More Rehospitalizations for Younger Women
1-Year Post-MI

Marilynn Larkin

May 04, 2023

Younger women (those aged 18-55) have more adverse outcomes than men in the year after an acute myocardial infarction (AMI) and are at greater risk for both cardiac and noncardiac rehospitalizations, a new analysis of the VIRGO study suggests.

All-cause hospitalization rates within 1 year of discharge were 34.8% for women compared with 23% for men. Most hospitalizations for women were coronary-related.

Women with a myocardial infarction with nonobstructive coronary arteries (MINOCA) had lower rates of rehospitalization than women who experienced myocardial infarction with obstructive coronary artery disease (MI-CAD).

There was a more significant sex disparity between women and men for noncardiac hospitalizations compared with all other hospitalizations (incidence rate, 145.8 [women] vs 69.6 [men] per 1000 person-years).

"We were surprised to see the significance of sex difference in 1-year outcomes despite adjusting for over 30 variables, variables that often hold significant impact, such as belonging in the self-reported non-Hispanic Black population and lower socioeconomic status, [and] scores on health status questionnaires," Mitsuaki Sawano, MD, PhD, of the Yale School of Medicine, New Haven, Connecticut, told | Medscape Cardiology. "Our findings indicate that women may indeed be at higher risk for 1-year hospitalizations."

Comprehensive data capturing healthcare utilization in young patients with AMI is lacking in the United States, Sawano said. "That is exactly why the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study started more than decade ago."

"Since there is no indication that much has changed in the care provided to young patients over the last decade, we think the data from VIRGO remains relevant to this day," he added.

The results were published online May 1 in the Journal of the American College of Cardiology.

Sex Disparities Apparent

The VIRGO study enrolled men and women with AMI across 103 US hospitals. Average age of the patients was 47 years and 70% self-identified as non-Hispanic White. A high proportion of women self-identified as non-Hispanic Black compared with men.

Women also had a higher prevalence of comorbidities, including obesity, congestive heart failure, prior stroke, and renal disease, and a greater history of depression at baseline (48.7% vs 24.2%).

Among the 2979 patients (67% women) included in the analysis, at least one hospitalization occurred in 905 (30.4%) in the year after discharge.

The leading causes of hospitalization were coronary-related (incidence rate [IR], 171.8 among women vs 117.8 among men), followed by noncardiac hospitalization (IR, 145.8 vs 69.6) and dissection and vasospasm (1.4% vs 0.2%).

Women with MINOCA had a lower incidence of 1-year all-cause, coronary-related, and stable or unstable angina hospitalizations compared with women with MI-CAD. The women with MINOCA also reported lower treatment satisfaction compared with men or women presenting with MI-CAD.

At the time of discharge, the total length of stay was longer for women vs men, and women received lower rates of guideline-recommended medical therapies, including aspirin (92.6% vs 95%), statins (67.5% vs 71.7%), beta-blockers (89.6% vs 94.1%), and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (61.2% vs 70.6%).

"Greater burden of risk factors, chest discomfort symptoms deemed 'noncardiac,' delays in hospital presentation, delays in care after arriving at the hospital, inequalities in timely reperfusion therapies or any revascularization, lower prescription and continuation rate of optimal medical therapy, etc. all have been proposed as contributing factors to worse clinical outcomes in young women," Sawano said. "More importantly, we have not seen any full-scale attempts to lessen sex disparity."

To minimize the risk of avoidable hospitalizations, a multidisciplinary team of cardiologists, psychiatrists, ob/gyn doctors, diabetes clinicians, and obesity specialists, among others, "is warranted during the index hospitalization," he added.

"Clinicians would need to understand the patient better," including factors like financial status, insurance, access to healthcare, and possible constraints related to household roles. "All are relevant to taking care of the young patients," he said.

Beyond Traditional Risk Factors

"I am not surprised by the current findings, as young women are the least aware of their risk for heart attacks," American Heart Association volunteer expert Nieca Goldberg, MD, clinical associate professor of medicine at NYU Grossman School of Medicine and medical director of Atria, New York City, told | Medscape Cardiology. "The current health system seems fixed on the image of men and older women being at risk for heart disease. A different analysis will likely have the same results."

Physicians need to look beyond traditional risk factors like high blood pressure, high cholesterol, family history, cigarette smoking, lack of exercise and obesity, she said. "They should incorporate questions about autoimmune disease and pregnancy-related disorders such as preeclampsia, gestational diabetes, preterm birth as well as mental health issues like depression, anxiety, and stress. These disorders can widen out the net of women who are at risk for heart disease."

Martha Gulati, MD, MS, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, and colleagues conclude in a related editorial that the new analysis "adds to decades worth of literature clearly illustrating that young women with AMI experience more adverse outcomes than men.

"The disparities are evident," they conclude. "Now it is time to stop adding insult to infarct and to solve these persistent sex gaps in cardiovascular care."

The VIRGO study (NCT00597922) was supported by the National Heart, Lung, and Blood Institute. Sawano reports no relevant financial relationships, but several co-authors report ties to industry; the full list can be found with the original article. The editorialists and Goldberg report no relevant financial relationships.

J Am Coll Cardiol. Published online May 1, 2023. Abstract, Editorial

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