The incidence of coronary heart disease in women has increased over the past decade, yet evidence suggests that they typically receive fewer high-technology cardiac procedures than men. Before age 75, women also die in the hospital more often than men after a heart attack. According to a recent study, 29 percent of women and 20 percent of men have died 2 years after a heart attack, a difference that is fully explained by women's older age—about 8 years on average. The study, which was funded by the National Heart, Lung, and Blood Institute, and led by Viola Vaccarino, M.D., Ph.D., of Emory University School of Medicine, analyzed the outcomes of nearly 7,000 heart attack patients discharged from 16 Massachusetts hospitals.
In their study, Dr. Vaccarino and colleagues outlined several possible mechanisms that could contribute to worse outcomes in middle-aged women, including genetic, hormonal, and/or inflammatory factors. However, because the sex-based differences in mortality were independent of clinical severity and other clinical characteristics, the researchers note that nonbiological factors might be involved. These include behavioral, psychological, and social factors such as smoking, adherence to medication regimens, depression, social isolation and lack of support, low income, and emotional stress.
In an editorial accompanying the study, John Z. Ayanian, M.D., M.P.P., of Harvard Medical School, whose work is supported by the Agency for Healthcare Research and Quality (HS09718), notes that there was a higher 2-year mortality rate for women than men before age 60 (11 vs. 7 percent), but that mortality was lower for women than men after age 79 (46 vs. 51 percent). This interaction of age and sex remained a significant predictor of death even after adjustment for numerous demographic and clinical characteristics of patients, as well as the cardiac treatments they received while hospitalized.
Dr. Ayanian discusses the implications of this study for researchers and clinicians. First, the findings should spur the ongoing search for biological, psychosocial, and clinical factors that may contribute to increased mortality after heart attack in women younger than 60 years of age. Second, Dr. Ayanian points to the increasing number of heart attacks in patients 80 years of age and older and cites the need for increased emphasis on reducing the very high mortality rates in both men and women in this age group.
For more information, see "Increased mortality among middle-aged women after myocardial infarction: Searching for mechanisms and solutions," by Dr. Ayanian, in the February 6, 2001 Annals of Internal Medicine 134(3), pp. 239-241.
Editor's Note: For more information on the study discussed in Dr. Ayanian's editorial, see "Sex differences in 2-year mortality after hospital discharge for myocardial infarction," by Dr. Vaccarino, Harlan M. Krumholz, M.D., Jorge Yarzebski, M.D., M.P.H., and others, in the same journal, pp. 173-181.
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