J Epidemiol Community Health 2000;54:912-916 ( December )

Research report

Sex differences in risk factors, treatment and mortality after acute myocardial infarction: an observational study Barbara Hanratty^a, Deborah A Lawlor^b, Michael B Robinson^c, Rob J Sapsford^d, Darren Greenwood^c, Alistair Hall^d

^a Department of Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, ^b Department of Social Medicine, University of Bristol, ^c Nuffield Institute for Health, University of Leeds, ^d Yorkshire Heart Centre, Leeds General Infirmary

Correspondence to: Dr Hanratty (B.Hanratty{at}liverpool.ac.uk)

Accepted for publication 20 June 2000

BACKGROUNDCoronary heart disease is the major cause of death of postmenopausal women in industrialised countries. Although acute myocardial infarction (AMI) affects men in greater numbers, the short-term outcomes for women are worse. In the longer term, studies suggest that mortality risk for women is lower or similar to that of men. However, length of follow up and adjustment for confounding factors have varied and more importantly, the association between treatment and outcomes has not been examined.
STUDY OBJECTIVETo investigate the association between sex differences in risk factors and hospital treatment and mortality after AMI.
DESIGNA prospective observational study collecting demographic and clinical data on cases of AMI admitted to hospitals in Yorkshire. The main outcome measures were mortality status at discharge from hospital and two years later.
SETTINGAll district and university hospitals accepting emergency admissions in the former Yorkshire National Health Service (NHS) region of northern England.
PARTICIPANTS3684 consecutive patients with a possible diagnosis of AMI admitted to hospitals in Yorkshire between 1 September and 30 November 1995.
MAIN RESULTSAMI was confirmed by the attending consultant for 2196 admissions (2153 people, 850 women and 1303 men). Women were older and less likely than men to be smokers or have a history of ischaemic heart disease. Crude inhospital mortality was higher for women (30% versus 19% for men, crude odds ratio of death before discharge for women 1.78, 95% confidence intervals 1.46, 2.18, p=0.00). This difference persisted after adjustment for age, risk factors and comorbidities (adjusted OR 1.29, 95% CI 1.04, 1.63, p=0.02), but was not significant when treatment was taken into account. Women were less likely to be given thrombolysis (37% versus 46%, p<0.01) and aspirin (83% versus 90%, p<0.01), discharged with  blockers (33% versus 47%, p<0.01) and aspirin (82% versus 88% p<0.01) or be scheduled for angiography, exercise testing or revascularisation. Adjustment for age removed much of the disparity in treatment. Crude mortality rate at two years was higher for women (OR 1.81, 95%CI 1.41, 2.31, p=0.00). Age, existing risk factors and acute treatment accounted for most of this difference, with treatment on discharge having little additional influence.
CONCLUSIONSPatients admitted to hospital with AMI should be offered optimal treatment irrespective of age or sex. Women have a worse prognosis after AMI and under-treatment of older people with aspirin and thrombolysis may be contributing to this.


Keywords: sex inequalities; acute myocardial infarction

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© 2000 by Journal of Epidemiology and Community Health
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