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Sex Differences in Patients With Cardiogenic Shock Due to Acute MI
Quick Takes
- Women with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) are older, and have a higher prevalence of comorbidities and worse renal function on presentation.
- Women are less likely to receive guideline-directed medical therapy within 24 hours and at discharge, undergo cardiac catheterization, or receive temporary mechanical circulatory support devices.
- Although women have higher rates of in-hospital mortality and major bleeding, they have lower rates of new requirement for renal replacement therapy (i.e., dialysis). At 1 year, however, there were no differences between women and men surviving the index hospitalization in the risk of mortality and the composite of mortality or heart failure hospitalization.
Study Questions:
What are the sex differences in the risk profile, management, and outcomes among patients presenting with cardiogenic shock due to acute myocardial infarction (AMI-CS)?
Methods:
A total of 17,195 patients admitted with AMI-CS from the National Cardiovascular Data Registry (NCDR) Chest Pain-MI registry between October 2008–December 2017, were included. Sex differences in baseline characteristics, in-hospital management, and 1-year outcomes (all-cause mortality and the composite of mortality or heart failure hospitalization for elderly patients) were compared. The primary outcome of this study was in-hospital, all-cause mortality. Secondary outcomes included in-hospital management indicators (e.g., medical therapy and coronary revascularization) and in-hospital adverse events (e.g., stroke, major bleeding, and new dialysis requirement).
Data were linked to Medicare claims for 3,119 patients ≥65 years of age for analysis of 1-year outcomes. Multivariable logistic regression adjusting for patient- and hospital-related covariates was used to estimate sex-specific differences in in-hospital outcomes. Cox proportional hazards models adjusting for patient- and hospital-related covariates were used to estimate sex-specific differences in 1-year outcomes.
Results:
The final study cohort included 6,407 (37.3%) women among 17,195 patients presenting with AMI-CS. The women were older, had a greater number of comorbidities, had worse renal function at presentation, and were more likely to present with non–ST-segment elevation myocardial infarction (NSTEMI). Women were less likely to receive guideline-directed medical therapies within 24 hours and at discharge, undergo diagnostic angiography, or receive temporary mechanical circulatory support. The rate of primary percutaneous coronary intervention (PCI) among STEMI patients was not different. Women had higher risks of in-hospital mortality and adjusted odds of major bleeding. Elderly women did not have a higher risk of all-cause mortality and mortality or heart failure hospitalization at 1 year compared with men.
Conclusions:
In this large, contemporary, observational analysis of >17,000 patients presenting with AMI-CS, women were less likely to receive guideline-directed medical therapies, including revascularization, and had worse in-hospital outcomes. There were no sex differences in the risk of mortality at 1 year in the subset of elderly patients. Ongoing research efforts are needed to address sex disparities in the initial management of AMI-CS patients.
Perspective:
Despite advances in reperfusion therapy and temporary mechanical circulatory support, AMI-CS remains a leading cause of in-hospital morbidity and mortality. This analysis from the NCDR Chest Pain-MI registry represents the largest study to date from a clinical registry examining the sex differences among AMI-CS patients and builds upon prior work examining sex differences in AMI-CS that have been limited due to single-center registry data or poor representation of women in randomized clinical trials. Some key findings deserve further consideration.
The proportion of STEMI patients undergoing primary PCI was not different; however, women were less likely to achieve a door-to-device time of <90 minutes. Due to the observational nature of this study, it is not clear if this delay represents patient- or system-related delay in STEMI recognition or in care following STEMI recognition, and merits further investigation. Women with NSTEMI were less likely to undergo revascularization. Women had less extensive coronary artery disease (i.e., less likely to have three-vessel or left main disease), yet they experienced a higher risk of in-hospital mortality and major bleeding. The excess risk was observed even after adjusting for differences in baseline renal function and comorbidities.
While women had higher unadjusted rates of mortality and the composite of mortality or HF hospitalization at 1 year, there was no difference in 1-year outcomes between both groups after multivariable adjustment. In fact, the curves for both outcomes diverged early and then were mostly parallel afterwards. This study adds to the burgeoning literature delineating important sex disparities in the management and outcomes of AMI-CS, underscoring the need for future research endeavors to address these gaps.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Acute Coronary Syndrome, Angiography, Chest Pain, Chest Pain MI Registry, Coronary Artery Disease, Geriatrics, Heart Failure, Hemorrhage, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, Non-ST Elevated Myocardial Infarction, Patient Discharge, Percutaneous Coronary Intervention, Renal Dialysis, Reperfusion, Risk Factors, Sex Characteristics, Shock, Cardiogenic, ST Elevation Myocardial Infarction, Stroke, Women
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