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Multicenter Study
. 2025 Sep 12;11(6):719-729.
doi: 10.1093/ehjqcco/qcae035.

Coronary revascularization and sex differences in cardiovascular mortality after myocardial infarction in 12 high and middle-income European countries

Edina Cenko  1 , Jinsung Yoon  2 , Maria Bergami  1 , Chris P Gale  3 , Zorana Vasiljevic  4 , Marija Vavlukis  5   6 , Sasko Kedev  5   6 , Davor Miličić  7 , Maria Dorobantu  8 , Lina Badimon  9 , Olivia Manfrini  1   10 , Raffaele Bugiardini  1
Affiliations
Multicenter Study

Coronary revascularization and sex differences in cardiovascular mortality after myocardial infarction in 12 high and middle-income European countries

Edina Cenko et al. Eur Heart J Qual Care Clin Outcomes. .

Abstract

Background: Existing data on female sex and excess cardiovascular mortality after myocardial infarction (MI) mostly come from high-income countries (HICs). This study aimed to investigate how sex disparities in treatments and outcomes vary across countries with different income levels.

Methods: Data from the ISACS Archives registry included 22 087 MI patients from 6 HICs and 6 middle-income countries (MICs). MI data were disaggregated by clinical presentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). The primary outcome was 30-day mortality.

Results: Among STEMI patients, women in MICs had nearly double the 30-day mortality rate of men [12.4% vs. 5.8%; adjusted risk ratio (RR) 2.30, 95% CI 1.98-2.68]. This difference was less pronounced in HICs (6.8% vs. 5.1%; RR 1.36, 95% CI 1.05-1.75). Despite more frequent treatments and timely revascularization in MICs, sex-based mortality differences persisted even after revascularization (8.0% vs. 4.1%; RR 2.05, 95% CI, 1.68-2.50 in MICs and 5.6% vs. 2.6%; RR 2.17, 95% CI, 1.48-3.18) in HICs. Additionally, women from MICs had higher diabetes rates compared to HICs (31.8% vs. 25.1%, standardized difference = 0.15). NSTEMI outcomes were relatively similar between sexes and income groups.

Conclusions: Sex disparities in mortality rates following STEMI are more pronounced in MICs compared to HICs. These disparities cannot be solely attributed to sex-related inequities in revascularization. Variations in mortality may also be influenced by sex differences in socioeconomic factors and baseline comorbidities.

Keywords: Middle-income countries; Myocardial infarction; Outcomes; Sex differences.

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Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Flow chart of the study cohort. Patient inclusion and exclusion criteria from the ISACS Archives registry. Patients were considered eligible if they had clinically confirmed myocardial infarction. The initial group consisted of 23 044 patients. Patients presenting heart failure were excluded leaving a final study group of 22 087 patients. MI, myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Absolute and relative risk of 30-day mortality stratified by sex and income level in the overall population (panel A) and in patients undergoing revascularization (panel B).
Figure 3
Figure 3
Thirty-day mortality in MI patients stratified by sex and national income level group. Absolute and relative risk of 30-day mortality stratified by sex and income level in the overall population of STEMI and NSTEMI (panel A) and in patients undergoing revascularization (panel B). NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.
See this image and copyright information in PMC

Comment in

References

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