Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults

Abstract

Objective: To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS).

Materials and methods: A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay.

Results: In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality.

Conclusion: Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.

FIGURE 1.

Trends in the prevalence and in-hospital mortality in older acute myocardial infarction with cardiogenic shock (AMI-CS) admissions stratified by sex. A, Unadjusted temporal trends of the proportion of AMI admissions with CS stratified by sex (P<.001 for trend over time). B, Adjusted odds ratio for admission with AMI-CS by year with 2000 as the referent; adjusted for race/ethnicity, comorbid conditions, primary payer, socioeconomic status, and hospital characteristics (P<.001 for trend over time). C, Unadjusted in-hospital mortality in AMI-CS by year of admission, stratified by sex (P<.001 for trend over time). D, Adjusted multivariate logistic regression for in-hospital mortality temporal trends with 2000 as referent year; adjusted for race/ethnicity, admission year, primary payer status, socioeconomic stratum, hospital characteristics, comorbid conditions, AMI type, acute organ failure, cardiac arrest, and cardiac and noncardiac procedures (P<.001 for trend over time).

FIGURE 2.

Fifteen-year trends in the use of (A) coronary angiography, (B) percutaneous coronary intervention (PCI), (C) invasive hemodynamic monitoring (IHDM), and (D) mechanical circulatory support (MCS) in older acute myocardial infarction with cardiogenic shock (AMI-CS) admissions stratified by sex. All P<.001 for trend over time.

FIGURE 3.

Multivariate predictors of in-hospital mortality in older women with acute myocardial infarction with cardiogenic shock (AMI-CS) compared with older men. Multivariable adjusted odds ratios (95% CIs)* for in-hospital mortality in women stratified by race/ethnicity (non-Hispanic white/all other races/ethnicities), timing of cardiac arrest, type of AMI, performance of percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS) use; all P<.001. *Adjusted for race/ethnicity, year of admission, primary payer, socioeconomic status, hospital location/teaching status, hospital bed size, hospital region, comorbid conditions, type of AMI, acute organ failure, cardiac arrest, coronary angiography, PCI, invasive hemodynamic monitoring, MCS, mechanical ventilation, and hemodialysis. NSTEMI = non-ST-elevation myocardial infarction; STEMI = ST-elevation myocardial infarction.