Practice Update - ESC Congress 2017

The Gender Gap in Death fromAcute Myocardial Infarction is Closing, Particularly inWomen Younger than Age 60

The data indicated that for every 1000 patients treated for an aver- age of 23 months, rivaroxaban plus aspirin prevented 13 heart attacks, strokes, or cardiovascular deaths, and seven deaths from any cause, at a cost of 12 major bleeds, most of which were readily treatable. The benefits of the drug combina- tion were achieved in patients in whom lipid-lowering and blood pressure-lowering drugs, and angiotensin converting enzyme inhibitors were used widely. Results of a composite net clinical benefit endpoint incorporating risks of the most serious bleeds still favored the anticoagulant–aspirin combination. In a written release, Salim Yusuf, MD, also of McMaster University, stated that “It is noteworthy that the benefits of the combination of rivaroxaban and aspirin were on top of proven therapies. If rivaroxaban plus aspirin is widely adopted, the potential benefits are enormous. Use of the combination in 10% of the approximately 300 million persons around the world with known cardiovascular disease would prevent as many as 100,000 deaths and twice as many prema- ture vascular events each year.”

The gender gap in death from acute myocardial infarction has been closing over the past two decades, particularly in women younger than 60 years of age. The retrospective analysis included over 50,000 patients and found that overall in-hospital mortality for patients with acute myocardial infarction halved over the 20-year period. It was presented at the 2017 European Society of Cardiology (ESC) Congress, from August 26–30.

Dr. Dragana Radovanovic

D ragana Radovanovic, MD, of the AMIS Plus Data Centre, University of Zurich, Switzerland, explained that research in the 1990s “showed that younger women with acute myocardial infarction had a higher mortality than men of similar age. Little is known about whether this gender difference has persisted over the years." Dr. Radovanovic and colleagues set out to assess changes in in-hospital mortality of men and women with acute myocar- dial infarction over a 20-year period. The adjusted in-hospital mortality rate was cal- culated logistic regression analysis. Data were collected from 1997 through 2016 in the nationwide Acute Myocardial Infarction in Switzerland registry (AMIS Plus). The study included 51,725 patients with acute myocardial infarction from 83 Swiss hospitals. Among them, 30,398 (59%) presented with ST-segment elevation myo- cardial infarction (STEMI) and 21,327 (41%) with non-ST-segment elevation myocardial infarction (NSTEMI). The study population was 73% male (mean age 63.9 ± 12.8 years) and 27% female (mean age 71.7 ± 12.5 years). Women were older than men in both the STEMI (71.3 ± 12.7 vs 62.8 ± 12.8 years, P < .001) and the NSTEMI group (72.2 ± 12.2 vs 65.6 ± 12.6 years, P < .001). Mean age did not change for either gender during the observation period. The researchers found a decrease in crude in-hospital mortality from 1997 to 2016. In STEMI patients, in-hospital mortality dropped significantly, from 9.8% to 5.5% in men and from 18.3% to 6.9% in women (P < .001 for both). In NSTEMI patients, it fell from 7.1% to 2.1% in men and 11.0% to 3.6% in women (P < .001 for both). Dr. Radovanovic said that in-hospital mortality of patients with acute myocardial infarction fell by at least half over the 20-year period.

Differences in death rates between men and women also dropped. Previous research showed that younger women with acute myocardial infarction experienced higher mortality than men of similar age; there- fore, Dr. Radovanovic and coinvestigators analyzed mortality separately in patients younger than 60 years of age. Inwomen, they found 6% and 13%decreases in mortality with each subsequent admission year for STEMI and NSTEMI, respectively. No significant decreases were observed in men younger than 60 years of age. Mortality per year decreased dramatically in NSTEMI women (odds ratio 0.87, 95% confidence interval 0.80–0.94, P < .001) but was not significant in men (odds ratio 0.98, 95% confidence interval 0.94–1.03). The interaction between gender and admission year was significant at P = .006. Dr. Radovanovic noted that women still experience higher in-hospital mortality from acute myocardial infarction than men, probably because they are on average 8 years older when they suffer a heart attack, and they harbor more cardiovascular risk factors and comorbidities. According to Dr. Radovanovic, although in-hospital mortality continues to be higher in women than men, overall age-adjusted mortality has decreased more prominently in women than men, particularly those younger than 60 years of age. The narrow- ing of the gender gap in mortality over the past 20 years may be due to increasing use of percutaneous coronary intervention (PCI) in women. The use of reperfusion to open blocked arteries, especially PCI, increased in all patients admitted for acute myocar- dial infarction. In STEMI patients, use of PCI increased from 60% to 93% in men and 45% to 90% in women.

PracticeUpdate Editorial Team

PracticeUpdate Editorial Team

© ESC Congress 2017 – European Society of Cardiology

ESC Congress 2017 • PRACTICEUPDATE CONFERENCE SERIES 19