Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis

doi:10.1016/j.ijcard.2015.07.001

International Journal of Cardiology

Volume 198, 1 November 2015, Pages 123-130

https://doi.org/10.1016/j.ijcard.2015.07.001 Get rights and content

Abstract

Introduction

Women with acute myocardial infarction are treated less aggressively than men and have a higher mortality. It is possible that these sex-related differences in outcome are a result of differences in baseline risk and management.

Methods and results

We undertook a meta-analysis to study the differences in mortality among women and men with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (P-PCI). Studies reporting sex-specific crude mortality rates and/or adjusted effect estimates in STEMI patients undergoing P-PCI were identified. Among 48 studies, involving 103,895 patients, (26,556 women and 77,337 men), the crude in-hospital [pooled relative risk (RR): 1.94, 95% confidence interval (CI): 1.74–2.16, p < 0.001; 23 studies (n = 43,872)], 30-day [RR: 1.76, 95% CI: 1.50–2.07, p < 0.001; 20 studies (n = 43,279)], and long-term [RR: 1.60, 95% CI: 1.46–1.76, p < 0.001; 26 studies (n = 51,656)] mortality was significantly higher in women compared to men. When meta-analysis using adjusted effect estimates from individual studies was performed, in-hospital [RR: 1.31, 95% CI: 1.08–1.65, p = 0.007; 14 studies (n = 33,380)] and 30-day mortality [RR: 1.19, 95% CI: 1.01–1.39, p = 0.03; 14 studies (n = 28,564)] remained significant while long-term mortality [RR: 1.01, 95% CI: 0.93–1.11, p = 0.75; 20 studies (n = 52,492)] was no longer different between women and men.

Conclusions

Sex-based differences exist in short and long-term mortality among patients with STEMI undergoing P-PCI. However, these differences were markedly attenuated following adjustment for clinical differences and/or hospital course. Despite adjustment, short-term mortality remains higher in women than men, while long-term mortality was no longer significantly different.

Introduction

It is well accepted that there are differences in the presentation and outcome of women and men with acute myocardial infarction (AMI). Women with AMI are sicker than men on presentation and have higher short and long-term mortality [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Although much of the difference in sex-specific outcomes has been attributable to differences in baseline variables and therapies provided, most of the earlier reports examining the cohort of women and men with ST-segment elevation myocardial infarction (STEMI) demonstrated a higher event rate in women even after adjustment for differences in cardiovascular risk profiles and management [1], [2], [10], [11], [12], [13], [14], [15].

Current guidelines recommend percutaneous coronary intervention (PCI) as first line therapy for STEMI [16]. Primary PCI (P-PCI) is widely used throughout the country and there have been numerous practice and quality improvement initiatives aimed at reducing door-to-balloon time in an effort to improve outcomes. Since women with STEMI have higher risk profiles compared to men, the similar relative risk reduction observed with P-PCI would translate into an even larger absolute benefit for women [3], [4]. To this effect, many subsequent studies have investigated the impact of gender differences in short and long-term mortality in STEMI patients undergoing P-PCI. Among these studies, there is a great variability in reported results with some but not all reporting similar mortality in women and men. The majority of these studies however are small in size (including fewer than 300 women) and therefore may have been under-powered to examine mortality as a clinical endpoint [3], [4], [5], [6], [7], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39]. Hence, we performed a meta-analysis of all published studies that reported sex-specific data on short and long-term mortality among STEMI patients undergoing P-PCI, aimed at comprehensively and quantitatively reviewing evidence from all available studies.

Section snippets

Search strategy

We searched MEDLINE, EMBASE and SCOPUS databases for manuscripts published from inception to November 2014. We used the following key words and medical subject headings: (“ST-elevation myocardial infarction”, “STEMI”, “myocardial infarction”, “percutaneous coronary intervention”, “PCI”, “primary PCI”, “angioplasty”, “primary angioplasty”) and (“gender”, “sex”, “female”, “male”). A manual search of reference lists of the original retrieved studies and appropriate review articles was also

Results

The search strategy retrieved 2874 citations after removing duplicates. Among these citations, 63 articles were selected for full text review. Based on our selection criteria, a total of 48 studies [3], [4], [5], [6], [7], [8], [9], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [42], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62] were included in the

Discussion

Primary PCI is the recommended treated for acute STEMI [21] and is now the most common method of reperfusion in the US. Our meta-analysis examined a population of women and men with STEMI who were exclusively referred for P-PCI and demonstrated higher in-hospital, 30-day and long-term mortality in women compared to men. After adjustment for baseline co-morbidities, clinical profile and treatment, the association was attenuated but still significant for in-hospital and 30-day mortality whereas

Limitations

Several limitations of this meta-analysis should be considered. One major limitation in conducting a meta-analysis of observational studies is the inevitability of combining data from studies that are not equally designed. Study samples were heterogeneous in terms of clinical profile, baseline characteristics and geographic location. Such differences may have contributed to the moderate heterogeneity observed in our study. Second, we used multivariable adjusted effect estimate; however not all

Conclusions

Sex-based differences exist in short and long-term mortality among patients with STEMI undergoing P-PCI. However these differences are markedly attenuated following adjustment for age, clinical differences and/or angiographic parameters and therapies provided, such that long-term mortality appears similar in women and men. This reinforces the importance of providing prompt evidence based reperfusion therapy to eligible women and men with acute STEMI.

Conflict of interest/disclosures

None of the authors have any financial or other relations that could lead to a conflict of interest.

References (72)

S. Bangalore et al.
Get with the Guidelines Steering C, Investigators. Age and gender differences in quality of care and outcomes for patients with ST-segment elevation myocardial infarction
Am. J. Med.
(2012)
J.E. Tamis-Holland et al.
Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the global use of strategies to open occluded arteries in acute coronary syndromes angioplasty (GUSTO II-B) angioplasty substudy
Am. Heart J.
(2004)
G.W. Stone et al.
Comparison of in-hospital outcome in men versus women treated by either thrombolytic therapy or primary coronary angioplasty for acute myocardial infarction
Am. J. Cardiol.
(1995)
D. Antoniucci et al.
Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction
Am. J. Cardiol.
(2001)
R.R. Azar et al.
Short- and medium-term outcome differences in women and men after primary percutaneous transluminal mechanical revascularization for acute myocardial infarction
Am. J. Cardiol.
(2000)
C.I. Cheng et al.
Comparison of baseline characteristics, clinical features, angiographic results, and early outcomes in men vs women with acute myocardial infarction undergoing primary coronary intervention
Chest
(2004)
G. De Luca et al.
Sex-related differences in outcome after ST-segment elevation myocardial infarction treated by primary angioplasty: data from the Zwolle Myocardial Infarction Study
Am. Heart J.
(2004)
S.L. Woodfield et al.
Gender and acute myocardial infarction: is there a different response to thrombolysis?
J. Am. Coll. Cardiol.
(1997)
A.M. Lincoff et al.
Thrombolytic therapy for women with myocardial infarction: is there a gender gap? Thrombolysis and angioplasty in myocardial infarction study group
J. Am. Coll. Cardiol.
(1993)
B. Waldecker et al.
Direct angioplasty eliminates sex differences in mortality early after acute myocardial infarction
Am. J. Cardiol.
(2001)

J. Hurtado-Martinez et al.

In-hospital and long-term mortality in women with acute myocardial infarction treated by primary angioplasty

Rev. Esp. Cardiol.

(2006)

G. Ferrante et al.

Impact of female sex on long-term outcomes in patients with ST-elevation myocardial infarction treated by primary percutaneous coronary intervention

Can. J. Cardiol.

(2011)

G. Ferrante et al.

Sex-specific benefits of sirolimus-eluting stent on long-term outcomes in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: insights from the multicenter evaluation of single high-dose bolus tirofiban versus abciximab with sirolimus-eluting stent or bare-metal stent in acute myocardial infarction study trial

Am. Heart J.

(2012)

J. Pu et al.

Gender differences in epicardial and tissue-level reperfusion in patients undergoing primary angioplasty for acute myocardial infarction

Atherosclerosis

(2011)

J.J. Ferrer-Hita et al.

Female gender is an independent predictor of in-hospital mortality in patients with st segment elevation acute myocardial infarction treated with primary angioplasty

Med. Intensiva

(2008)

R. DerSimonian et al.

Meta-analysis in clinical trials

Control. Clin. Trials

(1986)

S. Rasoul et al.

Zwolle Myocardial Infarction Study G. Primary percutaneous coronary intervention for ST-elevation myocardial infarction: from clinical trial to clinical practice

Int. J. Cardiol.

(2009)

S.M. Meller et al.

Implications of myocardial reperfusion on survival in women versus men with acute myocardial infarction undergoing primary coronary intervention

Am. J. Cardiol.

(2013)

I. Mrdovic et al.

Sex-related analysis of short- and long-term clinical outcomes and bleeding among patients treated with primary percutaneous coronary intervention: an evaluation of the risk-PCI data

Can. J. Cardiol.

(2013)

G. De Luca et al.

Gender-related differences in outcome after BMS or des implantation in patients with st-segment elevation myocardial infarction treated by primary angioplasty: insights from the desert cooperation

Atherosclerosis

(2013)

M.A. Velders et al.

Influence of gender on ischemic times and outcomes after ST-elevation myocardial infarction

Am. J. Cardiol.

(2013)

V. Kunadian et al.

Gender comparisons in cardiogenic shock during ST elevation myocardial infarction treated by primary percutaneous coronary intervention

Am. J. Cardiol.

(2013)

R. Cale et al.

Investigadores do Registo Nacional de Cardiologia de I. [Primary angioplasty in women: data from the Portuguese Registry of Interventional Cardiology]

Rev. Port. Cardiol.

(2014)

S.P. de Boer et al.

Excess mortality in women compared to men after PCI in STEMI: an analysis of 11,931 patients during 2000–2009

Int. J. Cardiol.

(2014)

J. Galcera-Tomas et al.

Female sex is inversely and independently associated with marked ST-segment elevation. A study in patients with ST-segment elevation acute myocardial infarction and early admission

Rev. Esp. Cardiol.

(2009)

S.S. Anand et al.

Differences in the management and prognosis of women and men who suffer from acute coronary syndromes

J. Am. Coll. Cardiol.

(2005)

J.P. Loh et al.

Incidence and correlates of major bleeding after percutaneous coronary intervention across different clinical presentations

Am. Heart J.

(2014)

J.H. Lichtman et al.

Age and sex differences in inhospital complication rates and mortality after percutaneous coronary intervention procedures: evidence from the NCDR((R))

Am. Heart J.

(2014)

V. Vaccarino et al.

Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants

N. Engl. J. Med.

(1999)

A.J. Lansky et al.

Gender differences in outcomes after primary angioplasty versus primary stenting with and without abciximab for acute myocardial infarction: results of the controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial

Circulation

(2005)

J.S. Hochman et al.

Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIB investigators

N. Engl. J. Med.

(1999)

W.D. Weaver et al.

Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy. GUSTO-I investigators

JAMA

(1996)

R. Malacrida et al.

A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group

N. Engl. J. Med.

(1998)

R.C. Becker et al.

Comparison of clinical outcomes for women and men after acute myocardial infarction. The thrombolysis in myocardial infarction investigators

Ann. Intern. Med.

(1994)

P.T. O'Gara et al.

ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Circulation

(2013)

H. Tillmanns et al.

Gender differences in the outcome of cardiac interventions

Herz

(2005)

Cited by (47)

LDL-cholesterol target levels achievement in high-risk patients: An (un)expected gender bias
2024, Nutrition, Metabolism and Cardiovascular Diseases
Lowering low-density lipoprotein cholesterol (LDL-C) is the cornerstone of cardiovascular disease prevention. Collection of epidemiological data is crucial for monitoring healthcare appropriateness. This analysis aimed to evaluate the proportion of high-risk patients who achieved guidelines recommended LDL-C goal, and explore the predictors of therapeutic failure, with a focus on the role of gender.
Health administrative and laboratory data from seven Local Health Districts in Tuscany were collected for residents aged ≥45 years with a history of major adverse cardiac or cerebrovascular event (MACCE) and/or type 2 diabetes mellitus (T2DM) from January 1, 2019, to January 1, 2021. The study aimed to assess the number of patients with optimal levels of LDL-C (<55 mg/dl for patients with MACCE and <70 mg/dl for patients with T2DM without MACCE). A cohort of 174 200 individuals (55% males) was analyzed and it was found that 11.6% of them achieved the target LDL-C levels. Female gender was identified as an independent predictor of LDL-C target underattainment in patients with MACCE with or without T2DM, after adjusting for age, cardiovascular risk factors, comorbidities, and district area (adjusted-IRR 0.58 ± 0.01; p < 0.001). This result was consistent in subjects without lipid-lowering therapies (adjusted-IRR 0.56 ± 0.01; p < 0.001).
In an unselected cohort of high-risk individuals, females have a significantly lower probability of reaching LDL-C recommended targets. These results emphasize the need for action to implement education for clinicians and patients and to establish clinical care pathways for high-risk patients, with a special focus on women.
Acute Coronary Syndrome in Women
2022, Emergency Medicine Clinics of North America
Citation Excerpt :
A study from 2010 to 2014 demonstrated women have a higher risk of in-hospital mortality after Percutaneous Intervention (PCI).48 These short-term (30 days) mortality disparities exist after controlling for age and comorbidities but they resolve in long-term (>6 month) follow-up.49 In part due to older age at presentation and additional comorbidities, women are more likely to die of noncardiac causes 6 years after ACS, whereas in men cardiovascular causes of death remain the most likely for any period of time following ACS.50
Sex differences in the management of patients with acute coronary syndrome: A population-based ecological cross-sectional study in Spain
2021, REC: CardioClinics
Citation Excerpt :
In line with previous evidence,17–19 female sex has been postulated as an independent predictor of short-term bleeding after acute myocardial infarction.12,16,20 Inconsistent results have been published regarding the influence of sex on ACS outcomes,11,21–24 which may be explained by the inclusion of populations with different baseline characteristics and/or variability in the methodology used for data analysis.25 Nonetheless, among patients with ACS, sex differences in the management of cardiovascular events and subsequent mortality rates remain a concern nowadays.12
Despite evidence of a reduction in the incidence and mortality of acute coronary syndrome (ACS), some studies have highlighted differences in outcomes between men and women. We aimed to explore sex differences in the management and treatment of patients with ACS in Spain.
This ecological cross-sectional study combined ACS data from 10 Spanish registries (54 centres). Meta-regression analysis was performed using aggregated data of baseline characteristics, interventional procedures, treatments, and events that occurred during hospitalization and one-year follow-up.
Aggregated data from 34 605 patients (75.1% men) was included. ST-segment elevation myocardial infarction was the most frequent diagnosis (58.9%) and almost 80% of patients were Killip Class I. Compared to men, women were older (mean age: 71.0 vs 63.3 years) and presented higher rates of hypertension (68.1% vs 51.7%) and diabetes (37.7% vs 26.5%). Women were also less likely to undergo percutaneous coronary interventions, revascularization surgery, and to receive drug-eluting stents during hospitalization. Regarding to antiplatelet therapy, even though indicated, 23.1% of women were not treated with P2Y₁₂ inhibitors (vs 14.2% of men; P < .001); clopidogrel was the most frequently administered agent (> 60%). Significantly higher in-hospital (5.4% vs 3.7%) and 1-year (8.2% vs 4.9%) mortality was observed among women compared to men, which was mainly attributed to cardiovascular causes.
Despite older age and unfavourable risk profile, female ACS patients seem to be suboptimally treated with P2Y₁₂ inhibitors. To reduce mortality associated with ACS, improved prevention and optimized therapeutic approaches are needed.
A pesar del descenso en la incidencia y en la mortalidad por síndrome coronario agudo (SCA), algunos estudios indican discrepancias en los resultados entre varones y mujeres. Nuestro objetivo fue investigar la influencia del sexo en el tratamiento de pacientes con SCA en España.
Estudio ecológico transversal que recogió datos de 10 registros españoles de SCA (54 centros). Se realizó un análisis de meta-regresión con datos agregados de características basales, procedimientos, tratamientos y eventos intrahospitalarios y durante un año de seguimiento.
En 34.605 pacientes (75,1% varones), el diagnóstico más frecuente fue infarto agudo de miocardio con elevación del segmento ST (58,9%) y 80% fueron clase Killip I. Las mujeres presentaron mayor edad (media: 71.0 frente a 63.3 años), tasa de hipertensión (68,1% frente a 51,7%) y diabetes (37,7% frente a 26,5%) que los varones. El número de intervenciones coronarias percutáneas, cirugía de revascularización y uso de stent fármaco-activo fueron menores en las mujeres. Respecto a la terapia antiagregante, el 23,1% de mujeres no recibieron inhibidores P2Y₁₂, aun estando indicado (frente a 14,2% de varones; p < 0,001); clopidogrel fue el más administrado (> 60%). La mortalidad intrahospitalaria (5,4% frente a 3,7%) y al año (8,2% frente a 4,9%) aumentó significativamente en las mujeres respecto a los varones, principalmente por causas cardiovasculares.
A pesar de su mayor edad y perfil de riesgo desfavorable, las mujeres con SCA parecen estar infratratadas con inhibidores P2Y₁₂. Reducir la mortalidad asociada con el SCA requiere una mejor prevención y enfoques terapéuticos optimizados.
Sex-Based Differences in Characteristics and In-Hospital Outcomes among Patients With Diagnosed Acute Myocarditis
2020, American Journal of Cardiology
Data are scarce regarding sex differences among patients with acute myocarditis (AM). Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to AM. We analyzed data of 322 consecutive patients from January 2005 to December 2017 who were hospitalized with the diagnosis of AM. Eighty-four percent (N = 272) of the patients were males. When compared to females, male patients were younger (36 ± 14 vs 45 ± 17 years, p <0.001), more likely to present with ST segment elevation (75% vs 44%. p <0.001) as well as PR depression upon ECG, and have higher admission troponin levels (7.6 ± 11 vs 2.3 ± 4 µg/L, p <0.001). Moreover, males were more likely to have late gadolinium enhancement upon cardiac magnetic resonance. While male patients were more likely to have ventricular arrhythmias during hospitalization (7% vs 0%, p = 0.05), there were no differences in the incidence of in-hospital mortality or the need for escalation therapy during hospitalization between both groups. There were no episodes of mortality upon all patients among a follow-up of 1 year. In conclusion, male patients, which constitute the majority of patients admitted with AM were younger, more likely to present with ST elevation, had higher troponin levels at admission, and had a higher rate of ventricular arrhythmias compared to females. There were no differences in post-discharge mortality rates between males and females.
ST-elevation myocardial infarction in a real world population - An observational retrospective study with a sex perspective
2019, European Journal of Internal Medicine
Citation Excerpt :
Many studies have observed a higher mortality in women with myocardial infarction compared to men [1–8].
Mortality after myocardial infarction is higher in women than in men. Data on the association between sex and mortality are conflicting and inconclusive. We evaluated whether there is a sex difference in survival and if sex is associated with the outcome in patients with ST-elevation myocardial infarction (STEMI).
We analyzed 3671 STEMI patients. Long-term and 30-day mortality in men and women were compared.
Unadjusted mortality at day 30 was higher in women [221 (8.7%) men died compared to 147 (13.1%) women; p < 0.0001]. After multivariate adjustments, this became insignificant (OR 1.65; 95% CI; 0.81 to 1.40). The long-term, unadjusted mortality was also higher in women [674 (26.3%) men died compared to 382 (34%) women; p < 0.0001]. After multivariable adjustments, female sex (adjusted HR 0.81; 95% CI 0.71 to 0.93; p = 0.002), bleeding (adjusted HR 1.79; 95% CI 1.52 to 2.10; p < 0.0001), renal dysfunction adjusted HR (1.60; 95% CI 1.40 to 1.84; p < 0.0001), hyperlipidemia (adjusted HR 1.61; 95% CI 1.40 to 1.85; p < 0.0001), arterial hypertension (adjusted HR 1.17; 95% CI 1.03 to 1.33; p = 0.015), diabetes (adjusted HR 1.55; 95% CI 1.35 to 1.78; p < 0.0001), age (adjusted HR 1.05; 95% CI 1.04 to 1.06; p < 0.0001), anemia on admission (adjusted HR 1.38; 95% CI 1.23 to 1.58; p < 0.0001), and heart failure (adjusted HR 2.40; 95% CI 2.09 to 2.75; p < 0.0001) predicted long-term mortality.
Female sex was associated with a lower risk of dying in the long term. However, risk factors, age, and comorbidities associated with female patients affected the worse outcome.
Gender is Not a Predictor of Mortality or Major Adverse Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes
2019, Heart Lung and Circulation
Citation Excerpt :
Duvernoy, et al.’s data from 2002 to 2003 showed an increased risk of in-hospital death and MACE in women following PCI [5]. Two meta-analyses of STEMI patients reported a higher risk of death in women within 30 days of PCI [17,18] The publication of a large study showing higher mortality in women <50 years of age after PCI in the 90s was a cause for concern [19]. The authors speculated that the result may have occurred due to higher prevalence of baseline comorbidities such as diabetes and heart failure, and the presence of smaller vessel size in women, making PCI more challenging.
Historically, studies of percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have reported worse outcomes for women. We sought to determine if contemporary PCI techniques eliminate gender differences in PCI outcomes.
This was a retrospective study of 4,776 consecutive patients who underwent PCI for acute coronary syndromes between January 2008 and July 2015. Primary outcomes studied were major adverse cardiovascular events (MACE) and death at 1 year.
Percutaneous coronary intervention success was similar in men and women (97.8% v 97.7%, p = 0.76). There was no significant gender difference in the number of vessels attempted (1.14 vs 1.12, p = 0.25), mean number of lesions treated (1.34 vs 1.32, p = 0.21) or the mean number of stents used (1.32 vs 1.30, p = 0.31). There was equivalent use of drug eluting stents (38.2% vs 38.3%, p = 0.94). Women with ST-elevation myocardial infarction STEMI had longer median symptom-to-door time (111 vs 90 mins, p = 0.0411) but there was no gender difference in door-to-balloon time or symptom-to-balloon time. There was no significant difference in percentages of women and men <75 years treated with prasugrel or ticagrelor (11.1% vs 13.4%, p = 0.092). Unadjusted 1-year mortality was 6.4% for women and 4% for men (p = 0.0012), but on multivariate analysis, female sex was not a predictor of death. There was no significant gender difference in the overall incidence of unadjusted 1-year MACE (11.6% vs 10.8%, p = 0.434).
When contemporary PCI techniques are applied equally to men and women with ACS there is no gender difference in mortality or MACE at 1 year.

View all citing articles on Scopus

^☆: Presented in a part at the American Heart Association Scientific Sessions, Chicago, November 2014.

^☆☆: All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

View full text

Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis☆,☆☆

Abstract

Introduction

Methods and results

Conclusions

Introduction

Section snippets

Search strategy

Results

Discussion

Limitations

Conclusions

Conflict of interest/disclosures

Am. J. Med.

Am. Heart J.

Am. J. Cardiol.

Am. J. Cardiol.

Am. J. Cardiol.

Chest

Am. Heart J.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

Rev. Esp. Cardiol.

Can. J. Cardiol.

Am. Heart J.

Atherosclerosis

Med. Intensiva

Control. Clin. Trials

Int. J. Cardiol.

Am. J. Cardiol.

Can. J. Cardiol.

Atherosclerosis

Am. J. Cardiol.

Am. J. Cardiol.

Rev. Port. Cardiol.

Int. J. Cardiol.

Rev. Esp. Cardiol.

J. Am. Coll. Cardiol.

Am. Heart J.

Am. Heart J.

Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants

N. Engl. J. Med.

Gender differences in outcomes after primary angioplasty versus primary stenting with and without abciximab for acute myocardial infarction: results of the controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial

Circulation

Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global use of strategies to open occluded coronary arteries in acute coronary syndromes IIB investigators

N. Engl. J. Med.

Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy. GUSTO-I investigators

JAMA

A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group

N. Engl. J. Med.

Comparison of clinical outcomes for women and men after acute myocardial infarction. The thrombolysis in myocardial infarction investigators

Ann. Intern. Med.

ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Circulation

Gender differences in the outcome of cardiac interventions

Herz