Gender differences in acute myocardial infarction-A nationwide German real-life analysis from 2014 to 2017

Abstract

Background: Female sex was reported to be associated with an unfavorable outcome in acute myocardial infarction (AMI). In this nationwide analysis we assessed sex differences in acute outcomes of AMI and recent trends in patient healthcare.

Methods: We analyzed 875 735 German cases hospitalized with a main diagnosis of ST- (STEMI) and non ST-elevation myocardial infarction (NSTEMI) between January 01 2014 and December 31 2017 regarding morbidity, in-hospital mortality and treatments. A multivariable logistic regression model was designed to evaluate the use of interventions and their impact on in-hospital mortality.

Results: STEMI cases decreased from 72 894 in 2014 to 68 213 in 2017, with 70% assignable to men. Female sex was associated with older age (74 vs. 62 years), and higher prevalence of cardiovascular risk factors such as chronic kidney disease (19.2% vs. 12.5%), hypertension (69.0% vs. 65.0%) and left ventricular heart failure (36.0% vs. 32.1%). In NSTEMI, female sex was also associated with older age (78 vs. 71 years), and higher prevalence of cardiovascular risk factors such as chronic kidney disease (29.7% vs. 23.9%), hypertension (77.4% vs. 74.5%) and left ventricular heart failure (40.5% vs. 36.4%). Overall, 74.3% of female and 81.3% of male STEMI cases received percutaneous coronary intervention (PCI, p < 0.001). In NSTEMI, PCI was performed in 40.8% of female and 52.0% of male cases (p < 0.001). In-hospital mortality was notably increased in female patients with STEMI (15.0% vs. 9.6%; p < 0.001; OR 1.07; 95% CI 1.03-1.10) and NSTEMI (8.3% vs. 6.3%; p < 0.001; OR 0.91; 95% CI 0.89-0.93) compared to males.

Conclusions: Our nationwide real-world data document that in-patient STEMI cases continue to decrease in women and men. The observed higher in-hospital mortality in women was largely attributed to a more unfavorable risk and age distribution rather than to female-intrinsic factors. Women with AMI continue to be less likely to receive revascularization therapies.

Keywords: acute coronary syndrome; epidemiology; gender; health care research; multivariable logistic regression analysis; women.

Conflict of interest statement

Lena Makowski reports other from Bayer Vital, outside the submitted work. Jannik Feld, Jeanette Koeppe, Julia Illner, Leonie Kuehnemund, Achim Wiederhold and Joachim Gerß have nothing to disclose. Holger Reinecke reports personal fees from Daiichi, grants from BMS/Pfizer, personal fees from MedUpdate, personal fees from DiaPlan, personal fees from NeoVasc, grants and personal fees from Pluristem, grants from Bard, grants from Biotronik, personal fees from NovoNordisk, outside the submitted work. Eva Freisinger reports non‐financial support from BAYER, non‐financial support from Vascuros, outside the submitted work.

© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.

Figures

FIGURE 1

In‐hospital treatment dependent on sex in STEMI and NSTEMI. In‐hospital treatment of acute myocardial infarction 2014–2017: STEMI (panel A) and NSTEMI (panel B). With regard to therapeutic strategies, 74.3% of female and 81.3% of male STEMI cases received percutaneous coronary intervention (PCI; p 

FIGURE 2

Age‐ and sex‐dependent application of PCI in STEMI and NSTEMI. The observed (bars) application of percutaneous coronary intervention (PCI) is given for female (red) and male (blue) cases for STEMI (panel A) and NSTEMI (panel B). The chance of receiving PCI decreases particularly in females at the upper bounds of the age distribution in both, STEMI and NSTEMI. Of the 5125 female and 2015 male STEMI patients aged 90 years and older, these received statistically notable less frequent percutaneous coronary intervention (42.5% female vs. 52.8% male; p 

FIGURE 3

In‐hospital mortality dependent on sex. Observed (bars) data show in‐hospital mortality of STEMI (panel A) and NSTEMI (panel B). The observed in‐hospital mortality was notably increased in female compared to male patients with STEMI (15.0% vs. 9.6%; p 

FIGURE 4

Forest‐plot of a multivariable logistic regression analysis for in‐hospital mortality of STEMI and NSTEMI. Multivariable logistic regression analysis for in‐hospital mortality of ST‐elevation myocardial (STEMI; panel A) and non ST‐elevation myocardial infarct (NSTEMI; panel B) was performed to evaluate the association of sex and in‐hospital death adjusted by patient's risk profile in a full model (including all patients) and for female and male sex separately. The models included age, diabetes mellitus (DM), chronic heart failure (CHF), chronic kidney disease (CKD), peripheral arterial disease (PAD), atrial fibrillation and/or flutter (Afib), hypertension, previous stroke, dyslipidemia, obesity, smoking, cancer and a disjoint categorical variable (no angiography, diagnostic angiography only without revascularization, PCI, CABG) to considered different treatment strategies