Skip to main content

Advertisement

SpringerLink
Log in

Impact of gender on short-term and long-term all-cause mortality in patients with non-ST-segment elevation acute coronary syndromes: a meta-analysis

  • CE- SYSTEMATIC REVIEW
  • Published:
Internal and Emergency Medicine Aims and scope Submit manuscript

Abstract

A meta-analysis to determine the impact of gender on mortality in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS): PubMed, EMBASE, and Cochrane Library, was systematically searched. Two investigators independently reviewed retrieved articles and assessed eligibility. Unadjusted mortality rates or adjusted effect estimates regarding gender-specific short-term and long-term all-cause mortality were identified. A total of 30 studies involving 358,827 patients with NSTE-ACS (129, 632 women and 229,195 men) were identified. In the unadjusted analysis, women had significantly higher risk of short-term all-cause mortality (RR 1.37; 95% CI 1.26–1.49; P < 0.00001) and long-term all-cause mortality (RR 1.18; 95% CI 1.07–1.31; P = 0.001) compared with men. However, when a meta-analysis was performed using adjusted effect estimates, the association between women and higher risk of short-term mortality (RR 0.99; 95% CI 0.91–1.07; P = 0.74) and long-term all-cause mortality (RR 0.84; 95% CI 0.68–1.03; P = 0.09) was markedly attenuated. Adjusted short-term and long-term all-cause mortality appeared similar in women and men. In conclusion, women with NSTE-ACS have higher short-term and long-term mortality compared with men. However, gender differences do not differ following adjustment for baseline cardiovascular risk factors and clinical differences.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR et al (2017) Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation 127:e6–e245

    Google Scholar 

  2. Lerner DJ, Kannel WB (1986) Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J 111:383–390

    Article  CAS  PubMed  Google Scholar 

  3. Lichtman JH, Leifheit-Limson EC, Watanabe E, Allen NB, Garavalia B et al (2015) Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Circ Cardiovasc Qual Outcomes 8:S31–S38

    Article  PubMed  PubMed Central  Google Scholar 

  4. Khan NA, Daskalopoulou SS, Karp I, Eisenberg MJ, Pelletier R et al (2013) Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med 173:1863–1871

    PubMed  Google Scholar 

  5. Worrall-Carter L, McEvedy S, Wilson A, Rahman MA (2016) Gender differences in presentation, coronary intervention, and outcomes of 28,985 acute coronary syndrome patients in Victoria, Australia. Womens Health Issues 26:14–20

    Article  PubMed  Google Scholar 

  6. Dreyer RP, Smolderen KG, Strait KM, Beltrame JF, Lichtman JH et al (2016) Gender differences in pre-event health status of young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care 5:43–54

    Article  PubMed  Google Scholar 

  7. Leung Yinko SS, Maheswaran J, Pelletier R, Bacon SL, Daskalopoulou SS et al (2015) Sex differences in health behavior change after premature acute coronary syndrome. Am Heart J 170:242–248

    Article  PubMed  Google Scholar 

  8. Bavishi C, Bangalore S, Patel D, Chatterjee S, Trivedi V et al (2015) Short and long-term mortality in women and men undergoing primary angioplasty: a comprehensive meta-analysis. Int J Cardiol 198:123–130

    Article  PubMed  Google Scholar 

  9. Khera S, Kolte D, Gupta T, Subramanian KS, Khanna N et al (2015) Temporal trends and sex differences in revascularization and outcomes of ST-segment elevation myocardial infarction in younger adults in the United States. J Am Coll Cardiol 66:1961–1972

    Article  PubMed  Google Scholar 

  10. Pancholy SB, Shantha GP, Patel T, Cheskin LJ (2014) Sex differences in short-term and long-term all-cause mortality among patients with ST-segment elevation myocardial infarction treated by primary percutaneous intervention: a meta-analysis. JAMA Intern Med 174:1822–1830

    Article  PubMed  Google Scholar 

  11. Otten AM, Maas AH, Ottervanger JP, Kloosterman A, van’t Hof AW et al (2013) Is the difference in outcome between men and women treated by primary percutaneous coronary intervention age dependent? Gender difference in STEMI stratified on age. Eur Heart J Acute Cardiovasc Care 2:334–341

    Article  PubMed  PubMed Central  Google Scholar 

  12. Clemmensen P, Roe MT, Hochman JS, Cyr DD, Neely ML et al (2015) Long-term outcomes for women versus men with unstable angina/non-ST-segment elevation myocardial infarction managed medically without revascularization: insights from the targeted platelet inhibition to clarify the optimal strategy to medically manage acute coronary syndromes trial. Am Heart J 170:695–705

    Article  PubMed  Google Scholar 

  13. Vogel B, Farhan S, Hahne S, Kozanli I, Kalla K et al (2016) Sex-related differences in baseline characteristics, management and outcome in patients with acute coronary syndrome without ST-segment elevation. Eur Heart J Acute Cardiovasc Care 5:347–353

    Article  PubMed  Google Scholar 

  14. Johnston N, Jönelid B, Christersson C, Kero T, Renlund H et al (2015) Effect of gender on patients with ST-elevation and non-ST-elevation myocardial infarction without obstructive coronary artery disease. Am J Cardiol 115:1661–1666

    Article  PubMed  Google Scholar 

  15. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD et al (2000) Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA 283:2008–2012

    Article  CAS  PubMed  Google Scholar 

  16. Wells GA, Shea B, O’Connell D, Peterson J, Welchet V et al (2011) The Newcastle–Ottawa scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa. http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm. Accessed 21 Dec 2016

  17. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

    Article  PubMed  Google Scholar 

  18. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188

    Article  CAS  PubMed  Google Scholar 

  19. Begg CB, Mazumdar M (1994) Operating characteristics of a rank correlation test for publication bias. Biometrics 50:1088–1101

    Article  CAS  PubMed  Google Scholar 

  20. Egger M, Smith GD, Schneider M, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Numasawa Y, Inohara T, Ishii H, Kuno T, Kodaira M et al (2017) Comparison of outcomes of women versus men with non-ST-elevation acute coronary syndromes undergoing percutaneous coronary intervention (from the Japanese Nationwide Registry). Am J Cardiol 119:826–831

    Article  PubMed  Google Scholar 

  22. Edmund Anstey D, Li S, Thomas L, Wang TY, Wiviott SD (2016) Race and sex differences in management and outcomes of patients after ST-elevation and non-ST-elevation myocardial infarct: results from the NCDR. Clin Cardiol 39:585–595

    Article  CAS  PubMed  Google Scholar 

  23. Pelletier R, Choi J, Winters N, Eisenberg MJ, Bacon SL et al (2016) Sex differences in clinical outcomes after premature acute coronary syndrome. Can J Cardiol 32:1447–1453

    Article  PubMed  Google Scholar 

  24. De Carlo M, Morici N, Savonitto S, Grassia V, Sbarzaglia P et al (2015) Sex-related outcomes in elderly patients presenting with non-ST-segment elevation acute coronary syndrome: insights from the Italian elderly ACS study. JACC Cardiovasc Interv 8:791–796

    Article  PubMed  Google Scholar 

  25. Isorni MA, Blanchard D, Teixeira N, le Breton H, Renault N et al (2015) Impact of gender on use of revascularization in acute coronary syndromes: the national observational study of diagnostic and interventional cardiac catheterization (ONACI). Catheter Cardiovasc Interv 86:E58–E65

    Article  PubMed  Google Scholar 

  26. Lu HT, Nordin R, Wan Ahmad WA, Lee CY, Zambahari R et al (2014) Sex differences in acute coronary syndrome in a multiethnic Asian population: results of the malaysian national cardiovascular disease database-acute coronary syndrome (NCVD-ACS) registry. Glob Heart 9:381–390

    Article  PubMed  Google Scholar 

  27. Gnavi R, Rusciani R, Dalmasso M, Giammaria M, Anselmino M et al (2014) Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities? Int J Cardiol 176:724–730

    Article  PubMed  Google Scholar 

  28. Hersi A, Al-Habib K, Al-Faleh H, Al-Nemer K, Alsaif S et al (2013) Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia. Ann Saudi Med 33:339–346

    Article  PubMed  Google Scholar 

  29. Lee CY, Hairi NN, Wan Ahmad WA, Ismail O, Liew HB et al (2013) Are there gender differences in coronary artery disease? The Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) Registry. PLoS One 8:e72382

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Pain TE, Jones DA, Rathod KS, Gallagher SM, Knight CJ et al (2013) Influence of female sex on long-term mortality after acute coronary syndromes treated by percutaneous coronary intervention: a cohort study of 7304 patients. Coron Artery Dis 24:183–190

    Article  PubMed  Google Scholar 

  31. Kumbhani DJ, Shishehbor MH, Willis JM, Karim S, Singh D et al (2012) Influence of gender on long-term mortality in patients presenting with non-ST-elevation acute coronary syndromes undergoing percutaneous coronary intervention. Am J Cardiol 109:1087–1091

    Article  PubMed  Google Scholar 

  32. Janion-Sadowska A, Sielski J, Gierlotka M, Nowalany-Kozielska E, Janion M et al (2011) Gender-related differences in clinical course, therapeutic approach and prognosis in patients with non-ST segment elevation myocardial infarction. Kardiol Pol 69:784–792

    PubMed  Google Scholar 

  33. Huang SS, Chen YH, Lu TM, Wu TC, Charng MJ et al (2012) Effect of invasive strategy on different genders of Chinese patients with non-ST-elevation myocardial infarction. Catheter Cardiovasc Interv 79:946–955

    Article  PubMed  Google Scholar 

  34. Berthillot C, Stephan D, Chauvin M, Roul G (2010) In-hospital complications after invasive strategy for the management of Non STEMI: women fare as well as men. BMC Cardiovasc Disord 10:31

    Article  PubMed  PubMed Central  Google Scholar 

  35. Shao CL, Qiao SB, Zhu J, Chen J, Yang WX et al (2010) The clinical characteristics and prognosis of non ST segment elevation acute coronary syndrome in different genders. Zhonghua Nei Ke Za Zhi 49:754–757

    CAS  PubMed  Google Scholar 

  36. Halvorsen S, Eritsland J, Abdelnoor M, Holst Hansen C, Risøe C et al (2009) Gender differences in management and outcome of acute myocardial infarctions treated in 2006–2007. Cardiology 114:83–88

    Article  PubMed  Google Scholar 

  37. Gehrie ER, Reynolds HR, Chen AY, Neelon BH, Roe MT et al (2009) Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative. Am Heart J 158:688–694

    Article  PubMed  Google Scholar 

  38. Lee KH, Jeong MH, Ahn YK, Kim JH, Chae SC et al (2008) Gender differences of success rate of percutaneous coronary intervention and short term cardiac events in Korea Acute Myocardial Infarction Registry. Int J Cardiol 130:227–234

    Article  PubMed  Google Scholar 

  39. Alfredsson J, Stenestrand U, Wallentin L, Swahn E (2007) Gender differences in management and outcome in non-ST-elevation acute coronary syndrome. Heart 93:1357–1362

    Article  PubMed  Google Scholar 

  40. Elkoustaf RA, Mamkin I, Mather JF, Murphy D, Hirst JA et al (2006) Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women. Am J Cardiol 98:182–186

    Article  PubMed  Google Scholar 

  41. Sinkovic A, Marinsek M, Svensek F (2006) Women and men with unstable angina and/or non-ST-elevation myocardial infarction. Wien Klin Wochenschr 118(Suppl 2):52–57

    Article  PubMed  Google Scholar 

  42. Heer T, Gitt AK, Juenger C, Schiele R, Wienbergen H et al (2006) Gender differences in acute non-ST-segment elevation myocardial infarction. Am J Cardiol 98:160–166

    Article  PubMed  Google Scholar 

  43. Clayton TC, Pocock SJ, Henderson RA, Poole-Wilson PA, Shaw TR et al (2004) Do men benefit more than women from an interventional strategy in patients with unstable angina or non-ST-elevation myocardial infarction? The impact of gender in the RITA 3 trial. Eur Heart J 25:1641–1650

    Article  CAS  PubMed  Google Scholar 

  44. Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K et al (2005) Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. J Am Coll Cardiol 45:832–837

    Article  PubMed  Google Scholar 

  45. Mueller C, Neumann FJ, Roskamm H, Buser P, Hodgson JM et al (2002) Women do have an improved long-term outcome after non-ST-elevation acute coronary syndromes treated very early and predominantly with percutaneous coronary intervention: a prospective study in 1,450 consecutive patients. J Am Coll Cardiol 40:245–250

    Article  PubMed  Google Scholar 

  46. Passos LC, Lopes AA, Costa U, Lobo N, Rabelo Júnior A (1999) Difference in the in-hospital mortality of unstable angina pectoris between men and women. Arq Bras Cardiol 72:669–676

    Article  CAS  PubMed  Google Scholar 

  47. Worrall-Carter L, McEvedy S, Wilson A, Rahman MA (2016) Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome. Catheter Cardiovasc Interv 87:E128–E136

    Article  PubMed  Google Scholar 

  48. Woo JS, Kim W, Ha SJ, Kim SJ, Kang WY et al (2010) Impact of gender differences on long-term outcomes after successful percutaneous coronary intervention in patients with acute myocardial infarction. Int J Cardiol 145:516–518

    Article  PubMed  Google Scholar 

  49. Vikman S, Airaksinen KE, Tierala I, Peuhkurinen K, Majamaa-Voltti K et al (2007) Gender-related differences in the management of non-ST-elevation acute coronary syndrome patients. Scand Cardiovasc J 41:287–293

    Article  PubMed  Google Scholar 

  50. Tavris D, Shoaibi A, Chen AY, Uchida T, Roe MT et al (2010) Gender differences in the treatment of non-ST-segment elevation myocardial infarction. Clin Cardiol 33:99–103

    Article  PubMed  Google Scholar 

  51. Kunadian V, Qiu W, Lagerqvist B, Johnston N, Sinclair H et al (2017) Gender differences in outcomes and predictors of all-cause mortality after percutaneous coronary intervention (data from United Kingdom and Sweden). Am J Cardiol 119:210–216

    Article  PubMed  Google Scholar 

  52. Kragholm K, Halim SA, Yang Q, Schulte PJ, Hochman JS et al (2015) Sex-stratified trends in enrollment, patient characteristics, treatment, and outcomes among non-ST-segment elevation acute coronary syndrome patients: insights from clinical trials over 17 years. Circ Cardiovasc Qual Outcomes 8:357–367

    Article  PubMed  PubMed Central  Google Scholar 

  53. Kudenchuk PJ, Maynard C, Martin JS, Wirkus M, Weaver WD (1996) Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry). Am J Cardiol 78:9–14

    Article  CAS  PubMed  Google Scholar 

  54. Chandra NC, Ziegelstein RC, Rogers WJ, Tiefenbrunn AJ, Gore JM et al (1998) Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 158:981–988

    Article  CAS  PubMed  Google Scholar 

  55. Kostis JB, Wilson AC, O’Dowd K, Gregory P, Chelton S et al (1994) Sex differences in the management and long-term outcome of acute myocardial infarction: a statewide study. Circulation 90:1715–1730

    Article  CAS  PubMed  Google Scholar 

  56. Chandrasekhar J, Mehran R (2016) Sex-based differences in acute coronary syndromes: insights from invasive and noninvasive coronary technologies. JACC Cardiovasc Imaging 9:451–464

    Article  PubMed  Google Scholar 

  57. Champney KP, Frederick PD, Bueno H, Parashar S, Foody J et al (2009) The joint contribution of sex, age and type of myocardial infarction on hospital mortality following acute myocardial infarction. Heart 95:895–899

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Ma Q, Wang J, Jin J, Gao M, Liu F et al (2017) Clinical characteristics and prognosis of acute coronary syndrome in young women and men: a systematic review and meta-analysis of prospective studies. Int J Cardiol 228:837–843

    Article  PubMed  Google Scholar 

  59. Colan MG, Folson AR, Finch A, Davis CE, Sorlie P et al (1993) Association of factor VIII and Von Willebrand factor with age, race, sex and risk factors for atherosclerosis; the atherosclerosis risk in the communities (ARIC Study). Thromb Haemost 70:380–385

    Google Scholar 

  60. Kalaria VG, Zareba W, Moss AJ, Pancio G, Marder VJ et al (2000) Gender-related differences in thrombogenic factors predicting recurrent cardiac events in patients after acute myocardial infarction. The THROMBO Investigators. Am J Cardiol 85:1401–1418

    Article  CAS  PubMed  Google Scholar 

  61. Hara H, Yajima J, Kirigaya H, Nagashima K, Oikawa Y et al (2004) Sex differences in coronary atherosclerosis: coronary angiography and intravascular ultrasonography. J Cardiol 43:215–221

    PubMed  Google Scholar 

  62. Anand SS, Xie CC, Mehta S, Franzosi MG, Joyner C et al (2005) Differences in the management and prognosis of women and men who suffer from acute coronary syndromes. J Am Coll Cardiol 46:1845–1851

    Article  PubMed  Google Scholar 

  63. Alfredsson J, Clayton T, Damman P, Fox KA, Fredriksson M et al (2014) Impact of an invasive strategy on 5 years outcome in men and women with non-ST-segment elevation acute coronary syndromes. Am Heart J 168:522–529

    Article  PubMed  Google Scholar 

  64. Donataccio MP, Puymirat E, Parapid B, Steg PG, Eltchaninoff H et al (2015) In-hospital outcomes and long-term mortality according to sex and management strategy in acute myocardial infarction. Insights from the French ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 Registry. Int J Cardiol 201:265–270

    Article  PubMed  Google Scholar 

  65. Mackay MH, Ratner PA, Johnson JL, Humphries KH, Buller CE (2011) Gender differences in symptoms of myocardial ischaemia. Eur Heart J 32:3107–3114

    Article  PubMed  Google Scholar 

  66. Kosuge M, Kimura K, Ishikawa T, Ebina T, Hibi K et al (2006) Differences between men and women in terms of clinical features of ST-segment elevation acute myocardial infarction. Circ J 70:222–226

    Article  PubMed  Google Scholar 

  67. Toyota T, Furukawa Y, Ehara N, Funakoshi S, Morimoto T et al (2013) Sex-based differences in clinical practice and outcomes for Japanese patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. Circ J 77:1508–1517

    Article  PubMed  Google Scholar 

  68. Iannaccone M, Quadri G, Taha S, D’Ascenzo F, Montefusco A et al (2016) Prevalence and predictors of culprit plaque rupture at OCT in patients with coronary artery disease: a meta-analysis. Eur Heart J Cardiovasc Imaging 17:1128–1137

    Article  PubMed  Google Scholar 

  69. Arbustini E, Dal Bello B, Morbini P, Burke AP, Bocciarelli M et al (1999) Plaque erosion is a major substrate for coronary thrombosis in acute myocardial infarction. Heart 82:269–272

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Berger JS, Elliott L, Gallup D, Roe M, Granger CB et al (2009) Sex differences in mortality following acute coronary syndromes. JAMA 302:874–882

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China

    Yushu Wang, Rongsheng Du, Juteng Zhou, Yucheng Chen & Qing Zhang

  2. Department of Epidemiology and Biostatistics, School of Public Health, Sichuan University, Chengdu, Sichuan, China

    Sui Zhu

Authors
  1. Yushu Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sui Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rongsheng Du
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Juteng Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yucheng Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Qing Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Qing Zhang.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Statement of human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

All of the eligible articles included in the meta analysis stated that they had obtained informed consent from participants.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wang, Y., Zhu, S., Du, R. et al. Impact of gender on short-term and long-term all-cause mortality in patients with non-ST-segment elevation acute coronary syndromes: a meta-analysis. Intern Emerg Med 13, 273–285 (2018). https://doi.org/10.1007/s11739-017-1684-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-017-1684-y

Keywords

Search

Navigation