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      Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

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          Abstract

          Background

          Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

          Methods

          Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

          Results

          Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

          Conclusions

          Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

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          Most cited references29

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          Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease.

          Coronary heart disease is the leading cause of death and disability in the U.S., but recent advances have not led to declines in case fatality rates for women. The current review highlights gender-specific issues in ischemic heart disease (IHD) presentation, evaluation, and outcomes with a special focus on the results derived from the National Institutes of Health-National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. In the second part of this review, we will assess new evidence on gender-based differences in vascular wall or metabolic alterations, atherosclerotic plaque deposition, and functional expression on worsening outcomes of women. Additionally, innovative cardiovascular imaging techniques will be discussed. Finally, we identify critical areas of further inquiry needed to advance this new gender-specific IHD understanding into improved outcomes for women.
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            Performance of comorbidity scores to control for confounding in epidemiologic studies using claims data.

            Comorbidity is an important confounder in epidemiologic studies. The authors compared the predictive performance of comorbidity scores for use in epidemiologic research with administrative databases. Study participants were British Columbia, Canada, residents aged >or=65 years who received angiotensin-converting enzyme inhibitors or calcium channel blockers at least once during the observation period. Six scores were computed for all 141,161 participants during the baseline year (1995-1996). Endpoints were death and health care utilization during a 12-month follow-up (1996-1997). Performance was measured by using the c statistic ranging from 0.5 for chance prediction of outcome to 1.0 for perfect prediction. In logistic regression models controlling for age and gender, four scores based on the International Classification of Diseases, Ninth Revision (ICD-9) generally performed better at predicting 1-year mortality (c = 0.771, c = 0.768, c = 0.745, c = 0.745) than medication-based Chronic Disease Score (CDS)-1 and CDS-2 (c = 0.738, c = 0.718). Number of distinct medications used was the best predictor of future physician visits (R(2) = 0.121) and expenditures (R(2) = 0.128) and a good predictor of mortality (c = 0.745). Combining ICD-9 and medication-based scores improved the c statistics (1.7% and 6.2%, respectively) for predicting mortality. Generalizability of results may be limited to an elderly, predominantly White population with equal access to state-funded health care.
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              Sex differences in medical care and early death after acute myocardial infarction.

              Women receive less evidence-based medical care than men and have higher rates of death after acute myocardial infarction (AMI). It is unclear whether efforts undertaken to improve AMI care have mitigated these sex disparities in the current era. Using the Get With the Guidelines-Coronary Artery Disease database, we examined sex differences in care processes and in-hospital death among 78 254 patients with AMI in 420 US hospitals from 2001 to 2006. Women were older, had more comorbidities, less often presented with ST-elevation myocardial infarction (STEMI), and had higher unadjusted in-hospital death (8.2% versus 5.7%; P<0.0001) than men. After multivariable adjustment, sex differences in in-hospital mortality rates were no longer observed in the overall AMI cohort (adjusted odds ratio [OR]=1.04; 95% CI, 0.99 to 1.10) but persisted among STEMI patients (10.2% versus 5.5%; P<0.0001; adjusted OR=1.12; 95% CI, 1.02 to 1.23). Compared with men, women were less likely to receive early aspirin treatment (adjusted OR=0.86; 95% CI, 0.81 to 0.90), early beta-blocker treatment (adjusted OR=0.90; 95% CI, 0.86 to 0.93), reperfusion therapy (adjusted OR=0.75; 95% CI, 0.70 to 0.80), or timely reperfusion (door-to-needle time
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                Author and article information

                Contributors
                +61399533637 , +61399533385 , George.Mnatzaganian@acu.edu.au
                +61 3 9342 4875 , +61 3 9342 8777 , George.Braitberg@mh.org.au
                Journal
                BMC Cardiovasc Disord
                BMC Cardiovasc Disord
                BMC Cardiovascular Disorders
                BioMed Central (London )
                1471-2261
                26 May 2016
                26 May 2016
                2016
                : 16
                : 109
                Affiliations
                [ ]School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Fitzroy, Victoria 3065 Australia
                [ ]Department of Medicine, The University of Melbourne, Parkville, Victoria 3010 Australia
                [ ]Department of Emergency Medicine, Royal Melbourne Hospital, Parkville, Victoria 3010 Australia
                [ ]School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria 3122 Australia
                [ ]Discipline of Public Health, School of Population Health, The University of Adelaide, Adelaide, South Australia 5000 Australia
                [ ]School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria 3220 Australia
                [ ]School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Bentley, Western Australia 6102 Australia
                Article
                276
                10.1186/s12872-016-0276-5
                4937590
                27389522
                765739e5-14b2-4af9-b3ed-7df5fae57320
                © The Author(s). 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 14 December 2015
                : 13 May 2016
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000990, Australian Catholic University;
                Award ID: 2013000697
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2016

                Cardiovascular Medicine
                attributable risk,hospital setting,in-hospital mortality,myocardial infarction,sex disparity

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