Recurrent Events After MI Show Enduring Gender, Racial Gaps in Care

Rates of recurrent MI and all-cause death in the first year following an acute MI declined over a recent 10-year period for both men and women. But sex differences in recurrent events, as well as trends among nonwhite patients, suggest that there is still room for improvement, a range of experts say.

Sanne Peters, PhD (George Institute for Global Health, London, England), and colleagues looked at outcomes among 1.4 million US adults between 2008 and 2017, using both Medicare and private insurance data for younger adults, to document the decline. While rates of recurrent events are sloping downwards, that drop is steeper in women than men, they found. On the other hand, hospitalizations for heart failure remained higher in women than men.

“Despite the decline seen in this study, rates of recurrent events after an MI remain very high among both women and men,” Peters told TCTMD in an email. “Some of this may be preventable by ensuring that patients get the best possible care,” she continued. “Clinicians need to ensure men and women receive guideline recommended treatments to lower the risk for recurrent heart disease and death after hospital discharge for MI, [and] patients should speak with their doctors to ensure that they get the right medical treatments and must make sure they adopt or maintain a healthy life.”

Study co-author Paul Muntner, PhD (University of Alabama at Birmingham), added that it’s important not to overlook the “good news” inherent in the study findings. “The good news is that rates of recurrent cardiovascular disease are going down and they’re going down for both men and women, so I don’t want to overlook that. I think that’s a success,” he told TCTMD. “That said, I think that there’s more work to be done. . . . There are these disparities that everyone needs to work to try to eliminate.”

Peters and colleagues’ paper appeared online before print yesterday in Circulation.

After an MI

The researchers analyzed data from 770,408 women and 700,477 men who were hospitalized for MI between 2008 and 2017 then followed for a year after their index event. For the group as a whole, the age-standardized MI rates per 1,000 person-years declined from 89.2 to 72.3 in women and from 94.2 to 81.3 in men. Recurrent coronary heart disease events, capturing MI as well as coronary revascularizations, showed a similar pattern, declining from 166.3 to 133.3 in women and from 198.1 to 176.8 in men. For both endpoints, men were more likely to have these kinds of subsequent events than women, whereas although heart failure hospitalization rates declined for both groups, women remain more likely than men to be hospitalized for heart failure (177.4 to 158.1 in women and from 162.9 to 156.1 in men). All-cause mortality rates after MI declined in both groups but were higher in men than in women.

Despite the decline seen in this study, rates of recurrent events after a  MI remain very high among both women and men. Sanne Peters

To TCTMD, Muntner pointed out that in the period prior to that examined in the current study, rates for post-MI outcomes actually declined faster for men than for women, so part of what the study may be picking up now may be some “catch-up” for women. That said, he continued, it’s already well-known that women tend not to be managed as aggressively following an MI, so this degree of catch-up is somewhat surprising. The heart failure data, on the other hand, are troubling.

“In the past 30 years, the number of people living with cardiovascular disease has been increasing, and therefore [the fact that] women might be more likely to develop heart failure after a heart attack than men is disconcerting given the growing size of this population,” Muntner said.

Peters et al, in the paper, point out that women are more likely to develop heart failure with preserved ejection fraction (HFpEF) than men, who more typically develop the reduced EF phenotype. Fewer effective HFpEF medications, inadequate doses, or a dearth of sex-specific treatment options may help explain the signal of more heart failure in women, they write.

Other Gaps

Commenting on the study for TCTMD, American Heart Association spokesperson Donald Lloyd-Jones, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), praised its use of claims data linked to discharge diagnosis codes, which made for a rigorous analysis based on “real events” rather than self-reported data. As a result, “it's a very nice snapshot of what's happened over the last decade with regard to recurrent events in patients who've had a heart attack,” he said. “I think it is good news in that we see essentially declining trends in recurrent heart attack, recurrent coronary events, and mortality very nicely over this decade. And as the authors point out, they remain higher than we would like, but I think that the trends are certainly positive.”

As for the statistically significant differences between men and women, Lloyd-Jones wasn’t particularly concerned, noting that the declining event rates are relatively parallel between men and women. “We’re not seeing really any closing of the gap between men and women, we're just seeing consistent declines and I think the decline is the good news. The fact that, you know, these rates are still overall much higher than we'd like to see is perhaps the work that is yet to be done,” he said, as is closing the gap between men and women.

These are not genetic differences between races. These are entirely socioeconomic differences that are built into the structural racism in our society. Donald Lloyd-Jones

The more striking finding for Lloyd-Jones was one not heavily emphasized by the authors, and this was the difference in event rates between white and Black patients, particularly with regard to heart failure and death.

“It’s a gap that is not closing and it is a continued problem in this country,” Lloyd-Jones said. “The persistent problems, which drive a lot of the disparities, particularly racial disparities, I think are very much around structural racism and social determinants of health. . . . A Black man or woman who has a heart attack is still less likely to get a coronary angiogram or a stent placed, is less likely to go home with the full array of medications that are required to keep them alive and healthy and prevent further events than a white person, and they are less likely to have access to high-quality medical care to make sure that they continue to be healthy. And unfortunately for socioeconomic reasons, they're less likely to be able to afford the medications and the ongoing care that are needed.

“These are not genetic differences between races. These are entirely socioeconomic differences that are built into the structural racism in our society,” he emphasized.