Women receive unequal treatment after myocardial infarction, Scottish study finds

2nd January 2025

Women in Scotland were undertreated compared to men after a myocardial infarction, with the odds of receiving medicines that can prevent another myocardial infarction ‘stacked against you’ if you are female, researchers suggest.

The first national study in Scotland to examine the difference in treatment and outcomes between the sexes found that women are less likely to receive medicines that can prevent future myocardial infarction, strokes and cardiovascular complications.

The findings are published in the European Journal of Preventive Cardiology and build on an earlier study by the same authors, which found that following a diagnosis of heart disease, the death rate from cardiovascular causes for women increased relative to that of men.

Myocardial infarction is a leading cause of death and disability around the world, affecting men and women differently. The overall association between a person‘s sex and myocardial infarction outcomes is unclear and could be related to different treatment practices between the sexes in healthcare systems.

The researchers examined the treatment and outcome of 15,776 women and 31,287 men admitted to hospital after a myocardial infarction across Scotland between 2010 and 2016. Outcomes in the hospital were analysed according to rates of percutaneous coronary intervention, secondary prevention and mortality.

Each patient was followed for an average of eight years post-hospital discharge until the end of 2021, and rates of cardiovascular mortality and new cardiovascular events were monitored.

The researchers compared the findings to 81,341 matched healthy people without heart disease.

The study found that women were 13% less likely to undergo percutaneous coronary intervention and 6% less likely to undergo cardiac catheterisation than men whilst they were in hospital. Women were also 9% less likely to receive preventative treatments such as statins, beta-blockers or antiplatelets over the follow-up period.

Overall, female patients had lower long-term death rates in comparison to men, but the ‘female survival advantage’ – an observation in which women usually live longer than men – was less pronounced in the people with myocardial infarction.

The researchers found no significant differences in areas across Scotland, but sex differences were more pronounced in deprived areas.

Dr Tiberiu Pana, honorary early career clinical research fellow at the University of Aberdeen, who led the study, said: ‘Our results confirm the presence of important sex differences amongst Scottish heart attack patients. This important finding should guide patients and doctors to work together to improve prescription uptake and compliance with recommended preventative treatments to reduce the burden of heart disease in our population.

Dr Pana emphasised the need to improve the long-term outcomes of women after myocardial infarction, but the researchers also found that treatment for men could also be improved.

Dr Sonya Babu-Narayan, clinical director at the British Heart Foundation and consultant cardiologist, said it was important that existing evidence-based treatments reach both men and women.

But, she added: ‘Time and time again, data show that the odds of receiving medicines that can prevent another heart attack, or a future stroke appear stacked against you if you are a woman. Solving why, including by redressing system and society biases, could help more women in Scotland and other countries live in good health for longer.’

In May 2024, a study revealed that cholesterol-lowering drugs are less frequently prescribed to women compared to men, despite European Society of Cardiology guidelines recommending statins for all patients with chronic coronary syndrome.

A version of this article was originally published by our sister publication Nursing in Practice.

Researchers encourage removal of gender from clinical risk scores in atrial fibrillation

19th September 2024

Gender should not play a role in decision-making for oral anticoagulation in patients with atrial fibrillation, a new study concludes.

The research, published in the European Heart Journal, indicates that removing gender from clinical risk scores could simplify the process of deciding which patients should be given blood thinning medication without compromising on accuracy.

Streamlining the risk stratification process would also contribute to equality in care, according to the study’s authors.

The researchers say the findings contribute to growing evidence to avoid consideration of the patient’s gender when offering this type of medication in atrial fibrillation management.

The findings are in line with the new 2024 European Society of Cardiology (ESC) guidelines, which were presented this month at the ESC Congress in London.

Historical data has reported higher rates of strokes in women with atrial fibrillation, but this is likely associated with other risk factors, such as older age at the time of the stroke and lower anticoagulation rates in women, and higher mortality rates in men.

More recently, gender has been considered a risk modifier. However, international guidelines vary considerably.

To understand whether female gender should play a role in the decision-making process for the prescription of anticoagulants, researchers from the University of Birmingham conducted a large observational study.

The analysis involved 78,852 patients with atrial fibrillation, 28,590 of whom were female.

All patients over the age of 75 and those with a history of a prior stroke were excluded since the use of anticoagulants is standard clinical practice in these groups, regardless of gender.

The research cohort focused on a group of patients where the need for anticoagulation medication was less clear.

Differences between men and women, including age and other health conditions were accounted for.

Using UK primary care electronic health records, the analysis showed women with atrial fibrillation had a lower a rate of death from any cause, stroke or major blood clot, combined, than men. This was mainly due to lower mortality among the women. Rates of stroke, arterial blood clots and vascular dementia did not differ between women and men during the average of five years of follow-up.

The team then examined the effectiveness of the most commonly used global stroke risk assessment tool, the CHA₂DS₂-VASc score, which is recommended by NICE.

The findings showed that the tool only modestly predicted which patients would go on to have an adverse outcome, like stroke, and when used without gender input (CHA₂DS₂-VA) the tool had slightly better precision.

Dr Asgher Champsi, clinical research fellow at the University of Birmingham and co-first author of the paper, said: ‘This research questions whether gender should be used to make decisions on the prevention of stroke, blood clots and death in patients with atrial fibrillation.

‘Removing gender from clinical risk scores could streamline risk stratification without compromising accuracy, and contribute to equality in care.’

Dipak Kotecha, Professor of cardiology at the University of Birmingham, added: ‘Healthcare professionals and patients need to be aware of the poor performance of available risk scores.

‘A personalised approach to decision-making on oral anticoagulation is critical to improve outcomes for patients with atrial fibrillation and reduce the huge burden of health and social care costs.

‘Rather than gender, this includes a broader range of factors that can lead to blood clots beyond conventional risk scores.’

A version of this article was originally published by our sister publication Nursing in Practice.

Sex-related heart failure mortality influenced by left ventricular ejection fraction

4th January 2022

Sex-related differences in mortality after heart-failure hospitalisation is influenced by the left ventricular ejection fraction

Sex-related differences in mortality in patients with heart failure hospitalisations appear to be affected by the left ventricular ejection fraction according to researchers from the Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain.

Although the risk of heart failure (HF) is similar between men and women, there are some notable sex-related differences, with men being predisposed to HF with reduced ejection fraction and women with preserved ejection fraction.

Although there is some evidence that women with HF live longer than men, they experience more psychological and physical disability. However, much of the available data is derived from patients with stable HF and what is less clear, is if there are any sex-related prognostic differences among patients hospitalised following decompensated heart failure.

For the present study, the Spanish team retrospectively examined gender differences in mortality across the left ventricular ejection fraction spectrum in a cohort of patients after a hospitalisation for acute HF.

The researchers used a multi-centre prospective registry of those hospitalised and collected demographics, medical history, laboratory and echocardiographic parameters and followed patients over a 6-month period.

The primary study endpoints were all-cause, cardiovascular and HF-related mortality. Cardiovascular death was considered secondary to a worsening of HF, acute myocardial infarction, stroke or transient ischaemic attack, whereas HF-related deaths were considered secondary to a worsening of the HF or a sudden cardiac death.

Findings

A total of 4812 patients with a mean age of 74.2 years (46.6% women) were included in the analysis. The proportion of patients with a left ventricular ejection fraction (LVEF) of < 40%, 41 – 49% and > 50% was 31.5%, 14.3% and 54.2% respectively. Women were generally older with a mean age of 76.8 years compared to 71.9 years for men and had a higher preserved ejection fraction (70.5% vs 39.9%, female vs male, p < 0.001).

After 6 months, 645 (13.4%) of the patients had died with mortality rates of 13.3% and 13.5% (women vs men, p = 0.82) and there were no significant sex-related differences in all-cause mortality. Moreover, LVEF was not an independent predictor of mortality (HR = 1.02, 95% CI 0.99 – 1.05, p = 0.13). Similarly, rates of cardiovascular mortality were not different between the sexes.

However, there was a significant interaction between sex and levels of LVEF (p for interaction = 0.030) and women had a significantly lower risk of cardiovascular mortality at lower LVEF levels (< 25%). There were also no differences between the sexes in HF-related mortality although as with cardiovascular mortality, there were differences across the levels of LVEF and women had a reduced risk of HR-related death.

For example, compared to men, women had a reduced risk of HF death at a LVEF of < 43% (HR = 0.77, 95% CI 0.59 – 0.99) In contrast, this risk of death in women became higher as the LVEF increased above 80%.

Commenting on these findings, the authors noted that while sex was not a determinant of 6 month all-cause mortality, women had a lower risk of cardiovascular and HR-related mortality where the LVEF was < 25% and < 43% but higher where the LVEF was > 80%.

They concluded that further work is required to confirm these findings and to evaluate the potential negative implications of a supra-normal LVEF in women with a preserved ejection fraction.

Citation

Santas E et al. Sex-Related Differences in Mortality Following Admission for Acute Heart Failure Across the Left Ventricular Ejection Fraction Spectrum J Am Heart Assoc 2021.