More Women Than Men Develop HF or Die After STEMI

Women are more likely than men to develop heart failure (HF) both during and after STEMI and are also more likely to die, according to a large Canadian study. The increased risk was not seen among women with NSTEMI.

The findings suggest that while “differences in outcomes have slowly narrowed over time and improved, they’re still not zero yet,” said lead author Justin A. Ezekowitz, MBBCh, MSc (University of Alberta, Canada). He added that few prior studies looking at gender disparity have focused on post-MI HF risk.

In the paper, published online November 30, 2020, ahead of print in Circulation, Ezekowitz and colleagues say that in addition to better treatment strategies, there is a need for longitudinal surveillance and intervention before HF develops in those most at risk, particularly women.

Not surprisingly, women in the study were more likely than their male counterparts to be older and to have a more complicated medical history but less-severe disease on angiography. When Ezekowitz and colleagues looked at medication prescribing, they found that women were less likely than men to be receiving beta-blockers, ACE inhibitors or ARBs, lipid-lowering agents, or P2Y12 receptor antagonists. Women also were less likely to undergo diagnostic angiography and were less often attended to in the hospital by a cardiovascular specialist, regardless of their MI presentation.

Ezekowitz said while the older age and geographic availability of specialists may explain some of the latter, this can have important implications for follow-up care.

“If somebody is seen in the hospital by a cardiovascular specialist, they're also then more likely to be seen as an outpatient by a cardiovascular specialist,” he noted.

Higher Death Rates for Women at 1 and 5 Years

For the study, Ezekowitz and colleagues examined outcomes data for 45,064 patients hospitalized between 2002 and 2016 with a first STEMI or NSTEMI and followed for at least 5 years after discharge. Compared with men, women were about 10 years older and had more comorbidities, including cerebrovascular disease, chronic obstructive pulmonary disease, hypertension, and A-fib. Regardless of whether they presented with STEMI or NSTEMI, men were more likely than women to undergo PCI or CABG.

Women who did undergo angiography were less likely than men to have left main disease, two-vessel with proximal left anterior descending disease, or three-vessel disease compared with men (33.4% vs. 40.9%; P < 0.0001), and they more likely to have single-vessel disease or nonobstructive CAD (39.6% vs. 29.1%; P < 0.0001).

In-hospital mortality was higher for women than men in patients with STEMI (9.4% vs 4.5%) and in those with NSTEMI (4.7% vs 2.9%; P < 0.0001 for both). The higher mortality rate for women remained significant for STEMI after adjustment (adjusted OR 1.42; 95% CI 1.24-1.64) but was no longer significant for NSTEMI. After discharge, all-cause mortality rates were 24.6% in women with STEMI versus 14.5% in men with STEMI; with NSTEMI, the rates were 29.9% versus 20.2%, respectively (P < 0.0001 for both).

Rates of in-hospital HF were higher for women than men for both STEMI (adjusted OR 1.26; 95% CI 1.13-1.40) and NSTEMI (adjusted OR 1.20; 95% CI 1.1-1.32). At 5 years following discharge for the index event, hospitalization for HF had occurred in 22.5% of women versus 14.9% of men with STEMI, and in 23.2% of women versus 15.7% of men with NSTEMI (P < 0.0001 for both). There were no differences, however, between women and men for risk of hospitalization for MI or stroke after discharge from the index MI.

“Given its frequency, further attention should be paid to all patients with acute coronary syndromes for the prevention of future HF outcomes,” Ezekowitz and colleagues say.