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Original Investigation
May 2018

Sex Differences in Outcomes After STEMIEffect Modification by Treatment Strategy and Age

Author Affiliations
  • 1Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
  • 2Department of Electrical and Computer Engineering, University of California, Los Angeles
  • 3University Clinic of Cardiology, Medical Faculty, University Ss. Cyril and Methodius, Skopje, Macedonia
  • 4Clinical Center of Serbia, Department of Cardiology, Medical Faculty, University of Belgrade, Belgrade, Serbia.
  • 5Medical Faculty, University of Belgrade, Belgrade, Serbia
  • 6Department for Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
  • 7Cardiovascular Research Institute (ICCC), CiberCV-Institute Carlos III, IIB-Sant Pau, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
JAMA Intern Med. 2018;178(5):632-639. doi:10.1001/jamainternmed.2018.0514
Key Points

Question  Can sex differences in outcomes in young patients after STEMI be explained only by sex disparities in the quality and timing of care?

Findings  This observaional study found that a disproportionate burden of coronary risk factors and comorbidities is a clear feature of younger women with STEMI, but does not account for age-dependent difference in mortality. Younger age was associated with higher 30-day mortality rates in women even after adjustment for medications, primary PCI, and other coexisting comorbidities, but this difference declined after age 60 and was no longer observed in oldest women.

Meaning  Sex-related pathophysiological differences may contribute to the higher mortality rates in younger women compared with men of the same age category.


Importance  Previous works have shown that women hospitalized with ST-segment elevation myocardial infarction (STEMI) have higher short-term mortality rates than men. However, it is unclear if these differences persist among patients undergoing contemporary primary percutaneous coronary intervention (PCI).

Objective  To investigate whether the risk of 30-day mortality after STEMI is higher in women than men and, if so, to assess the role of age, medications, and primary PCI in this excess of risk.

Design, Setting, and Participants  From January 2010 to January 2016, a total of 8834 patients were hospitalized and received medical treatment for STEMI in 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776).

Exposures  Demographics, baseline characteristics, clinical profile, and pharmacological treatment within 24 hours and primary PCI.

Main Outcomes and Measures  Adjusted 30-day mortality rates estimated using inverse probability of treatment weighted (IPTW) logistic regression models.

Results  There were 2657 women with a mean (SD) age of 66.1 (11.6) years and 6177 men with a mean (SD) age of 59.9 (11.7) years included in the study. Thirty-day mortality was significantly higher for women than for men (11.6% vs 6.0%, P < .001). The gap in sex-specific mortality narrowed if restricting the analysis to men and women undergoing primary PCI (7.1% vs 3.3%, P < .001). After multivariable adjustment for comorbidities and treatment covariates, women under 60 had higher early mortality risk than men of the same age category (OR, 1.88; 95% CI, 1.04-3.26; P = .02). The risk in the subgroups aged 60 to 74 years and over 75 years was not significantly different between sexes (OR, 1.28; 95% CI, 0.88-1.88; P = .19 and OR, 1.17; 95% CI, 0.80-1.73; P = .40; respectively). After IPTW adjustment for baseline clinical covariates, the relationship among sex, age category, and 30-day mortality was similar (OR, 1.56 [95% CI, 1.05-2.3]; OR, 1.49 [95% CI, 1.15-1.92]; and OR, 1.21 [95% CI, 0.93-1.57]; respectively).

Conclusions and Relevance  Younger age was associated with higher 30-day mortality rates in women with STEMI even after adjustment for medications, primary PCI, and other coexisting comorbidities. This difference declines after age 60 and is no longer observed in oldest women.

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