Comparisons of Characteristics and Outcomes Among Women and Men With Acute Myocardial Infarction Treated With Thrombolytic Therapy

OBJECTIVE To compare baseline characteristics, complications, and treatment-specific outcomes of women and men with acute myocardial infarction treated with thrombolytic therapy. DESIGN Randomized controlled trial. PATIENTS AND SETTING A total of 10315 women and 30706 men with acute myocardial infarction treated in 1081 hospitals in 15 countries as part of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I). INTERVENTION One of four thrombolytic regimens: (1) streptokinase with subcutaneous heparin; (2) streptokinase with intravenous heparin; (3) streptokinase plus alteplase (tissue-type plasminogen activator) with intravenous heparin; or (4) accelerated alteplase with intravenous heparin. MAIN OUTCOME MEASURES Mortality, stroke, and nonfatal complications during 30-day follow-up. RESULTS Women were on average 7 years older than men and delayed 18 minutes (median) longer after symptom onset before presenting to the hospital. After adjustment for age, women more often had a history of diabetes, hypertension, and smoking than men. Time to treatment was significantly longer in women (1.2 vs 1.0 hours; P<.001). Women had more nonfatal complications after treatment, including shock (9% vs 5%; P<.001), congestive heart failure (22% vs 14%; P<.001), serious bleeding (15% vs 7%; P<.001), and reinfarction (5.1% vs 3.6%; P<.001). Women had twice as many total strokes as men (2.1% vs 1.2%; P<.001), secondary to their older age at presentation. The unadjusted mortality rate was twice as high in women as men (11.3% vs 5.5%; P<.001); the relative risk (RR) of death was greater among women than men after adjustment for differences in baseline characteristics (RR=1.15; 95% confidence interval, 1.0 to 1.31). Although women and men underwent angiography at similar rates, there were small but significant differences in their rates of revascularization procedures (angioplasty: 35% of women and 32% of men; bypass surgery: 7% of women and 9% of men; P<.001 for both). The higher rate of stroke in women after treatment with alteplase (2.0% vs 1.9% with streptokinase and intravenous heparin) was offset by a greater relative reduction in mortality (10.3% vs 11.1%). CONCLUSION Women who received thrombolytic therapy for treatment of acute myocardial infarction were at greater risk for both fatal and nonfatal complications than men.

[1]  E. J. Benjamin,et al.  Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. , 1995, Journal of the American College of Cardiology.

[2]  J Col,et al.  Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators. , 1995, Circulation.

[3]  I. V. Van Gelder,et al.  Benefits and risks of antiarrhythmic drug therapy after DC electrical cardioversion of atrial fibrillation or flutter. , 1994, European heart journal.

[4]  C. Oakley,et al.  Influence of haemodynamics and myocardial ischaemia on Doppler transmitral flow in patients undergoing dobutamine echocardiography. , 1994, European heart journal.

[5]  Johan Herlitz,et al.  Indications for fibrinolytic therapy in suspected acute myocardial infarction : collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients , 1994 .

[6]  K. Lee,et al.  Thrombolytic therapy for women with myocardial infarction: is there a gender gap? Thrombolysis and Angioplasty in Myocardial Infarction Study Group. , 1993, Journal of the American College of Cardiology.

[7]  Gusto Angiographic Investigators The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. , 1993, The New England journal of medicine.

[8]  R. Diaz,et al.  After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. The Investigators of the International Tissue Plasminogen Activator/Streptoki , 1993, Circulation.

[9]  J S Alpert,et al.  A community-wide perspective of gender differences and temporal trends in the use of diagnostic and revascularization procedures for acute myocardial infarction. , 1993, The American journal of cardiology.

[10]  Frans Van de Werf,et al.  An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. , 1993, The New England journal of medicine.

[11]  F. Van de Werf,et al.  The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico II (GISSI-2), and The International Study Group. , 1992, The New England journal of medicine.

[12]  G. Schuler,et al.  Regular Physical Exercise and Low‐Fat Diet: Effects on Progression of Coronary Artery Disease , 1992, Circulation.

[13]  M. Lauer,et al.  Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias? , 1992, Annals of internal medicine.

[14]  W. Weaver,et al.  Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. , 1992, Archives of internal medicine.

[15]  E. Braunwald,et al.  Predictors of Early Morbidity and Mortality After Thrombolytic Therapy of Acute Myocardial Infarction: Analyses of Patient Subgroups in the Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase II , 1992, Circulation.

[16]  U. Goldbourt,et al.  Long-term prognosis of patients with paroxysmal atrial fibrillation complicating acute myocardial infarction , 1992 .

[17]  P. Kudenchuk,et al.  Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. The MITI Project Group. , 1991, Journal of the American College of Cardiology.

[18]  J Z Ayanian,et al.  Differences in the use of procedures between women and men hospitalized for coronary heart disease. , 1991, The New England journal of medicine.

[19]  M. Pfeffer,et al.  Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators. , 1991, The New England journal of medicine.

[20]  P. Greenland,et al.  In-hospital and 1-year mortality in 1,524 women after myocardial infarction. Comparison with 4,315 men. , 1991, Circulation.

[21]  C. Viscoli,et al.  Differences between women and men in survival after myocardial infarction. Biology or methodology , 1990 .

[22]  E. Braunwald,et al.  Mortality for women after acute myocardial infarction , 1989 .

[23]  E. Gilpin,et al.  Acute myocardial infarction in women: influence of gender on mortality and prognostic variables. , 1988, The American journal of cardiology.

[24]  A. Folsom,et al.  Improvement in long-term survival among patients hospitalized with acute myocardial infarction, 1970 to 1980. The Minnesota Heart Survey. , 1987, The New England journal of medicine.

[25]  S. Willich,et al.  Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women. , 1987, Journal of the American College of Cardiology.

[26]  R. Coleman,et al.  Sex-related differences in the normal cardiac response to upright exercise. , 1984, Circulation.

[27]  M. Puletti,et al.  Acute myocardial infarction: sex-related differences in prognosis. , 1984, American heart journal.