Comparison of Gender-Specific Mortality in Patients

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<ul><li><p>Comparison of Gender-Specific Mortality in Patients 70 Years Old With Acute Myocardial Infarction</p><p>ue, MD, Y, Hirimot</p><p>gate tyearsacutefter thrs oldpertemyo</p><p>eater i 0.04.9%,der an8, 95%atiension,farctio. All r</p><p>mohagrerispatients with AMI are an average of 10 years older thanmale patients. It has been reported that older age accountsforwigeoldsesAM</p><p>M</p><p>wi24HoAMmyitanape</p><p>tw27senshi</p><p>Emergency coronary angiography was performed as pre-11</p><p>Ma29,</p><p>000doia greater part of the excess deaths among female patientsth AMI.810 However, it remains unknown whether thender-specific mortality after AMI is different betweener and younger patients. In the present study, we as-sed the in-hospital mortality of women and men withI aged 70 and 70 years.</p><p>ethodsThe present study consisted of 2,677 consecutive patientsth AMI who had undergone coronary angiography withinhours after the onset of symptoms at Hiroshima Cityspital, a tertiary referral institution of Hiroshima City.I was diagnosed by chest pain consistent with ongoing</p><p>ocardial ischemia persisting 30 minutes and concom-nt electrocardiographic changes. The serum creatine ki-se was measured every 3 hours for 24 hours, and theak creatine kinase value was required to be more than</p><p>viously reported. Selective coronary angiography wasperformed in multiple projections before the initiation ofreperfusion therapy. Immediately after diagnostic angiogra-phy, reperfusion therapy was performed. The allocation ofreperfusion therapy was the physicians decision.</p><p>All coronary angiograms were reviewed by 2 angiogra-phers without knowledge of the clinical variables. The per-fusion status of the infarct-related artery was determined inaccordance with the Thrombolysis In Myocardial Infarction(TIMI) study classification.12 An initially occluded arterywas defined as TIMI 0 or TIMI 1 flow before the initiationof reperfusion therapy. Successful reperfusion was definedas TIMI 3 flow on the final shot of the angiogram. Multi-vessel coronary disease was defined as 75% stenosis in1 vessels remote from the infarct artery. Collateral circu-lation was considered present if partial or complete filling ofthe infarct artery distal to the infarct lesion was present.</p><p>Categorical data are reported as the proportions andcontinuous data as the mean SD. Statistical analysis wasperformed using the chi-square test for categorical vari-ables. The t test was used for continuous variables. Logisticregression analysis was used to obtain the odds ratio (OR)and 95% confidence interval (CI) for in-hospital mortality.Multivariate analysis was performed, adjusting for age</p><p>Department of Cardiology, Hiroshima City Hospital, Hiroshima, Japan.nuscript received April 6, 2011; manuscript received and accepted April2011.*Corresponding author: Tel: (81) 82-221-2291; fax: (81) 82-223-1447.E-mail address: ishifami@fb3.so (M. Ishihara).</p><p>2-9149/11/$ see front matter 2011 Elsevier Inc. All rights reserved. www.ajconline.org:10.1016/j.amjcard.2011.04.030Masaharu Ishihara, MD, PhD*, Ichiro InoYuji Shimatani, MD, Fumiharu Miura, MD, Ph</p><p>Takayuki Ootani, MD, Kuniomi Ooi, MDMasayuki Nakamura, MD, Shinji KishThe aim of the present study was to investimyocardial infarction in those aged 70 years old age than in men03) but was comparable between womenrespectively; p 0.59). On multivariated in-hospital mortality in patients &gt;70confidential interval 1.05 to 3.00), but</p><p>ts 70 years old but not inights reserved. (Am J Cardiol 2011;108:</p><p>ice the normal upper limit. The patients were divided intogroups: 1,810 patients 70 years old and 867 patients0 years old. All patients provided written informed con-t, and the ethical committee of human research of Hiro-ma City Hospital approved the study.</p></li><li><p>(mrenloclatnauseCalev</p><p>Re</p><p>2,1oldressig</p><p>TabBas</p><p>Va W(n</p><p>Ag 77.1Hy 176Dia 88Cu 34Pre 28Kil 54Inte 5.9An 143Init 217Co 64Mu 120Rep</p><p>PUTC</p><p>Fin</p><p>*</p><p>TabBas</p><p>Va</p><p>AgHyDiaCuPreKilInteAnInitCoMu 9Rep</p><p>PUTC</p><p>Fin</p><p>*</p><p>773Coronary Artery Disease/Gender and Age in AMIodel 1) or for age, hypertension, diabetes mellitus, cur-t smoking, Killip class, interval to angiography, infarctation, initial occlusion of the infarct artery, collateral circu-ion, multivessel disease, use of primary percutaneous coro-ry angioplasty (PCI) and final reperfusion (model 2). Wed the JMP statistical package, version 5.1 J (SAS Institute,ry, North Carolina), for statistical analysis. A significanceel of p 0.05 was used and 2-tailed tests were applied.</p><p>sults</p><p>Of the 2,677 patients, 559 were women (20.9%) and18 were men (79.1%). The women were significantlyer than the men (69.2 10.8 vs 61.5 11.4 years,</p><p>le 1eline characteristics of patients 70 years old</p><p>riable</p><p>e (y)pertensionbetes mellitus</p><p>rrent smokervious myocardial infarctionlip class 24rval to admission (hr)</p><p>terior wall locationial Thrombolysis In Myocardial Infarction 0-1llateralsltivessel coronary diseaseerfusion therapy</p><p>rimary coronary angioplastyse of stentshrombolysisoronary bypass surgeryal Thrombolysis In Myocardial Infarction 3 (n 837)*Patients undergoing bypass surgery were excluded.</p><p>le 2eline characteristics of patients 70 years old</p><p>riable</p><p>e (y)pertensionbetes mellitus</p><p>rrent smokervious myocardial infarctionlip class 24rval to admission (hr)</p><p>terior wall locationial Thrombolysis In Myocardial Infarction 0-1llateralsltivessel coronary diseaseerfusion therapy</p><p>rimary coronary angioplastyse of stentshrombolysisoronary bypass surgeryal Thrombolysis In Myocardial Infarction 3 (n 1,731)*Patients undergoing bypass surgery were excluded.pectively; p 0.001). The proportion of women wasnificantly larger in the 70-year-old group than in the</p><p>ge70-year-old group (34.1% vs 14.5%, respectively; p.001). The baseline clinical and angiographic character-</p><p>ics of the women and men aged 70 years are listed inble 1. These variables for the patients aged70 years areted in Table 2.Of the 2,677 patients, 192 (7.2%) died before hospitalcharge. The in-hospital mortality rate was significantlyater in the women than in the men (11.3% vs 6.1%,pectively; p 0.001) and in those aged 70 years thaned 70 years (11.7% vs 5.0%, respectively; p 0.001).</p><p>the patients 70 years old, in-hospital mortality wasnificantly greater in women than in men (16.2% vs 9.3%,pectively; p 0.003; Figure 1). However, no significant</p><p>omen 290)</p><p>Men(n 571)</p><p>p Value</p><p> 5.5 75.4 4.6 0.001(60%) 288 (45%) 0.001(30%) 135 (24%) 0.05(12%) 242 (42%) 0.001(10%) 89 (16%) 0.01(18%) 81 (14%) 0.12 5.5 5.3 4.9 0.12(48%) 253 (44%) 0.26(73%) 412 (72%) 0.72(22%) 144 (25%) 0.24(41%) 242 (42%) 0.60</p><p>(79%) 447 (78%) 0.88(51%) 291 (51%) 0.94(14%) 72 (13%) 0.71(2%) 27 (5%) 0.08(74%) 421 (77%) 0.28</p><p>omen 263)</p><p>Men(n 1,547)</p><p>p Value</p><p>.4 8.2 56.4 8.5 0.0016 (51%) 612 (40%) 0.0010 (30%) 370 (24%) 0.032 (35%) 984 (64%) 0.0010 (4%) 187 (12%) 0.0013 (13%) 181 (12%) 0.67</p><p>.1 4.9 5.0 4.9 0.815 (51%) 815 (53%) 0.882 (77%) 1,194 (77%) 0.893 (28%) 467 (30%) 0.426 (37%) 537 (35%) 0.57</p><p>6 (71%) 1,152 (75%) 0.213 (39%) 671 (43%) 0.200 (19%) 255 (17%) 0.327 (3%) 72 (5%) 0.125 (76%) 1,188 (81%) 0.1170istTalis</p><p>disgreresagOfsigres</p><p>18105</p><p>19233150</p><p>407</p><p>214</p><p>W(n</p><p>60138913</p><p>513207nder difference in mortality was found among patients0 years old (5.7% vs 4.9%, p 0.59).</p></li><li><p>in(TKirepmopre7femcanpre</p><p>pewo95CI7yede4.0</p><p>Di</p><p>mofemitieit rpeforagthe</p><p>termoeli</p><p>7</p><p>Fig ld, womdiff</p><p>TabUn</p><p>Va</p><p>p Va</p><p>Un 0.00Ad 0.00Ad 0.03</p><p>MM Killip c</p><p>arte s coron</p><p>774 The American Journal of Cardiology (www.ajconline.org)Female gender was associated with in-hospital mortalitypatients 70 years old but not those aged 70 years</p><p>able 3). Multivariate analysis (model 2) found that age,llip class, infarct location, multivessel disease, and finalerfusion were independently associated with in-hospitalrtality in patients 70 years old. All these variables andvious myocardial infarction were significant in patients0 years old. On multivariate analysis, the association ofale gender and in-hospital mortality remained signifi-t in patients 70 years old. However, gender was not adictor of in-hospital mortality in patients 70 years old.The final reperfusion (TIMI 3 flow) was a strong inde-</p><p>ndent predictor of decreased in-hospital mortality inmen (OR 0.16, 95% CI 0.07 to 0.37) and men (OR 0.14,% CI 0.06 to 0.32)70 years old, women (OR 0.14, 95%0.03 to 0.67) and men (OR 0.15, 95% CI 0.08 to 0.28)0 years old. However, even when only patients 70</p><p>ars old with final reperfusion were analyzed, female gen-r was still associated with in-hospital mortality (8.8% vs%, p 0.02).</p><p>scussionA considerable number of studies have demonstrated thatrtality after AMI is greater in women than in men. Theale patients with AMI were older, had more co-morbid-</p><p>s, and less often received reperfusion therapy. Althoughemains controversial whether female gender is an inde-</p><p>ndent predictor of mortality after AMI after adjustmentage and co-morbid factors,13,14 most studies are in</p><p>ure 1. In-hospital mortality of women and men. (A) In patients70 years oerences in mortality were not observed.</p><p>le 3adjusted and adjusted odds ratios for women and in-hospital mortalityriable Age 70 yr</p><p>OR 95% CI</p><p>adjusted 1.89 1.242.88justed (model 1) 1.77 1.162.71justed (model 2) 1.78 1.053.00</p><p>odel 1 adjusted for age.odel 2 adjusted for age, hypertension, diabetes mellitus, current smoking,</p><p>ry, collateral circulation, multivessel disease, use of primary percutaneoureement that womens older age is largely contributory toadverse outcomes of women with AMI. The third In-</p><p>cosmnational Study of Infarct Survival (ISIS-3) reported thatre than 2/3 of the excess mortality among women was</p><p>minated by the adjustment for age.8 Although some pre-us studies have reported that younger women have</p><p>orer outcomes than younger men,15 the results of thesent study found no gender-specific difference in mor-</p><p>ity after AMI among patients 70 years old. In contrast,patients 70 years old, women had an approximately-fold greater risk of in-hospital mortality after AMI.Consistent with previous studies, we found that women</p><p>d more co-morbidities than men, including hypertensiond diabetes. In contrast, men were more likely to be smok-</p><p>and to have a history of previous myocardial infarction.though these findings were comparable between patients0 years old and those70 years old, the effect of gendermortality was different. In patients 70 years old, the</p><p>nventional risk factors, including age, Killip class, infarctation, multivessel disease, and final reperfusion status,re associated with in-hospital mortality, but gender wast. In patients 70 years old, however, female gender wasredictor of mortality after AMI, as were other conven-</p><p>nal risk factors. Compared to men70 years old, women0 years old had greater mortality, even after adjustmentage and co-morbid risk factors.</p><p>Gender differences in the clinical manifestation of acuteronary syndrome have been demonstrated in several stud-.16 Women generally present with atypical symptoms.vious studies have reported that women with AMI weres likely to receive reperfusion therapy, or if received, it</p><p>17,18</p><p>en had greater mortality than men. (B) In patients70 years old, gender</p><p>Age 70 yr</p><p>lue OR 95% CI p Value</p><p>3 1.17 0.662.08 0.599 1.01 0.571.79 0.98</p><p>1.09 0.532.24 0.82</p><p>lass, interval to angiography, infarct location, initial occlusion of infarctary angioplasty, and final reperfusion.oncolocwenoa ptio7for</p><p>coiesPrelesviopopretalin1.9</p><p>haanersAluld be delayed. At catheterization, women havealler coronary arteries, which might influence the device</p></li><li><p>use for PCI, with a lower use of stents.19 The risk of adverseevents during PCI is greater in women than in men. In thepresent study, we registered only patients who had under-gone emergent coronary angiography. Female gender wasnot associated with a delayed interval to angiography. Mostof the patients underwent primary PCI, and the use of stentswas comparable between both genders. Final reperfusionwadifpromeAlevsigev</p><p>evcoglesmrefthegomaSTnoHonoginstuaremo</p><p>1.</p><p>2.</p><p>3.</p><p>4.</p><p>5. Kosuge M, Kimura K, Kojima S, Sakamoto T, Ishihara M, Asada Y,Tei C, Miyazaki S, Sonoda M, Tsuchihashi K, Yamagishi M, Ikeda M,Shirai M, Hiraoka S, Inoue T, Saito F, Ogawa H; Japanese AcuteCoronary Syndrome Study (JACSS) Investigators. Sex differences inearly mortality of patients undergoing primary stenting for acute myo-cardial infarction. Circ J 2006;70:217221.</p><p>6. Jackson EA, Moscucci M, Smith DE, Share D, Dixon S, GreenbaumA, Grossman PM, Gurm HS; Blue Shield of Michigan CardiovascularConsortium (BMC2). The association of sex with outcomes among</p><p>7.</p><p>8.</p><p>9.</p><p>10.</p><p>11.</p><p>12.</p><p>13.</p><p>14.</p><p>15.</p><p>16.</p><p>17.</p><p>18.</p><p>19.</p><p>775Coronary Artery Disease/Gender and Age in AMIs achieved in 75% of the patients, with no genderferences. Final reperfusion was associated with an ap-ximately 85% decrease in mortality in both women andn and in patients both 70 years old and 70 years old.though final reperfusion effectively reduced mortalityen in women 70 years old, in-hospital mortality wasnificantly greater in women 70 years old than in men,en with timely reperfusion.This was a retrospective and observational study. How-</p><p>er, all consecutive patients with AMI who underwentronary angiography were prospectively included in a sin--center registry. The prevalence of women was relativelyaller in our study than in previous studies from tertiaryerral institutions, suggesting a possible selection bias forpresent study because we included only patients under-</p><p>ing coronary angiography. Gender differences in thenifestation of acute coronary syndromes, including-segment elevation myocardial infarction (STEMI),n-STEMI, and unstable angina, have been reported.wever, our study included those with STEMI andn-STEMI and did not include those with unstable an-a. The small sample size was another limitation of ourdy. Analyses from large-scale nationwide registrieswarranted to assess the genderage interaction in the</p><p>rtality of patients with AMI.</p><p>Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM,Carnethon MR, Dai S, de Simone G, Ford ES, Fox CS, Fullerton HJ,Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, HowardVJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD,Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM,Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, PaynterNP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB,Wong ND, Wylie-Rosett J; American Heart Association StatisticsCommittee and Stroke Statistics Subcommittee. Heart disease andstroke statistics2011 update: a report from the American HeartAssociation. Circulation 2011;123:e18e209.Vaccarino V, Krumholz HM, Berkman LF, Horwitz RI. Sex differ-ences in mortality after myocardial infarction: is there evidence for anincreased risk for women? Circulation 1995;91:18611871.Mehilli J, Kastrati A, Dirschinger J, Pache J, Seyfarth M, Blasini R,Hall D, Neumann FJ, Schmig A. Sex-based analysis of outcome inpatients with acute myocardial infarction treated predominantly withpercutaneous coronary intervention. JAMA 2002;287:210215.Movahed MR, John J, Hashemzadeh M, Jamal MM, Hashemzadeh M.Trends in the age adjusted mortality from acute ST...</p></li></ul>

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