Higher mortality risk for women in the year after a heart attack

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Heart attacks pose a greater threat to women than to men. A team at the Technical University of Munich (TUM) has determined that in the first year after a heart attack, women are subject to a significantly higher mortality risk than men with similar case histories. The scientists are urging doctors to provide intensive support to female heart attack patients, above all in the first 365 days after the event.

Heart attacks are still seen as a disease that primarily affects men. That is true in the sense that men account for around two thirds of patients hospitalised after suffering a heart attack. Studies in recent years have shown, however, that women have a higher incidence of death from heart attacks and their consequences. One reason for this is that women suffer “different” heart attacks: Statistically, they tend to be 10 years older at the time of the infarct and are more likely to have accompanying conditions such as diabetes. Moreover, it is less common for heart attacks in women to be triggered by a local narrowing of blood vessels that can be widened relatively easily.

Instead they suffer more often from diffuse coronary artery disease. In these cases, local ablation procedures have less chance of success. Dr Romy Ubrich, the first author of the paper, explains the approach: “We wanted to find out whether the mortality risk of female patients after a heart attack is still higher after adjusting for those factors.” The research drew on patient data collected in two studies (“ISAR-RISK” and “ART“) with a total of 4,100 participants.

“If we look at the full five-year investigation period after the heart attack, there are no unusually large gender-specific differences if we adjust for factors such as age, accompanying conditions and type of treatment,” says Ubrich. “But we were surprised by the data for the first 365 days after the event: During that time, women were 1.5 times as likely to die as men.”

There are a number of possible reasons for this. The last author of the study, Professor Georg Schmidt, a cardiologist at the internal medicine unit at TUM’s university hospital Rechts der Isar, believes that societal and psychological causes play an important role. “In everyday life, women often face different expectations after a heart attack than men. They are expected to start ‘functioning’ again sooner, which means that they are subject to bigger stresses,” says Schmidt. Another important factor is the prevalence of depressive conditions. Studies have shown that such conditions are not only dangerous in themselves, but are also a risk factor in combination with other illnesses.

The studies providing the data for the current investigation did not cover psycho-social factors, however. Future studies would have to consider whether they represent the main cause of the differences, or whether there are other reasons, possibly biological in nature, says Schmidt. In any case, he says, the spotlight now shifts to the doctors of women recovering from heart attacks: “Our study shows that it is important to pay close attention to female patients especially in the first year after the event.”

Schmidt hopes that the message reaches family medicine practices in particular: “Family doctors have to be keenly aware of the social situation of these women and try to provide support. Particularly when there are signs of depression, family doctors need to be especially alert. If such indications are observed, it is important to refer the patients quickly to specialists so that they can start working with a therapist as soon as possible if needed.”

Background: Mortality rates in females who survived acute myocardial infarction (AMI) exceed those in males. Differences between sexes in age, cardiovascular risk factors and revascularization therapy have been proposed as possible reasons.
Objective: To select sets of female and male patients comparable in respect of relevant risk factors in order to compare the sex-specific risk in a systematic manner.
Methods: Data of the ISAR-RISK and ART studies were investigated. Patients were enrolled between 1996 and 2005 and suffered from AMI within 4 weeks prior to enrolment. Patients of each sex were selected with 1:1 equivalent age, previous AMI history, sinus-rhythm presence, hypertension, diabetes mellitus, smoking status, left ventricular ejection fraction (LVEF), and revascularization therapy. Survival times were compared between sex groups in the whole study cohort and in the matched cohort.
Results: Of 3840 consecutive AMI survivors, 994 (25.9%) were females and 2846 (74.1%) were males. Females were older and suffered more frequently from hypertension and diabetes mellitus. In the whole cohort, females showed an increased mortality with a hazard ratio (HR) of 1.54 compared to males (p<0.0001). The matched cohort comprised 802 patients of each sex and revealed a trend towards poorer survival in females (HR for female sex 1.14; p = 0.359). However, significant mortality differences with a higher risk in matched females was observed during the first year after AMI (HR = 1.61; p = 0.045) but not during the subsequent years.
Conclusion: Matched sub-groups of post-AMI patients showed a comparable long-term mortality. However, a female excess mortality remained during first year after AMI and cannot be explained by differences in age, cardiovascular risk factors, and modes of acute treatment. Other causal factors, including clinical as well as psychological and social aspects, need to be considered. Female post-AMI patients should be followed more actively particularly during the first year after AMI.

Romy Ubrich, Petra Barthel, Bernhard Haller, Katerina Hnatkova, Katharina Maria Huster, Alexander Steger, Alexander Müller, Marek Malik, Georg Schmidt

Technical University of Munich material
PLOS One abstract

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