A community-wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction

doi:10.1016/0002-9149(93)90789-F

The American Journal of Cardiology

Volume 71, Issue 4, 1 February 1993, Pages 268-273

https://doi.org/10.1016/0002-9149(93)90789-F Get rights and content

Abstract

This study compares the overall use, as well as temporal trends, of various diagnostic and revascularization procedures for acute myocardial infarction (AMI) in men and women. The study sample comprised a total of 2,924 men and 1,838 women with validated AMI admitted to any of the 16 teaching and community hospitals in the Worcester, Massachusetts, metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988. During the period under study there was a significant increase in use of each of the examined procedures during hospitalization for AMI in both men and women. Increasing use of multiple procedures was also seen for each of the sexes. After controlling for a variety of demographic and clinical factors that might affect utilization rates, men were marginally more likely to undergo radionuclide ventriculography, and significantly more likely to undergo Holter monitoring, exercise treadmill testing, cardiac catheterization, and percutaneous transluminal coronary angioplasty than women. However, there were no gender differences in the use of coronary artery bypass grafting. On the other hand, men were significantly less likely to undergo echocardiography. The results of this multihospital, population-based study suggest sex differences in the use of several diagnostic and revascularization procedures during hospitalization for AMI. These differences may be attributed to physicians' practice patterns, although gender bias in the delivery of medical care cannot be excluded. Temporal trends in increased overall use of these procedures raise questions about cost-effectiveness that need to be further addressed.

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In recent years, the prevalence of myocardial infarction (MI) has increased among women and decreased among men aged 35 to 54 years. To determine the extent to which changes in incidence account for recent variations in prevalence, we assessed the temporal trends in gender-specific hospitalization rates for MI. Using the Nationwide Inpatient Sample, we identified patients aged 35 to 64 years admitted to United States hospitals with a primary discharge diagnosis of MI from 1997 to 2006 (n = 2,824,615). The age-standardized MI hospitalization rates per 100,000 subjects were assessed for men and women aged 35 to 44, 45 to 54, and 55 to 64 years. The MI hospitalization rates per 100,000 subjects decreased by 26% from 168 to 126 for men and by 18% from 56 to 46 for women (both p <0.001). The reductions in the MI hospitalization rates were greatest among men aged 45 to 54, men aged 55 to 64, and women aged 55 to 64 years (standardized rates of change −3%, −4%, and −3% annually, p <0.001). The MI hospitalization rates decreased slightly for women aged 45 to 54 years and men aged 35 to 44 years (standardized rate of change −2% annually, p <0.001) and increased for women aged 35 to 44 years (standardized rate of change 2% annually, p = 0.008). In conclusion, from 1997 to 2006, men and women aged 35 to 64 years experienced an overall decrease in MI hospitalization rates; the reductions were more pronounced in men than in women. The slight increase in MI hospitalizations among women aged 35 to 44 years might have played a small role in the previously noted increases in MI prevalence among middle-age women.
Percutaneous revascularization in women with coronary artery disease: We've come so far, yet have so far to go
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Citation Excerpt :
Women with suspected CAD traditionally have less frequent diagnostic evaluation, and when diagnosed, undergo less revascularization [2–5]. In addition, women experiencing MI have longer wait times to seek and receive treatment and worse in-hospital outcomes [6,7]. Despite these disparities in treatment of CAD, overall outcomes for women undergoing percutaneous coronary intervention (PCI) have improved [8].
Coronary artery disease (CAD) has traditionally been thought of as a disease that predominantly affects men. Women, however, are more likely than men to die from a myocardial infarction (MI). In this article, the data on access to cardiovascular care, treatment of stable and unstable coronary disease, and outcomes in women undergoing percutaneous coronary intervention (PCI) will be reviewed. Despite increased awareness of heart disease in women, and improved outcomes after PCI, women with MI have more mortality and delays to treatment than men. Women with CAD have symptoms that differ from men with CAD. Improved understanding of the symptoms of CAD in women by patients and health care providers may improve treatment and outcomes in women with CAD.
Gender differences in the surgical management and early clinical outcome of coronary artery disease: Single centre experience
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To investigate the gender disparity in the distribution of patient-related risk factors and their effect on the surgical management and clinical outcome of coronary artery disease in Saudi population.
We carried out a retrospective analysis of prospectively collected data of 971 patients undergoing isolated coronary artery bypass grafting (CABG) at our institution between January 2005 and December 2008. Seven hundred and eighty seven patients (81%) were males and 184 patients (19%) were females. We analyzed gender-based difference in clinical presentation and patient-related pre-operative risk factors and studied their impact on surgical management and clinical outcome.
The mean age was 59.5 years in males and 63.4 years in females (p = <0.0001). Associated co-morbidities were higher in females. Prevalence of diabetes mellitus was 61.2% in males and 78.8% in females (p-value = <0.0001); hypertension 61.9% in males and 79.9% in females (p-value <0.0001); hyperlipidemia 66.7% in males and 77.7% in females (p-value 0.0035); morbid obesity 24.7% in males and 45.1% in females (p-value <0.0001); and Hypothyroidism 2.5% in males and 13.6% in females (p-value <0.0001). Smoking was the only risk factor with higher prevalence in males compared to females (44.2% v/s 2.2%; p-value <0.0001). The mean logistic euroSCORE was 3.94 in males and 5.51 in females (p < 0.0003). On-pump and off-pump CABG was carried out in equal numbers in two groups. Females required urgent surgery and less than 3 grafts more frequently while males underwent elective surgery and more than 3 grafts in greater numbers. No significant difference was present between the two gender groups in aortic occlusion times and bypass times. Univariant analysis revealed females gender as an independent risk factor for higher in-hospital mortality (1.1% versus 4.9% p = 0.0026) and higher incidence of post-operative complications like surgical wound infection, need for prolonged ventilation, low cardiac output state and multi-organ failure (p-values 0.01 or less).
Female gender is an independent predictor of adverse outcome after isolated CABG due to significantly higher co-morbidities and acute presentation and independent of their peri-operative management. Therefore, major socioeconomic education and preventive measures are needed to reduce the burden of major co-morbidities in females and to seek early cardiac advice and care.
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Citation Excerpt :
Data from the National Registry of Myocardial Infarction demonstrated that men were more likely than women to receive cardiac interventions after an AMI.10 In the Worcester Heart Attack Study, the likelihood of receiving a cardiac catheterization was nearly 50% higher in men than women.20 A study of Medicare patients with AMI in the mid-1990s showed that overweight patients were more likely to undergo cardiac procedures than patients with a normal body mass index.21
Although current guidelines strongly recommend the measurement of ejection fraction (EF) in all patients hospitalized with acute myocardial infarction (AMI), there are limited data available describing trends in the use of diagnostic modalities to assess EF in these patients. The purpose of this study was to evaluate trends in the use of ventriculography and echocardiography to measure EF in a community sample of patients hospitalized with AMI.
The medical records of 5,380 residents of the Worcester (MA) metropolitan area hospitalized with AMI at 11 greater Worcester medical centers between 1997 and 2005 were reviewed.
Between 1997 and 2005, the proportion of patients hospitalized with AMI undergoing measurement of EF by both ventriculography and echocardiography increased from 11% to 18%, whereas the percentage of patients who did not receive an evaluation of EF by either modality decreased from 37% to 27%. The percentage of patients undergoing measurement of EF by ventriculography alone increased from 14% to 20%, whereas the percentage of patients undergoing measurement of EF by echocardiography alone remained stable at 37%. In 1997, echocardiography was performed before ventriculography in approximately two thirds of hospitalized patients, whereas in 2005, ventriculography was performed before echocardiography in approximately two thirds of patients with AMI.
The use of left ventriculography and the concurrent use of both ventriculography and echocardiography to assess EF in patients with AMI are increasing. Although the proportion of patients who do not have their EF assessed has declined during recent years, many still do not receive a determination of their EF.

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A community-wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction

Abstract

Am Heart J

Clinical highlights and future directions. Cardiovascular disease in women

Cardiology

Differences in the use of procedures between women and men hospitalized for coronary heart disease

N Engl J Med

Noninvasive diagnosis of coronary heart disease in women

Cardiology

Differences between women and men in survival after myocardial infarction: biology or methodology?

JAMA