gms | German Medical Science

Background and current state of (inter)national research: Female sex is a known risk factor for in-hospital mortality and a poorer overall survival (OS) after ST-elevation myocardial infarction (STEMI). As women are generally older and suffer from more cardiovascular comorbidities at time of event, these factors contribute to poorer sex-specific survival.

Research questions and objectives: Little is known about the outcome after first event of STEMI in patients without history of coronary artery disease (CAD) and age-related influence of patient sex on mortality.

Methods or hypothesis: The study is part of the GenderVasc project funded by the joint federal committee, Germany. Retrospective data of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskrankenkasse) were analyzed. All adult patients (age ≥ 18 years) with STEMI as the principal in-patient diagnosis from 01/2014 to 12/2015 were selected for analysis. Patients with previous myocardial infarction, CAD, prior endovascular coronary treatment or coronary artery bypass grafting were excluded. A multivariable logistic regression model including age, sex, the interaction of age*sex and patient risk profile was used to analyze the association of sex on 30-day mortality depending on age. Multivariable Cox regression models with time-varying covariables were used to analyze the association of sex on OS and major adverse cardiovascular events (MACE) depending on age. STEMI patients were stratified by age into seven groups (<50, 50–59, 60–69, 70–79, 80–89, >89 years).

Results: Overall, 17,444 patients with first STEMI (without prior CAD) were included, thereof 33% were woman. Women were generally older (median age 74 (interquartile range IQR 22) in women versus 60 (IQR 19) years in men) and suffered from more cardiovascular co-morbidities. After adjustment of patient risk profile, in younger patients, female sex was associated with higher 30-day mortality (age <49 years: Odds ratio (OR) 1.78, 95% CI 1.27 –2.51; age 50–59 years: OR 1.38, 95% CI 1.08–1.76), a decreased OS (age < 49 years: Hazard ratio (HR) 1.70, 95% CI 1.29–2.23; age 50–59 years: HR 1.30, 95% CI 1.08–1.56), and a higher risk of MACE during follow-up (age <49years: HR 1.34, 95% CI 1.11–1.62; age 50–59 years: HR 1.16, 95% CI 1.01–1.33). For patients older than 60 years, no differences between both sexes were observed in all considered age decades (all p>0.05) for all endpoints. Furthermore, restricting the analysis to patients who have survived at least 90 days after STEMI, no sex-specific differences were observed throughout all age-decades for long-term OS (all p>0.05).

Discussion: In a real-world cohort of STEMI patients as primary manifestation of CAD, women younger than 60 years showed a poorer short- and long-term survival after STEMI compared to men after adjustment for risk profiles. This sex-specific difference was marked within 90 days after the event, but not thereafter. Further analyses are needed to identify causes and optimize care in young women, which are specifically at risk.

Appeal to practice (science and/or care) in one sentence: Compared to men, young women were at particular risk of adverse acute outcome after first STEMI, and should therefore consequently be given special attention.