Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes

doi:10.1016/j.ahj.2011.09.025

American Heart Journal

Volume 163, Issue 1, January 2012, Pages 66-73

https://doi.org/10.1016/j.ahj.2011.09.025 Get rights and content

Background

The question of whether gender-related disparities still exist in the treatment and outcomes of patients presenting with acute coronary syndromes (ACS) remains controversial. Using data from 4 registries spanning a decade, we sought to determine whether sex-related differences have persisted over time and to examine the treating physician's rationale for adopting a conservative management strategy in women compared with men.

Methods

From 1999 to 2008, 14,196 Canadian patients with non–ST-segment elevation ACS were recruited into the Acute Coronary Syndrome I (ACSI), ACSII, Global Registry of Acute Coronary Events (GRACE/GRACE²), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries.

Results

Women in the study population were found to be significantly older than men and were more likely to have a history of heart failure, diabetes, or hypertension. Fewer women were treated with thienopyridines, heparin, and glycoprotein IIb/IIIa inhibitors compared with men in GRACE and CANRACE. Female gender was independently associated with a lower in-hospital use of coronary angiography (adjusted odds ratio 0.76, 95% CI 0.69-0.84, P < .001) and higher in-hospital mortality (adjusted odds ratio 1.26, 95% CI 1.02-1.56, P = .036), irrespective of age (P for interaction =.76). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy in both men and women.

Conclusions

Despite temporal increases in the use of invasive cardiac procedures, women with ACS are still more likely to be treated conservatively, which may be due to underestimation of patient risk. Furthermore, they have worse in-hospital outcomes. Greater awareness of this paradox may assist in bridging the gap between current guidelines and management practices.

Section snippets

Methods

Full details of the Canadian Acute Coronary Syndrome I (ACSI), ACSII, Global Registry of Acute Coronary Events (GRACE/GRACE²), and Canadian Registry of Acute Coronary Events (CANRACE) registries have been published elsewhere.12, 13 Briefly, these were prospective, multicenter, observational studies of patients admitted with ACS in Canada. Both ACSI (1999-2001) and ACSII (2002-2003) enrolled patients ≥18 years old who presented to the hospital within 24 hours of a suspected ACS. In ACSII, only

Study population

A total of 4,874 women and 9,322 men with NSTE-ACS were included in this study. Baseline characteristics of the study population are presented in Table I. Women in these registries were found to be significantly older than men and were more likely to have a history of heart failure, diabetes, or hypertension. Female patients had a higher Killip class than their male counterparts. However, women were less likely to have had a history of revascularization, either with PCI or with CABG, than men.

Discussion

This multicenter observational study demonstrates that gender disparities still exist in the treatment and outcomes of patients with NSTE-ACS in Canada. In the more recent registries, fewer women were treated with thienopyridines, heparin, and GPIIb/IIIa inhibitors compared with men. Female gender was also independently associated with a lower in-hospital use of coronary angiography, even after adjusting for potential confounders. Underestimation of patient risk was the most common reason for

Conclusions

In conclusion, our study found that despite temporal increases in the use of invasive cardiac procedures, women with ACS are still more likely to be treated conservatively compared with their male counterparts. Underestimation of patient risk by the treating physician may be an important reason. Greater awareness of this treatment-risk paradox may help to eliminate the gender gap between our current guidelines and management practices.

Acknowledgements

We thank Sue Francis, BA, for her assistance in the preparation of this manuscript. We are indebted to all the study investigators, coordinators, and patients who participated in the Canadian ACSI, ACSII, GRACE/GRACE², and CANRACE registries. Dr Andrew Yan is supported by a New Investigator Award from the Heart and Stroke Foundation of Canada.

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^j: On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.

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Clinical InvestigationAcute Ischemic Heart DiseaseBridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes

Background

Methods

Results

Conclusions

Section snippets

Methods

Study population

Discussion

Conclusions

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Lancet

Prog Cardiovasc Dis

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Heart disease and stroke statistics: 2010 update

Treatment of acute myocardial infarction and 30-day mortality among women and men

N Engl J Med

Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry

Heart

Sex differences in medical care and early death after acute myocardial infarction

Circulation

Narrowing gender differences in procedure use for acute myocardial infarction: insights from the Worcester Heart Attack Study

J Gen Intern Med

Clinical Investigation
Acute Ischemic Heart Disease
Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes