Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes - 14/12/11

Doi : 10.1016/j.ahj.2011.09.025

Stephanie Poon, MD, MSc ^a, Shaun G. Goodman, MD, MSc ^a,^b,^{^{j
On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.}}, Raymond T. Yan, MD ^b, Raffaele Bugiardini, MD ^c, Arlene S. Bierman, MD, MSc ^d, Kim A. Eagle, MD ^e,^{^{j
On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.}}, Nina Johnston, MD ^f, Thao Huynh, MD, MSc ^g,^{^{j
On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.}}, Francois R. Grondin, MD ^h,^{^{j
On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.}}, Karin Schenck-Gustafsson, MD, PhD ⁱ, Andrew T. Yan, MD ^a,^b,^{^{j
On behalf of the Canadian Acute Coronary Syndrome Registries I and II, and the Canadian Global Registry of Acute Coronary Events (GRACE/GRACE²) Investigators. A list of participating Canadian ACS Registry I and II Investigators and Coordinators can be found in Arch Intern Med 2007;167:1009-1016. A list of participating Canadian GRACE and expanded-GRACE investigators and coordinators may be found in Am Heart J 2009;157:642-650.},}^{^⁎}
^a Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
^b Canadian Heart Research Centre, Toronto, Ontario, Canada
^c Dipartimento di Medicina Interna, Cardioangiologia, Epatologia (Padiglione 11), University of Bologna, Bologna, Italy
^d Departments of Nursing, Health Policy Management and Evaluation, and Medicine, University of Toronto and Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
^e University of Michigan Cardiovascular Center, Ann Arbor, MI
^f Department of Medical Sciences, Cardiology, Cardiothoracic Center, Uppsala University Hospital, Uppsala and Center for Gender Medicine, Karolinska Institutet, Stockholm, Sweden
^g McGill University Health Centre, Montreal, Quebec, Canada
^h Hôtel-Dieu de Lévis, Lévis, Quebec, Canada
ⁱ Center for Gender Medicine, Karolinska Institutet, Stockholm, Sweden

^⁎Reprint requests: Andrew T. Yan, MD, Division of Cardiology, St Michael's Hospital, 30 Bond St, Room 6-030 Queen, Toronto, Ontario, Canada M5B 1W8.

Résumé

Background

The question of whether gender-related disparities still exist in the treatment and outcomes of patients presenting with acute coronary syndromes (ACS) remains controversial. Using data from 4 registries spanning a decade, we sought to determine whether sex-related differences have persisted over time and to examine the treating physician's rationale for adopting a conservative management strategy in women compared with men.

Methods

From 1999 to 2008, 14,196 Canadian patients with non–ST-segment elevation ACS were recruited into the Acute Coronary Syndrome I (ACSI), ACSII, Global Registry of Acute Coronary Events (GRACE/GRACE²), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries.

Results

Women in the study population were found to be significantly older than men and were more likely to have a history of heart failure, diabetes, or hypertension. Fewer women were treated with thienopyridines, heparin, and glycoprotein IIb/IIIa inhibitors compared with men in GRACE and CANRACE. Female gender was independently associated with a lower in-hospital use of coronary angiography (adjusted odds ratio 0.76, 95% CI 0.69-0.84, P < .001) and higher in-hospital mortality (adjusted odds ratio 1.26, 95% CI 1.02-1.56, P = .036), irrespective of age (P for interaction =.76). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy in both men and women.

Conclusions

Despite temporal increases in the use of invasive cardiac procedures, women with ACS are still more likely to be treated conservatively, which may be due to underestimation of patient risk. Furthermore, they have worse in-hospital outcomes. Greater awareness of this paradox may assist in bridging the gap between current guidelines and management practices.

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Vol 163 - N° 1

P. 66-73 - janvier 2012 Retour au numéro

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Bridging the gender gap: Insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes - 14/12/11

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