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Management and Outcome in Non ST-Elevation Acute Coronary Syndromes: Similarities and Differences Between Women nad Men
Linköping University, Department of Medicine and Health Sciences, Cardiology . Linköping University, Faculty of Health Sciences.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Non ST-elevation Acute Coronary Syndromes are the most frequent manifestations of acute ischemic heart disease. Gender differences in treatment intensity, including differences in level of care, have been reported. Also differences in benefit from certain treatments, especially invasive treatment, have been discussed. Finally, difference in outcome between men and women, have been proposed. Results have been inconsistent, partly depending on if and how adjustment for differences in background characteristics has been made. The aims of the studies in this thesis were to assess differences between the genders in baseline characteristics, level of care, medical treatment and non-invasive and invasive cardiac procedures. The aims were also to determine gender differences in short and long-term mortality, including impact of level of care, and to determine differences between the genders in benefit from an invasive strategy, with special reference to benefit in women.

Method: We used prospectively collected data from the RIKS-HIA registry in two studies (Paper I and IV). In one study we merged data from patients admitted to general wards in the south-east region of Sweden (The AKUT registry), with data from patients admitted to CCU´s (RIKS-HIA) at participating hospitals during the same time (Paper II). We also randomly assigned women to a routine invasive or a selective invasive treatment strategy, and performed a meta-analysis, to determine gender differences in benefit from a routine invasive strategy (Paper III).

Results: Women were older than men and more likely to have a history of diabetes and hypertension, while men were more likely to have a history of myocardial infarction and revascularisation. Women were also more likely to have normal coronary arteries on the angiogram. After adjustment for baseline differences there were only minor, and directionally inconsistent, differences between women and men in pharmacological treatment. Men were more often referred for coronary angiography, even after adjustment. While CABG-rate was lower in women, after adjustment PCI-rate was similar or even higher compared to men. After adjustment for differences in age, longterm outcome was better in women. In our small but randomised trial there was no benefit from a routine invasive strategy in women. A meta-analysis indicated interaction between gender and treatment strategy, with lack of benefit in women, in contrast to in men. However, our large observational study indicated no gender difference with an invasive strategy. Moreover, benefit was similar in women and men with invasive treatment.

Conclusion: There are substantial differences between women and men in baseline characteristics that affect management and outcome more than gender per se. After adjustment women have better long-term outcome than men. There appear to be a difference in benefit from a routine invasive strategy between the genders, with less benefit in women, but in routine clinical management there was no difference between women and men managed with an invasive strategy.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 106 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1144
National Category
Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:liu:diva-56255ISBN: 978-91-7393-565-4 (print)OAI: oai:DiVA.org:liu-56255DiVA: diva2:317747
Public defence
2010-09-11, Elsa Brändströmsalen, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2010-09-13 Created: 2010-05-05 Last updated: 2013-09-11Bibliographically approved
List of papers
1. Gender differences in management and outcome in non-ST-elevation acute coronary syndrome
Open this publication in new window or tab >>Gender differences in management and outcome in non-ST-elevation acute coronary syndrome
2007 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 93, no 11, 1357-1362 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To study gender differences in management and outcome in patients with non-ST-elevation acute coronary syndrome. Design, setting and patients: Cohort study of 53 781 consecutive patients (37% women) from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), with a diagnosis of either unstable angina pectoris or non-ST-elevation myocardial infarction. All patients were admitted to intensive coronary care units in Sweden, between 1998 and 2002, and followed for 1 year. Main outcome measures: Treatment intensity and in-hospital, 30-day and 1 -year mortality. Results: Women were older (73 vs 69 years, p<0.001) and more likely to have a history of hypertension and diabetes, but less likely to have a history of myocardial infarction or revascularisation. After adjustment, there were no major differences in acute pharmacological treatment or prophylactic medication at discharge. Revascularisation was, however, even after adjustment, performed more often in men (OR 1.15, 95% CI, 1.09 to 1.21). After adjustment, there was no significant difference in in-hospital (OR 1.03, 95% CI, 0.94 to 1.13) or 30-days (OR 1.07, 95% CI, 0.99 to 1.15) mortality, but at 1 year being male was associated with higher mortality (OR 1.12, 95% CI, 1.06 to 1.19). Conclusion: Although women are somewhat less intensively treated, especially regarding invasive procedures, after adjustment for differences in background characteristics, they have better long-term outcomes than men.

Place, publisher, year, edition, pages
BMJ Publishing group Ltd, 2007
Keyword
acute coronary syndrome, gender
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-47844 (URN)10.1136/hrt.2006.102012 (DOI)17085528 (PubMedID)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13
2. Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome: A prospective cohort study in patients with non ST-elevation acute coronary syndromes
Open this publication in new window or tab >>Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome: A prospective cohort study in patients with non ST-elevation acute coronary syndromes
2009 (English)In: Acute cardiac care, ISSN 1748-295X, Vol. 11, no 3, 173-180 p.Article in journal (Refereed) Published
Abstract [en]

Background: The aim of this study was to assess gender differences in admission level of care, management and outcome in patients with non ST-elevation acute coronary syndromes (NSTE-ACS), initially admitted to either coronary care units (CCU) or general wards. Method: Patients admitted to CCUs were routinely registered in the RIKS-HIA registry. In addition, patients admitted to general wards with suspected ACS were also identified and registered. Multivariable regression analysis was used to adjust for baseline differences between the genders. Results: We included 570 consecutive patients with a discharge diagnosis of NSTE-ACS. Women were less likely to be admitted to coronary care units (56% versus 69%, P=0.002), even after adjustment (odds ratio (OR), 0.65; 95% confidence interval (CI): 0.43-0.98). After adjustment for differences in baseline characteristics, women were treated similarly to men. We found no significant differences in crude short-, or long-term mortality between the genders. However, adjustment for background characteristics revealed lower one-year mortality in women (OR: 0.58; 95% CI: 0.34-0.99). Conclusion: In this study on patients with NSTE-ACS, women were less likely to be admitted to coronary care units. However, the overall treatment was as intensive for women as for men. Moreover, after adjustment, one-year mortality was lower in women.

Place, publisher, year, edition, pages
Informa Healthcare, 2009
Keyword
Myocardial infarction; NSTE-ACS; gender differences; level of care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53576 (URN)10.1080/17482940903215190 (DOI)19742351 (PubMedID)
Available from: 2010-01-25 Created: 2010-01-25 Last updated: 2013-09-11
3.
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4. Similar outcome with an invasive strategy in men and women with Non ST-Elevation Acute Coronary Syndromes
Open this publication in new window or tab >>Similar outcome with an invasive strategy in men and women with Non ST-Elevation Acute Coronary Syndromes
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Gender differences in benefit from an early invasive strategy in patients with Non ST-elevation Acute Coronary Syndromes (NSTE ACS) have been debated and results are conflicting. Some studies have even indicated harm for women associated with a routine invasive strategy.

Method: We included 46 455 patients ( 14 819 women (32%) and 31 636 men (68%)) from The Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), with a diagnosis of either unstable angina pectoris or non-ST-elevation myocardial infarction. All patients were admitted to intensive coronary care units in Sweden, between 2000 and 2006, and followed for 1 year. Adjustment for baseline differences between the genders was made.

Results: In the non-invasive strategy arm relative risk (RR) of death was (women vs. men) 1.02 (95% CI, 0.94-1.11) and in the invasive strategy arm 1.12 (95% CI, 0.96-1.29). After adjustment for baseline differences between the genders with propensity score and discharge medication there was a trend towards lower mortality among women, RR 0.90 (95% CI, 0.82-0.99) in the early non-invasive group but still no difference in the early invasive cohort RR 0.90 (95% CI, 0.76-1.06). Results were similar with the combined end-point death/MI. The risk reduction with an invasive strategy was similar in women (RR 0.46 (95% CI 0.38-0.55)) and men (RR 0.45 (95% CI 0.40-0.52).

Conclusion: In this large cohort of patients with NSTE ACS, reflecting real life management, women and men had similar outcome and similar benefit with an early invasive strategy.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-53578 (URN)
Available from: 2010-01-25 Created: 2010-01-25 Last updated: 2013-09-11

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