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Effects of Clinical Characteristics and Treatments on Gender Difference in Outcomes after Acute Myocardial Infarction. A propensity score-matched analysis.

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Presentation on theme: "Effects of Clinical Characteristics and Treatments on Gender Difference in Outcomes after Acute Myocardial Infarction. A propensity score-matched analysis."— Presentation transcript:

1 Effects of Clinical Characteristics and Treatments on Gender Difference in Outcomes after Acute Myocardial Infarction. A propensity score-matched analysis François Schiele, MD, PhD, Nicolas Meneveau, MD, PhD, Marie France Seronde, MD, Vincent Descotes-Genon, MD, Joanna Dutheil, MD, Romain Chopard, MD, Fiona Ecarnot, and Jean-Pierre Bassand, MD. On behalf on the Reseau de Cardiologie de Franche Comté Department of Cardiology, University Hospital Jean Minjoz, Besançon, France. Conflict of Interest to Declare : Research Contracts and Consulting Servier, Sanofi, GSK, Astra-Zeneca, Takeda, Lilly

2 Women fare worse than men after acute MI 1.Women admitted for acute MI have % higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. Malacrida, ISIS-3, N Engl J Med 1998;338:8-14

3 1.Women admitted for acute MI have % higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. 2.Sex-age interaction : discrepancy between studies Malacrida, N Engl J Med 1998;338:8-14 Greater difference with older age Vaccarino, N Engl J Med 1999;341: Decrease in difference with age Women fare worse than men after acute MI

4 1.Women admitted for acute MI have % higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. 2.Sex-age interaction : discrepancy between studies 3.Sex-type of MI interaction : STEMI NSTEMI Berger, JAMA 2009;302: Women fare worse than men after acute MI

5 1.Women admitted for acute MI have % higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. 2.Sex-age interaction : discrepancy between studies 3.Sex-Type of MI interaction : STEMI NSTEMI 4.Women receive fewer treatments and no difference in mortality is observed after adjustment for co-morbidities and treatments Gan, N Engl J Med 2000;343:8-15 Women fare worse than men after acute MI

6 1.Women admitted for acute MI have % higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. 2.Sex-age interaction : discrepancy between studies 3.Sex-Type of MI interaction : STEMI NSTEMI 4.Women receive fewer treatments and no difference in mortality is observed after adjustment for co-morbidities and treatments To assess the effects of Clinical Characteristics and Treatments on Gender Difference, using a Propensity Score-Matched Analysis. Aim of the Study Women fare worse than men after acute MI

7 Methods All consecutive patients admitted between January 2006 and December 2007 CARDS dataset, dedicated team of data managers. Endpoint: 30 day all-cause mortality Use of matched pairs comparison: Two Propensity scores for being male by logistic regression, PS#1 with baseline characteristics (16 variables) PS#2 with baseline characteristics and treatments 1:1 matching on best 8 digits of the propensity score (match allowed for PS<0.015) 30 day mortality (Kaplan Meier curves and Odds ratios from conditional logistic regression) in unadjusted and matched cohorts Interactions : age, type of MI by Breslow-Day test.

8 VariablesWomen (%)Men (%)P ValueChi2/t N1119 (32)2391 (68) STEMI 461 (41)1117 (47) NSTEMI 658 (59)1274 (53)< Age (SD)74 (13)64 (13) < Diabetes301 (27)495 (21)< Hypertension762 (68)1143 (48)< Hypercholesterolemia451 (40)1132 (47)< Smoker258 (23)1583 (66)< Previous MI 151 (13)449 (19)< Previous angioplasty94 (8)349 (15)< Previous coronary surgery37 (3)105 (4) Previous Stroke79 (7)121 (5) Per. Vessel Disease86 (8)286 (12)< Baseline characteristics (1)

9 VariablesWomen (%)Men (%)P ValueChi2/t N1119 (32)2391 (68) Time to admission STEMI 4 [2;15]3 [2;9] < Admission heart rate80 (20)77 (20)< Admission Systolic BP134 (29)130 (28) Killip class >294 (8)127 (5)< Cardiogenic shock48 (4)94 (4) GRACE risk score147 [124 ;167]132 [110 ;152]< Admission Glucose7 (4.4)6.7 (3.5) BNP480 [180;1202] 217 [83;544]< Hs-CRP8 [3;27]6 [2;22] < Baseline characteristics (2)

10 VariablesWomen (%)Men (%)P ValueChi2/t Angiography805 (72)2080 (87)< No obstructive disease112(14)92(4)< PCI of infarct related artery 552(49)1662(69)< GPIIbIIIa inhibitors (NSTEMI)271 (40)682 (53) < Reperfusion (STEMI) 281/461 (61) 843/1117 (75) < Primary PCI (STEMI)215/461 (47)615/1117 (55)< Thrombolysis (STEMI)66/461 (14)228/1117 (20)< Aspirin1089 (97)2360 (99)< Clopidogrel1035 (92)2290 (96)< Aspirin + Clopidogrel1035 (92)2290 (96)< ACEI / ARB667 (60)2052 (86)< Betablockers791 (71)1847 (77)< Statins982 (88)2296 (96)< In-hospital Treatments

11 Selection of the matched populations 3510 patients with Acute Myocardial Infarction 1578 (45%) STEMI, 1932 (55%) NSTEMI 1119 (32%) Women, 2391 (68%) Men Matching on propensity score 1 = 649 pairs Comparison of treatments Comparison of mortality Propensity score 1 (being male) with baseline characteristics Propensity score 2 (being male) with baseline characteristics and treatments Matching on propensity score 2 = 584 pairs

12 Effect of matching on sex differences P values for the difference between men and women Unmatched dataset 0.05

13 Effect of matching on sex differences P values for the difference between men and women Unmatched datasetMatched #1 dataset 0.05

14 Effect of matching on sex differences P values for the difference between men and women Unmatched datasetMatched #1 datasetMatched #2 dataset 0.05

15 KM Cumulative mortality Unmatched n=3510 p=0.001 Matched #1 n=649 pairsp=0.23 Log-Rank test: p=0.95 Days At risk Women Men Unmatched n=3510 p=0.001 Matched #1 n=649 pairsp=0.23 Matched #2 n=584 pairsp=0.95

16 Aspirin unmatched OR= 1.35 [1.06; 1.80] Matched #1 OR= 1.10 [0.46; 2.62] Clopidogrel unmatched OR= 1.65 [1.38; 2.01] Matched #1 OR= 1.04 [0.58; 1.84] Aspirin and Clopidogel unmatched OR= 1.67 [1.40; 2.01] Matched #1 OR= 1.10 [0.46; 1.63] ACEI or ARB unmatched OR= 1.42 [1.24; 1.65] Matched #1 OR= 1.29 [0.97; 1.70] Beta blocker unmatched OR= 1.31 [1.15; 1.49] Matched #1 OR= 1.02 [0.64; 1.29] GPIIbIIIa (NSTEMI) unmatched OR= 1.66 [1.43; 1.96] Matched #1 OR= 1.40 [0.94; 1.56] Coronary Angiography unmatched OR= 2.82 [2.40; 3.41] Matched #1 OR= 1.57 [1.10; 2.18] Reperfusion /PPCI unmatched OR= 1.56 [1.29; 1.89] Matched #1 OR= 1.24 [1.12; 1.71] Reperfusion /FL unmatched OR= 1.82 [1.24; 2.12] Matched #1 OR= 1.72 [1.08; 2.73] In-Hospital mortality unmatched OR= 0.50 [0.37; 0.62] Matched #1 OR= 0.52 [0.32; 0.83] Matched #2 OR= 0.75 [0.45; 1.23] 30 day mortality unmatched OR= 0.53 [0.42; 0.57] Matched #1 OR= 0.70 [0.46; 1.01] Matched #2 OR= 0.89 [0.57; 1.36] Odds ratios for men versus women

17 Interaction with type of MI P=0.15 P=0.24 P=0.10 STEMI NSTEMI Women Men Women Men

18 Interaction with age <68 years 68 years Women Men Women Men P=0.04 P=0.01 P=0.29

19 Discussion Matching on propensity score with analysis by pairs Differences in characteristics, treatments and mortality Significant interaction with age: gender difference in older patients, disapears after matching. No significant interaction with the type of MI: higher mortality in women with STEMI, disappears after matching Sex differences in aspirin, clopidogrel, betablockers, ACEI and statins are explained by characteristics. Sex differences in coronary angiography and reperfusion in STEMI are not explained by characteristics No difference in mortality after matching on characteristics and treatments. Vaccarino, New Engl J Med 1999Austin, Use of PS.., Stat Med 2005Berger, JAMA 2009;302:874-82Blomkalns, CRUSADE, JACC 2005;45:832-7Rosengren Eur Heart J 2001; 22: 314–322,Milcent Circulation. 2007;115:

20 Conclusions As compared with men, women admitted for acute MI receive fewer effective treatments and have a twofold higher 30 day mortality. Comparison of cohorts matched on baseline characteristics shows that co-morbidities explain the lower use of treatments. Nevertheless, women are less often submitted to coronary angiography and reperfusion (STEMI) and have a higher in-hospital mortality. Comparison of cohorts matched on baseline characteristics and treatments shows similar in-hospital and 30 day mortality between genders, suggesting that a higher use of invasive procedures and reperfusion strategy could reduce the difference in mortality.


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