Gender differences in outcomes during initial hospitalization and at 1-year follow-up of patients with acute coronary syndrome: experience from the Croatian branch of the ISACS-CT Registry

    Authors

    Abstract

    **Background and Aim**: Women with ST-segment elevation myocardial infarction (STEMI) have a higher 30-day risk of all-cause mortality. (1) The aim is to study gender differences in in-hospital mortality and mortality at 1-year follow-up in the Croatian branch of the ISACS-CT registry (NCT01218776). **Patients and Methods**: From January 2012 to October 2017, 1898 patients were enrolled; 46% (n=881) presenting with STEMI, 36% (n=685) with non-ST-segment elevation myocardial infarction (NSTEMI), and 18% (n=332) with unstable angina (UA). Follow-up was performed on 33% (n=630) of the cohort, 44% (n=275) with STEMI, 34% (n=217) NSTEMI, and 22% (n=138) with UA. **Results**: At admission women were older, more burdened with comorbidities, and arrived at the hospital with a longer delay from symptom onset (**Figure 1**). During hospitalization, there were no gender differences in reaching an ejection fraction (EF) below 40%. Nevertheless, women with STEMI had significantly worse outcomes in the acute period (**Table 1****)**. After adjusting for gender, in-hospital mortality was associated with age (OR 1.09, 95% CI 1.06-1.13, p<0.001) and primary percutaneous coronary intervention (PCI) (OR 0.45, 95% CI 0.24-0.86, p=0.015). At hospital discharge there was no gender difference in prescribed ACE-inhibitors or statins, whereas after 1-year there was a significant reduction in ACE-inhibitor (female vs. male: 68.3% vs. 81.1%, p=0.042) and statin therapy in women (**Figure 2**). During follow-up, 15.7% of patients reached <40% EF, 7.6% underwent repeated PCI, 2.7% were readmitted with NSTEMI or UA, 1.3% hospitalized for heart failure, 0.8% had a coronary artery bypass graft (CABG) procedure, 0.6% a stroke or a transitory ischemic attack, and 0.5% were readmitted with STEMI. There was no gender difference in all-cause mortality or in any of the endpoints. After adjustment for the type of acute coronary event at initial presentation and gender - age (HR 1.10, 95% CI 1.06-1.15, p<0.001), EF at discharge (HR 0.95, 95% CI 0.92-0.97, p<0.001) and primary PCI (HR 0.30, 95% CI 0.13-0.65, p=0.002) proved to be significant predictors of survival. **Conclusion**: Our results concur with the current findings of significantly increased in-hospital mortality of female STEMI patients. At 1-year follow-up there was no gender disproportion in mortality or other endpoints. A decrease in statin therapy was noted in women during follow-up, suggesting more through control might be needed to maintain the prescription of statins or compliance. FIGURE 1. Gender differences in comorbidities and admission time in patients admitted due to acute coronary syndrome. ### TABLE 1: Gender differences in mortality at hospital discharge and at 1-year follow-up. | | **STEMI** | **STEMI** | **STEMI** | **NSTEMI** | **NSTEMI** | **NSTEMI** | **Unstable Angina** | **Unstable Angina** | **Unstable Angina** | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Mortality | Male | Female | P value | Male | Female | P value | Male | Female | P value | | In-hospital, n (%) | 25 (4.1) | 32 (12.1) | **<0.001** | 15 (3.3) | 9 (3.8) | 0.827 | 4 (1.7) | 0 (0) | 0.261 | | 1-year follow-up, n (%) | 11 (5.7) | 6 (7.4) | 0.586 | 9 (6.3) | 5 (6.8) | 0.895 | 2 (1.9) | 1 (3) | 0.699 | [†] STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myocardial infarction. FIGURE 2. Statin therapy over time in patients with acute coronary syndrome.

    Keywords

    acute coronary syndrome, ISACS-CT registry, gender differences, outcomes

    DOI

    https://doi.org/10.15836/ccar2018.438

    Literature

    1. Bugiardini R, Ricci B, Cenko E, Vasiljevic Z, Kedev S, Davidovic G, et al. Delayed Care and Mortality Among Women and Men With Myocardial Infarction. J Am Heart Assoc. 2017 Aug 21;6(8):e005968. https://doi.org/10.1161/JAHA.117.005968
    Cardiologia Croatica
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    Gender differences in outcomes during initial hospitalization and at 1-year follow-up of patients with acute coronary syndrome: experience from the Croatian branch of the ISACS-CT Registry

    Extended Abstract
    Issue11-12
    Published
    Pages438-439
    PDF via DOIhttps://doi.org/10.15836/ccar2018.438
    acute coronary syndrome
    ISACS-CT registry
    gender differences
    outcomes

    Authors

    Filip Lončarić*ORCIDInstitut biomedicinskog istraživanja August Pi Sunyer (IDIBAPS), Barcelona, Španjolska
    Petra MjehovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Dorja SabljakORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Antonija MiškovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Dominik OrozORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Ines VinkovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Vedrana VlahovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Grgur SalaiORCIDMedicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
    Saša PavasovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Nina JakušORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Dora FabijanovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Maja ČikešORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Davor MiličićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska

    *Correspondence email: loncaric.filip@gmail.com

    Abstract

    **Background and Aim**: Women with ST-segment elevation myocardial infarction (STEMI) have a higher 30-day risk of all-cause mortality. (1) The aim is to study gender differences in in-hospital mortality and mortality at 1-year follow-up in the Croatian branch of the ISACS-CT registry (NCT01218776). **Patients and Methods**: From January 2012 to October 2017, 1898 patients were enrolled; 46% (n=881) presenting with STEMI, 36% (n=685) with non-ST-segment elevation myocardial infarction (NSTEMI), and 18% (n=332) with unstable angina (UA). Follow-up was performed on 33% (n=630) of the cohort, 44% (n=275) with STEMI, 34% (n=217) NSTEMI, and 22% (n=138) with UA. **Results**: At admission women were older, more burdened with comorbidities, and arrived at the hospital with a longer delay from symptom onset (**Figure 1**). During hospitalization, there were no gender differences in reaching an ejection fraction (EF) below 40%. Nevertheless, women with STEMI had significantly worse outcomes in the acute period (**Table 1****)**. After adjusting for gender, in-hospital mortality was associated with age (OR 1.09, 95% CI 1.06-1.13, p<0.001) and primary percutaneous coronary intervention (PCI) (OR 0.45, 95% CI 0.24-0.86, p=0.015). At hospital discharge there was no gender difference in prescribed ACE-inhibitors or statins, whereas after 1-year there was a significant reduction in ACE-inhibitor (female vs. male: 68.3% vs. 81.1%, p=0.042) and statin therapy in women (**Figure 2**). During follow-up, 15.7% of patients reached <40% EF, 7.6% underwent repeated PCI, 2.7% were readmitted with NSTEMI or UA, 1.3% hospitalized for heart failure, 0.8% had a coronary artery bypass graft (CABG) procedure, 0.6% a stroke or a transitory ischemic attack, and 0.5% were readmitted with STEMI. There was no gender difference in all-cause mortality or in any of the endpoints. After adjustment for the type of acute coronary event at initial presentation and gender - age (HR 1.10, 95% CI 1.06-1.15, p<0.001), EF at discharge (HR 0.95, 95% CI 0.92-0.97, p<0.001) and primary PCI (HR 0.30, 95% CI 0.13-0.65, p=0.002) proved to be significant predictors of survival. **Conclusion**: Our results concur with the current findings of significantly increased in-hospital mortality of female STEMI patients. At 1-year follow-up there was no gender disproportion in mortality or other endpoints. A decrease in statin therapy was noted in women during follow-up, suggesting more through control might be needed to maintain the prescription of statins or compliance. FIGURE 1. Gender differences in comorbidities and admission time in patients admitted due to acute coronary syndrome. ### TABLE 1: Gender differences in mortality at hospital discharge and at 1-year follow-up. | | **STEMI** | **STEMI** | **STEMI** | **NSTEMI** | **NSTEMI** | **NSTEMI** | **Unstable Angina** | **Unstable Angina** | **Unstable Angina** | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Mortality | Male | Female | P value | Male | Female | P value | Male | Female | P value | | In-hospital, n (%) | 25 (4.1) | 32 (12.1) | **<0.001** | 15 (3.3) | 9 (3.8) | 0.827 | 4 (1.7) | 0 (0) | 0.261 | | 1-year follow-up, n (%) | 11 (5.7) | 6 (7.4) | 0.586 | 9 (6.3) | 5 (6.8) | 0.895 | 2 (1.9) | 1 (3) | 0.699 | [†] STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myocardial infarction. FIGURE 2. Statin therapy over time in patients with acute coronary syndrome.

    Literature

    1. 1.
      Bugiardini R, Ricci B, Cenko E, Vasiljevic Z, Kedev S, Davidovic G, et al. Delayed Care and Mortality Among Women and Men With Myocardial Infarction. J Am Heart Assoc. 2017 Aug 21;6(8):e005968.DOI