the influence of treatment variables on the differential risks for women and men (120).

These observations were supported by data from data from the Cooperative Cardiovascular Project that reviewed records from 138,956 Medicare beneficiaries (49% of them women) who had an acute myocardial infarction in 1994 or 1995. Women in all age groups were less likely to be recommended for diagnostic catheterization than men, and this difference was especially pronounced among women 85 yr of age or older.

Women were somewhat less likely than men to receive thrombolytic agents within 60 min (adjusted relative risk, 0.93; 95% CI: 0.90-0.96) or aspirin within 24 h after arrival at the hospital (adjusted relative risk, 0.96; 95% CI: 0.95-0.97), yet were equally likely to receive b-blockers (adjusted relative risk, 0.99; 95% CI: 0.95-1.03). Despite less aggressive treatment of women compared to men during the early management of acute myocardial infarction, 30-d mortality rates in this study were similar (121).

The prognosis for women following acute myocardial infarction in the thrombolytic era remains controversial. Women admitted during the first 6 h of an acute myocardial infarction, treated with thrombolytic agents or primary or rescue angioplasty, were more likely to be older (57 vs 67 yr, p < 0.001), with a greater incidence of hypertension and contraindications to thrombolytic therapy (28.5 vs 42.5%, p = 0.02) than men. Regardless of strategy, when equivalent rates of successful reperfusion of the infarct-related artery were achieved, women had a significantly higher in-hospital mortality compared to men (18.7 vs 7.2%, p = 0.001) (122). These observations were confirmed in a study that demonstrated that women treated with thrombolytic agents reach similar 90-min patency rates and regional ventricular function as men; however, these benefits did not influence 30-d mortality rates, which remained higher for women (13.1 vs 4.8%, p < 0.0001) (123).

It has been suggested that women have a worse outcome than men following acute myocardial infarction due to differences in recommendation and utilization of diagnostic coronary angiography and, therefore, revascularization, as part of the treatment plan. In the Atherosclerosis Risk in Communities (ARIC) study, women were less likely than men to undergo coronary angiography whether treated at a community or tertiary hospital (124). In contrast to these observations, a recent single center experience demonstrated that age-adjusted rates of coronary angiography following acute myocardial infarction were similar between women and men (125).

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