Effects of Clinical Characteristics and Treatments on Gender Difference in Outcomes after Acute Myocardial Infarction. A p...
Women fare worse than men after acute MI  <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as...
<ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is...
<ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is...
<ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is...
<ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is...
Methods <ul><li>All consecutive patients  admitted between January 2006 and December 2007 </li></ul><ul><li>CARDS dataset ...
Baseline characteristics (1) Variables Women (%) Men (%) P Value Chi2/ t N 1119 (32) 2391 (68) STEMI  461 (41) 1117 (47) 0...
Baseline characteristics (2) Variables Women (%) Men (%) P Value Chi2/ t N 1119 (32) 2391 (68) Time to admission STEMI   4...
In-hospital Treatments  Variables Women (%) Men (%) P Value Chi2/ t Angiography 805 (72) 2080 (87) <0.0001 130 No obstruct...
Selection of the matched populations 3510 patients with Acute Myocardial Infarction  1578 (45%) STEMI, 1932 (55%) NSTEMI 1...
Effect of matching on sex differences P values for the difference between men and women  Unmatched dataset 0.05
Effect of matching on sex differences P values for the difference between men and women  Unmatched dataset Matched #1 data...
Effect of matching on sex differences P values for the difference between men and women  Unmatched dataset Matched #1 data...
KM Cumulative mortality Unmatched n=3510  p=0.001 Unmatched n=3510  p=0.001 Matched #1 n=649 pairs p=0.23 Log-Rank test: p...
0.5  0.8  1  1.5  2  4  Aspirin unmatched   OR= 1.35 [1.06; 1.80] Matched #1   OR= 1.10 [0.46; 2.62] Clopidogrel unmatched...
Interaction between  Gender and type of MI Mort ality more than  twice as high in women than in men in STEMI, but no diffe...
Interaction between Gender and Age: difference according to mean age Unadjusted cohort Sex-age interaction P=0.002 Matched...
Discussion <ul><ul><li>Matching on propensity score with analysis by pairs  </li></ul></ul><ul><ul><li>Differences in char...
Conclusions <ul><li>As compared with men, women admitted for acute MI receive fewer effective treatments and have a twofol...
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  • ISIS3 = il y a 20 ans (publié lancet 92)
  • Malacrida= 20 ans; Vaccarino = 380000 patients de NRMI, exclu les transferts, &gt;90 ans, &lt;30 ans, admission depuis 1998
  • Meta analyse depuis Gusto2b (93) jusqu’à Gusto4 (2001), 35128 pts
  • Medicare, 139000 patients, pas de transferts, admis entre 94 et 95
  • CRUSADE entre 2000 et 2002
  • Gen Diff

    1. 1. Effects of Clinical Characteristics and Treatments on Gender Difference in Outcomes after Acute Myocardial Infarction. A propensity score-matched analysis François Schiele, MD, PhD, Nicolas Meneveau, MD, PhD, Marie France Seronde, MD, Vincent Descotes-Genon, MD, Joanna Dutheil, MD, Romain Chopard, MD, Fiona Ecarnot, and Jean-Pierre Bassand, MD. On behalf on the “Reseau de Cardiologie de Franche Comté” Department of Cardiology, University Hospital Jean Minjoz, Besançon, France. Confli c t of Interest to Declare : Research Contracts and Consulting Servier, Sanofi, GSK, Astra-Zeneca, Takeda, Lilly
    2. 2. Women fare worse than men after acute MI <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. </li></ul>Malacrida, ISIS-3, N Engl J Med 1998;338:8-14
    3. 3. <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. </li></ul><ul><li>Sex-age interaction : discrepancy between studies </li></ul>Women fare worse than men after acute MI Malacrida, N Engl J Med 1998;338:8-14 <ul><ul><li>Greater difference with older age </li></ul></ul>Vaccarino, N Engl J Med 1999;341:217-25 <ul><ul><li>Decrease in difference with age </li></ul></ul>
    4. 4. <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. </li></ul><ul><li>Sex-age interaction : discrepancy between studies </li></ul><ul><li>Sex-type of MI interaction : STEMI ≠ NSTEMI </li></ul>Berger, JAMA 2009;302:874-82 Women fare worse than men after acute MI
    5. 5. <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. </li></ul><ul><li>Sex-age interaction : discrepancy between studies </li></ul><ul><li>Sex-Type of MI interaction : STEMI ≠ NSTEMI </li></ul><ul><li>Women receive fewer treatments and no difference in mortality is observed after adjustment for co-morbidities and treatments </li></ul>Gan, N Engl J Med 2000;343:8-15 Women fare worse than men after acute MI
    6. 6. <ul><li>Women admitted for acute MI have 40-100% higher mortality at 30 days, as compared with men. This over-mortality is reduced after adjustment for age and co-morbidities. </li></ul><ul><li>Sex-age interaction : discrepancy between studies </li></ul><ul><li>Sex-Type of MI interaction : STEMI ≠ NSTEMI </li></ul><ul><li>Women receive fewer treatments and no difference in mortality is observed after adjustment for co-morbidities and treatments </li></ul>To assess the e ffects of Clinical Characteristics and Treatments on Gender Difference , using a Propensity Score-Matched Analysis. Aim of the Study Women fare worse than men after acute MI
    7. 7. Methods <ul><li>All consecutive patients admitted between January 2006 and December 2007 </li></ul><ul><li>CARDS dataset , dedicated team of data managers. </li></ul><ul><li>Endpoint : 30 day all-cause mortality </li></ul><ul><li>Use of matched pairs comparison : </li></ul><ul><li>Two Propensity scores for being male by logistic regression, </li></ul><ul><ul><li>PS#1 with baseline characteristics (16 variables) </li></ul></ul><ul><ul><li>PS#2 with baseline characteristics and treatments </li></ul></ul><ul><li>1:1 matching on best 8 digits of the propensity score (match allowed for PS<0.015) </li></ul><ul><li>30 day mortality (Kaplan Meier curves and Odds ratios from conditional logistic regression) in unadjusted and matched cohorts </li></ul><ul><li>Interactions : age, type of MI (STEMI vs NSTEMI). </li></ul>
    8. 8. Baseline characteristics (1) Variables Women (%) Men (%) P Value Chi2/ t N 1119 (32) 2391 (68) STEMI  461 (41) 1117 (47) 0.0008 9.38 NSTEMI  658 (59) 1274 (53) <0.0001 9.38 Age (SD) 74 (13) 64 (13)  <0.0001 18.9 Diabetes 301 (27) 495 (21) <0.0001 16.7 Hypertension 762 (68) 1143 (48) <0.0001 12.7 Hypercholesterolemia 451 (40) 1132 (47) <0.0001 15.9 Smoker 258 (23) 1583 (66) <0.0001 56.7 Previous MI 151 (13) 449 (19) <0.0001 15.2 Previous angioplasty 94 (8) 349 (15) <0.0001 26.5 Previous coronary surgery 37 (3) 105 (4) 0.12 2.33 Previous Stroke 79 (7) 121 (5) 0.002 5.6 Per. Vessel Disease 86 (8) 286 (12) <0.0001 14.8
    9. 9. Baseline characteristics (2) Variables Women (%) Men (%) P Value Chi2/ t N 1119 (32) 2391 (68) Time to admission STEMI  4 [2;15] 3 [2 ;9]  <0.0001 Admission heart rate 80 (20) 77 (20) <0.0001 4.0 Admission Systolic BP 134 (29) 130 (28) 0.79 0.09 Killip class >2 94 (8) 127 (5) <0.0001 12.3 Cardiogenic shock 48 (4) 94 (4) 0.61 0.25 GRACE risk score 147 [124 ;167] 132 [110 ;152] <0.0001 Admission Glucose 7 (4.4) 6.7 (3.5) 0.0035 2.99 BNP 480 [180;1202]  217 [83;544] <0.0001 Hs-CRP 8 [3;27] 6 [2;22]  <0.0001
    10. 10. In-hospital Treatments Variables Women (%) Men (%) P Value Chi2/ t Angiography 805 (72) 2080 (87) <0.0001 130 No obstructive disease 112(14) 92(4) <0.001 83 PCI of infarct related artery 552(49) 1662(69) <0.0001 133 GPIIbIIIa inhibitors (NSTEMI) 271 (40) 682 (53)  <0.0001 25.9 Reperfusion (STEMI) 281/461 (61) 843/1117 (75) <0.001 30.5 Primary PCI (STEMI) 215/461 (47) 615/1117 (55) <0.0001 19.0 Thrombolysis (STEMI) 66/461 ( 14) 228/1117 (20) <0.009 8.0 Aspirin 1089 (97) 2360 (99) <0.0001 16.8 Clopidogrel 1075 (96) 2290 (96) <0.0001 25.0 Aspirin + Clopidogrel 1035 (92) 2290 (96) <0.0001 31.8 ACEI / ARB 667 (60) 2052 (86) <0.0001 23.9 Betablockers 791 (71) 1847 (77) <0.0001 17.5 Statins 982 (88) 2296 (96) <0.0001 75.3
    11. 11. Selection of the matched populations 3510 patients with Acute Myocardial Infarction 1578 (45%) STEMI, 1932 (55%) NSTEMI 1119 (32%) Women, 2391 (68%) Men Matching on propensity score 1 = 649 pairs Comparison of treatments Comparison of mortality Comparison of mortality Propensity score 1 (being male) with baseline characteristics Propensity score 2 (being male) with baseline characteristics and treatments Matching on propensity score 2 = 584 pairs
    12. 12. Effect of matching on sex differences P values for the difference between men and women Unmatched dataset 0.05
    13. 13. Effect of matching on sex differences P values for the difference between men and women Unmatched dataset Matched #1 dataset 0.05
    14. 14. Effect of matching on sex differences P values for the difference between men and women Unmatched dataset Matched #1 dataset Matched #2 dataset 0.05
    15. 15. KM Cumulative mortality Unmatched n=3510 p=0.001 Unmatched n=3510 p=0.001 Matched #1 n=649 pairs p=0.23 Log-Rank test: p=0.95 Days 0 5 10 20 30 At risk 584 574 565 544 529 584 573 562 550 530 Women Men Unmatched n=3510 p=0.001 Matched #1 n=649 pairs p=0.23 Matched #2 n=584 pairs p=0.95
    16. 16. 0.5 0.8 1 1.5 2 4 Aspirin unmatched OR= 1.35 [1.06; 1.80] Matched #1 OR= 1.10 [0.46; 2.62] Clopidogrel unmatched OR= 1.65 [1.38; 2.01] Matched #1 OR= 1.04 [0.58; 1.84] Aspirin and Clopidogel unmatched OR= 1.67 [1.40; 2.01] Matched #1 OR= 1.10 [0.46; 1.63] ACEI or ARB unmatched OR= 1.42 [1.24; 1.65] Matched #1 OR= 1.29 [0.97; 1.70] Beta blocker unmatched OR= 1.31 [1.15; 1.49] Matched #1 OR= 1.02 [0.64; 1.29] GPIIbIIIa (NSTEMI) unmatched OR= 1.66 [1.43; 1.96] Matched #1 OR= 1.40 [0.94; 1.56] Coronary Angiography unmatched OR= 2.82 [2.40; 3.41] Matched #1 OR= 1.57 [1.10; 2.18] Reperfusion /PPCI unmatched OR= 1.56 [1.29; 1.89] Matched #1 OR= 1.24 [1.12; 1.71] Reperfusion /FL unmatched OR= 1.82 [1.24; 2.12] Matched #1 OR= 1.72 [1.08; 2.73] In-Hospital mortality unmatched OR= 0.50 [0.37; 0.62] Matched #1 OR= 0.52 [0.32; 0.83] Matched #2 OR= 0.75 [0.45; 1.23] 30 day mortality unmatched OR= 0.53 [0.42; 0.57] Matched #1 OR= 0.70 [0.46; 1.01] Matched #2 OR= 0.89 [0.57; 1.36] Odds ratios for men versus women
    17. 17. Interaction between Gender and type of MI Mort ality more than twice as high in women than in men in STEMI, but no difference in NSTEMI patients; significant interaction No higher mortality and no interaction after adjustment for characteristics No higher mortality and no interaction after adjustment for characteristics and treatments Sub-groups (1) P=0.009 P=0.009 P=0.36 P=0.009 P=0.36 P=0.13
    18. 18. Interaction between Gender and Age: difference according to mean age Unadjusted cohort Sex-age interaction P=0.002 Matched #2 No sex-age interaction P=0.16 Matched #1 Sex-age interaction P=0.005 Sub-groups (2)
    19. 19. Discussion <ul><ul><li>Matching on propensity score with analysis by pairs </li></ul></ul><ul><ul><li>Differences in characteristics, treatments and mortality </li></ul></ul><ul><ul><li>Sex-age interaction : significant interaction with greater gender difference in older patients, disappears after matching. </li></ul></ul><ul><ul><li>Sex-type of MI interaction disappears after matching </li></ul></ul><ul><ul><li>Sex differences in aspirin, clopidogrel, betablockers, ACEI and statins are explained by characteristics. </li></ul></ul><ul><ul><li>Sex differences in coronary angiography and reperfusion in STEMI are not explained by characteristics </li></ul></ul><ul><ul><li>No difference in mortality after matching on characteristics and treatments. </li></ul></ul>Vaccarino, New Engl J Med 1999 Austin, Use of PS.., Stat Med 2005 Berger, JAMA 2009;302:874-82 Blomkalns, CRUSADE, JACC 2005;45:832-7 Rosengren Eur Heart J 2001; 22: 314–322, Milcent Circulation. 2007;115:833-839
    20. 20. Conclusions <ul><li>As compared with men, women admitted for acute MI receive fewer effective treatments and have a twofold higher 30 day mortality. </li></ul><ul><li>Comparison of cohorts matched on baseline characteristics shows that co-morbidities explain the lower use of treatments. Nevertheless, women are less often submitted to coronary angiography and reperfusion (STEMI) and have a higher in-hospital mortality. </li></ul><ul><li>Comparison of cohorts matched on baseline characteristics and treatments shows similar in-hospital and 30 day mortality between genders, suggesting that a higher use of invasive procedures and reperfusion strategy could reduce the difference in mortality. </li></ul>

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