Elderly Women Worse Off Than Men Before and After Acute MI

Elderly women tend to have more difficulty with cognition, mobility, daily living, and other impairments after acute MI than do men of the same age, according to data from the SILVER-AMI study. Additionally, the subgroup of women with STEMI have a higher incidence of overall bleeding, driven by nonmajor events.

“Identification is a critical first step toward closing the treatment gaps that exist,” lead author Michael Nanna, MD (Duke Clinical Research Institute, Durham, NC), told TCTMD in an email. “Women in SILVER-AMI had more age-associated functional impairments, which has clear repercussions for their physical rehabilitation and occupational therapy needs during and following their hospitalization. We must recognize functional impairments in order to set our patients up for success when they leave the hospital.”

The differences in bleeding observed in the study also have clinical implications, he continued. “Where we expected the care to be most standardized, in patients with STEMI and those undergoing PCI, women had higher rates of bleeding. We must be vigilant with bleeding avoidance strategies in all patients, but especially among older adults who are at higher risk for bleeding complications.”

To see these findings is “very frustrating,” according to Gina Lundberg, MD (Emory University School of Medicine, Atlanta, GA), who was not involved in SILVER-AMI.

“Here's another study showing that we undertreat women—that even in our elderly population, we're undertreating women,” she told TCTMD. “We're afraid to give them statins, we're afraid to give them anticoagulation when they have A-fib, we're afraid to take them to the cath lab to give them evidence-based therapies, and why? Do we just think they're so frail? Or what is the bias here that keeps us from treating an elderly woman the way we would treat an elderly male?”

It could be that physicians see these patients as frail and use that as an excuse not to treat them aggressively, Lundberg suggested. “But study after study shows we don't treat young women with acute MI as aggressively as men, we don't treat middle-aged women as aggressively as we treat men, and now we know we don't treat elderly women [as such]. And the scary thing is the elderly population is predominately women.”

Baseline Differences

For the SILVER-AMI study, which was published online last week ahead of print in Circulation: Cardiovascular Quality and Outcomes, Nanna and colleagues included 3,041 patients (44% women) at least 75 years old and hospitalized for acute MI. Regardless of presentation, women were generally older than men and had less prior coronary disease. Among those with NSTEMI, women presented less frequently with chest pain as their primary symptom than did men (50.0% vs 58.6%; P < 0.001).

For both NSTEMI and STEMI patients, more women than men at baseline had age-associated functional impairments related to cognitive function, vision and hearing impairment, functional mobility, activities of daily living, or a history of falls.

Functional Impairments at Baseline 

As for medications, women with NSTEMI were more likely than men to receive an ACE inhibitor or angiotensin receptor blocker and low molecular weight heparin, but they were less likely to receive glycoprotein IIb/IIIa inhibitors and statins. Female STEMI patients were also less likely to receive statins than their male counterparts.

“We recently demonstrated sex differences in statin treatment among eligible adults in the PALM Registry, with women less likely to receive guideline-recommended care in the outpatient setting,” Nanna commented. “Unfortunately, we also observed this treatment disparity among older adults hospitalized with myocardial infarction in SILVER-AMI, with women less frequently receiving statins than their male counterparts despite a clear treatment indication.”

The lower use of statins observed “may represent greater hesitancy on the part of clinicians to prescribe medications that may exacerbate weakness and falls in the setting of a more geriatric phenotype, though this explanation should be interpreted with caution because we did not see this pattern with other medications,” the authors suggest.

Women with NSTEMI had lower rates of obstructive CAD compared with men (P < 0.001) with less three-vessel or left main disease, but revascularization was less common in women whether they had NSTEMI (55.6% vs 63.6%; P < 0.001) or STEMI (87.3% vs 93.3%; P = 0.01). This difference was driven by a lower rate of CABG in women with NSTEMI (10.9% vs 16.8%; P < 0.001) and lower rates of both PCI (84.9% vs 89.5%; P = 0.05) and CABG (4.0% vs 6.7%; P = 0.09) in women with STEMI.

Overall bleeding events were statistically comparable between women and men with NSTEMI (15.7% vs 17.8%; P = 0.21), although women who underwent PCI had more bleeding than men (11.0% vs 7.8%; P = 0.04). For STEMI, women had more bleeding than men both overall (26.2% vs 15.6%; P < 0.001) and following PCI (22.6% vs 14.8%; P = 0.02)—this was driven by a higher rate of nonmajor bleeding in women versus men. The rates of major bleeding was similar between the sexes in both those with STEMI and NSTEMI.

Lastly, in-hospital acute kidney injury rates were similar between women and men with both STEMI (19.1% vs 19.3%; P = 0.91) and NSTEMI (26.2% vs 24.3%; P = 0.30).

Equity in Care Delivery

Nanna said these findings should change clinical practice. “We need to recognize age-associated functional impairments in our older patients presenting with myocardial infarction in order to tailor their rehabilitation therapies,” he said. “Improving bleeding avoidance strategies in this vulnerable population will be absolutely essential. Ultimately, we must achieve equity in the delivery of proven lifesaving treatments while minimizing complications across the sexes.”

Adhering to evidence-based medicine is how physicians can “overcome” the current differences in care observed between the sexes, Lundberg said. “You have to trust the studies, you have to trust the evidence.” Additionally, shared decision-making comes into play as “the fear exists more in the providers of the elderly female patients than in the actual female patients themselves,” she observed. “You have to have a good discussion on the risk and benefits, but when she seems like a good candidate and she's interested, we should forge ahead and be aggressive with these women.”

When she seems like a good candidate and she's interested, we should forge ahead and be aggressive with these women. Gina Lundberg

Further, identifying any age-related functional impairments in the hospital “may allow for targeted interventions . . . that may improve outcomes,” the authors add. These include home safety checks for people at high risk for falls, pillboxes for those with likely to be nonadherent to medications due to cognitive impairments, and intensive physical rehabilitation for those with functional mobility limitations.

These are “cost-effective” solutions for patients that might lead to tangible long-term improvements, according to Eugenia Gianos, MD (Northwell Health, Manhasset, NY), who commented on the study for TCTMD. “With our growing population of elderly patients, particularly women, it is important for us to recognize patient-specific differences that are closely linked to better outcomes.”

Additionally, Laxmi Mehta, MD (The Ohio State University, Columbus), said improving outcomes for all patients will require a greater understanding of how physicians decide to prescribe preventive medications. Patient preference, “which is hard to capture,” also can affect outcomes, she told TCTMD. “There are many patients that hear about statins and are concerned about the side effects of statins, so that may be playing a role as well.”

Overall, these findings add to the literature that already shows clear gender-based differences in care, Mehta said. “It highlights that it's not just the young women but it's also the elderly women.”

Also, the high level of disability observed in the women at baseline, Lundberg said, “completely underscores the need to be sending these women to cardiac rehab because they weren't in great shape before. We really need to build them up and get them more active and more functional after their heart attack.”

“More work needs to be done to further elucidate the relationship between age-associated functional impairments and patient outcomes,” Nanna concluded. “We have room to improve bleeding avoidance strategies in our older patients; this represents an important area for future investigation.”