Gender disparities in management and treatment in acute myocardial infarction – a German nationwide real-life analysis
Authors: Kuehnemund L , Koeppe J , Feld J , Wiederhold A , Illner J , Makowski L , Gerss J , Reinecke H , Freisinger E 
Published: November 2020

Abstract

Background/Introduction
Acute myocardial infarction (AMI) continues to be one of the most frequent diseases worldwide, remaining among the most common causes of mortality in both women and men of industrialised nations. Female sex has been reported to be associated with an unfavourable outcome in AMI. Differences related to patients' sex have been reported for incidence, symptom presentation, pathophysiological characteristics as well as treatment strategies and outcome.

Purpose
Objective of this routine-data based analysis was to explore sex differences of recent nationwide trends in in-patient healthcare and acute outcome of AMI.

Methods
The data base provided by the Federal Statistical Offices comprises all in-patient treated patients on a case base per year. We identified all cases with a main diagnosis of ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) between 01.01.2014 and 31.12.2017. Further, data on concomitant diseases, risk constellations and selected cardiovascular procedures were acquired for sex-specific analysis.

Results
In total, we identified 280,515 STEMI and 595,220 NSTEMI cases over the four-year period. STEMI cases decreased from 72,894 in 2014, to 70,230 in 2015, to 69,178 in 2016, and to 68,213 in 2017 with 70% of STEMI cases assignable to men. Female sex was associated with older age (74 vs. 62 yrs), and higher prevalence of cardiovascular risk factors such as chronic kidney disease (19.21% vs. 12.5%), diabetes (26.4% vs. 21.7%), left ventricular heart failure (36% vs. 32.1%), or atrial fibrillation (17.6% vs. 13%). However, dyslipidemia (43.9% vs. 49.3%) and smoking (7.4% vs. 12.1%) were more frequent in male STEMI cases than in female STEMI cases.
Overall, 74.3% of female and 81.3% of male STEMI cases received percutaneous coronary intervention (PCI; p&lt;0.0001; s. Figure); coronary bypass surgery was performed in 2.7% of female vs. 4.2% of male cases (p&lt;0.0001). There were 5,125 female and 2,015 male STEMI patients aged 90 years and older. These received less frequent percutaneous coronary intervention (42.5% female vs. 52.8% male; p&lt;0.0001) and coronary bypass surgery (0.1% female vs. 0.4% male; p=0.0063) compared to younger age groups. Observed in-hospital mortality was significantly increased in female patients with STEMI (15% female vs. 9.6% male; p&lt;0.0001) and NSTEMI (8.4% vs. 6.3%; p&lt;0.0001).

Conclusion
In a nationwide real-world setting, in-patient STEMI cases continue to decrease over the recent past in both, male and female patients. Women with AMI are older and continue to be less likely to receive revascularization therapies than men. In addition, women present with significantly higher observed in-hospital mortality compared to men.
It is important to draw attention to the peculiarities of women with AMI and to supply revascularization therapy equally in high risk clientele.

Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): Innovationsfonds des gemeinsame Bundesausschusses