Ethnic variations in female vulnerability after an acute coronary event

Abstract

Objective: To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays. Design: Population based registry. Patients: Residents of Singapore between the ages of 20-64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project. Main outcome measures: Adjusted 28 day case fatality and long term mortality. Results: From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51.5% v 38.6%, p , 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1.43 to 1.88) and 1.50 (95% CI 1.37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p = 0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age. Conclusion: In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups. W hile acute myocardial infarction (MI) occurs more commonly among men, several studies have shown that short term mortality after the event is higher among women.1 2 A review of 27 studies concluded that the reasons for increased early mortality among women were older age and the presence of other unfavourable baseline clinical characteristics.3 Long term survival was shown to be better for women after adjusting for differences in age and other covariates in large MI population registries.3 Subsequent investigators found an interaction between sex and age, 4-7 with a female excess of mortality among younger patients (, 50 years of age) that diminished with age. Survival was similar between the sexes among the elderly (. 70 years of age).The higher early mortality among hospitalised women may also be attributed to a difference in survival pattern after an acute coronary event. Among those who died within 28 days in the Scottish MONICA (monitoring trends and determinants in cardiovascular disease) population of Glasgow, 8 men were more likely to die out of hospital (74.3% v 67.8%; p = 0.0004). After hospitalisation, women were more likely to die, resulting in a similar 28 day case fatality rate between men (49.8%) and women (48.5%). However, in the MONICA project of 37 populati...

Gender differences in acute myocardial infarction, twenty-five years registration

“…The strongest decrease in time of fatal attack rates in comparison with non-fatal ones might be explained, among others, by the improvement of therapeutic care intake. It might also be explained by several factors like the set up of intensive cardiologic care units for emergency and specialized care intake, with a persistent surveillance to detect any complication, by a prescription of early pre-hospital or hospital thrombolysis, by an expansion of proceeds in mechanical emergency revascularization with primary coronary angioplasty or by a development of centres and of programs on cardiac readjustment to effort after a coronary thrombosis [19].…”

Ethnic variations in acute coronary syndromes

“…4 The higher mortality in women reported in previous studies was largely attributed to worse clinical features at presentation, 2 15 and it has also been suggested that it might actually be apparent, concerning only in-hospital deaths, which would be counterbalanced by a higher pre-hospital mortality in men. 15 16 In the SMIR registry, however, both pre-and inhospital adjusted fatality rates were consistently higher in women in all ethnic groups.…”

“…Sex analysis, however, revealed that whereas fatality rates differed significantly among women, with persistence of the differences at long term follow up, there were no significant differences among men. 4 The higher mortality in Malay women does not seem to be explained by differences in clinical characteristics. Furthermore, the differences among groups were substantially related to pre-hospital fatality rates, thus excluding a major role for variations in acute hospital care or response to treatment (for example, thrombolysis, revascularisation procedures).…”

“…In this issue, Mak and colleagues 4 report data on sex differences in coronary mortality following an acute myocardial infarction (AMI) among the three major ethnic groups which form the population of the city-state of Singapore-that is, Chinese (61.8%), Indians (17.5%), and Malays (19.0%). Data are derived from the Singapore Myocardial Infarction Register (SMIR), which enrolled all potential cases of AMI in 25-64 year old people living in Singapore from 1991 to 1999.…”

Gender Differences in Patients With Coronary Artery Disease in Japan

“…13 Furthermore, parameters used are varied among the studies, and the weights of parameters are influenced by the covariate used. 16 Most studies report higher mortality after unstable angina 14 or MI [17][18][19][20][21][22][23] in women compared to men. This effect is primarily seen in younger women and progressively declines with age, with equivalent outcomes in the elderly.…”