Canadian VIGOUR Centre (J.A.E., A.S., R.C.W., F.A.M., S.G.G., P.K.), University of Alberta, Edmonton.
Department of Medicine, Faculty of Medicine and Dentistry (J.A.E., R.C.W., F.A.M.), University of Alberta, Edmonton.
Circulation. 2020 Dec 8;142(23):2231-2239. doi: 10.1161/CIRCULATIONAHA.120.048015. Epub 2020 Nov 30.
We hypothesized that disparities between sexes in the management of myocardial infarction (MI) may have changed over time, and thus altered the prognoses after MI, especially the risk for the development of heart failure.
Using a large population-based cohort of patients with MI between April 1, 2002, and March 31, 2016, we examined the incidence, angiographic findings, treatment (including revascularization), and clinical outcomes of patients with a first-time MI. To elucidate the differences between sexes, a series of multivariable models were created to explore all MI and non-ST-segment-elevation MI (NSTEMI) versus ST-segment-elevation MI (STEMI) over time.
Between 2002 and 2016, 45 064 patients (13 878 [30.8%] women) were hospitalized with a primary diagnosis of first-time MI (54.9% NSTEMI and 45.1% STEMI). Women were older (median age, 72 versus 61 years), had more comorbidities, and had lower rates of diagnostic angiography than did men (women, 74%, versus men, 87%). When angiography was performed, women had a lower proportion of left main, 2-vessel disease with proximal left anterior descending or 3-vessel disease compared with men (33.4% versus 40.9%, <0.0001), and a higher frequency of 1-vessel disease or nonobstructive coronary artery disease (39.6% versus 29.1%, <0.0001). Women had a higher unadjusted rate of in-hospital mortality than did men in both patients with STEMI (women, 9.4%, versus men, 4.5%) and patients with NSTEMI (women, 4.7%, versus men, 2.9%). After adjustment, this difference remained significant in STEMI (adjusted odds ratio, 1.42 [95% CI, 1.24-1.64]) but not in NSTEMI (adjusted odds ratio, 0.97 [95% CI, 0.83-1.13]). After discharge, women developed heart failure after STEMI (women, 22.5%, versus men, 14.9%) as well as after NSTEMI (women, 23.2%, versus men, 15.7%). The adjusted relative risk for women versus men of developing the outcomes of mortality and heart failure remained similar across years, although the differences were nonsignificantly attenuated over 5 years of follow-up.
Although some attenuation of differences in clinical outcomes over time has occurred, women remain at higher risk than men of dying or developing heart failure in the subsequent 5 years after STEMI or NSTEMI, even after accounting for differences in angiographic findings, revascularization, and other confounders.
我们假设，心肌梗死（MI）管理方面的性别差异可能随时间而变化，从而改变 MI 后的预后，尤其是心力衰竭的风险。
利用 2002 年 4 月 1 日至 2016 年 3 月 31 日期间的一项大型基于人群的 MI 患者队列，我们检查了首次 MI 患者的发病情况、血管造影结果、治疗（包括血运重建）和临床结局。为了阐明性别差异，我们创建了一系列多变量模型，以随时间探索所有 MI、非 ST 段抬高型心肌梗死（NSTEMI）与 ST 段抬高型心肌梗死（STEMI）之间的差异。
2002 年至 2016 年间，45064 名患者（13878 名[30.8%]女性）因首次 MI 被收治入院（54.9%为 NSTEMI，45.1%为 STEMI）。女性年龄较大（中位数年龄 72 岁 vs 61 岁），合并症更多，且接受诊断性血管造影的比例低于男性（女性 74% vs 男性 87%）。当进行血管造影时，女性左主干、前降支近端 2 支血管病变或 3 支血管病变的比例较男性更低（女性 33.4% vs 男性 40.9%，<0.0001），而 1 支血管病变或非阻塞性冠状动脉疾病的比例更高（女性 39.6% vs 男性 29.1%，<0.0001）。与男性 STEMI 患者（女性 9.4% vs 男性 4.5%）和 NSTEMI 患者（女性 4.7% vs 男性 2.9%）相比，女性在住院期间的死亡率均高于男性，这一差异在调整后仍具有统计学意义（STEMI 患者的校正比值比 1.42 [95%CI，1.24-1.64]；NSTEMI 患者的校正比值比 0.97 [95%CI，0.83-1.13]）。出院后，STEMI（女性 22.5% vs 男性 14.9%）和 NSTEMI（女性 23.2% vs 男性 15.7%）后女性心力衰竭的发生率也高于男性。尽管经过 5 年的随访，差异无统计学意义，但女性与男性发生死亡和心力衰竭的风险比值比在不同年份之间仍保持相似。
尽管随着时间的推移，临床结局方面的差异有所缓解，但 STEMI 或 NSTEMI 后 5 年内，女性发生死亡或心力衰竭的风险仍高于男性，即使考虑到血管造影结果、血运重建和其他混杂因素的差异也是如此。
