Rehospitalizations After Acute MI: Young Women Outpace Young Men
It’s possible that higher rates of depression among women may be driving some of the differences, the authors suggest.
Among young acute MI patients, hospitalizations within the following year are more likely to occur in women than men, an analysis of the VIRGO trial shows.
Data have previously shown that not only do women with acute MI fare worse than men, the numbers of women ages 35 to 54 with acute MI are on the rise. One thing that has remained unclear, however, is how young women and men differ in terms of adverse events and hospitalizations as time goes on.
For the new study, researchers led by Mitsuaki Sawano, MD, PhD (Yale School of Medicine, New Haven, CT), found that while most of the hospitalizations among young acute MI patients were coronary-related, the greatest sex disparities occurred among those with noncardiac hospitalizations.
“We are doing additional chart reviews right now to better understand this,” Sawano told TCTMD. “What we found so far is that as a group, these noncardiac hospitalizations in young women are caused by pain but [are] not related to coronary blockage. Also, we found gastrointestinal problems like stomach pain or stomach bleeding complications. Then there were also psychiatric issues that led these young women to come to the hospital after an acute MI discharge.”
Hospitalizations tended to peak within the first month after and slowly declined to a steady state by 3-month after discharge in both men and women.
In an accompanying editorial, Martha Gulati, MD (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA), and colleagues note that the VIRGO analysis is consistent with findings from the YOUNG-MI trial, which showed that women had higher rates of noncardiovascular death.
“This study importantly identifies an increased rate of cardiovascular and noncardiovascular rehospitalization in women in comparison with men, and a clear association with psychosocial and demographic factors,” they write. “Yet, the root cause of sex differences in psychosocial factors and rates of comorbid conditions remains elusive.”
Women Characterized by Low Income, Black, Delayed Presentation
For the study, published May 1, 2023, in the Journal of the American College of Cardiology, Sawano and colleagues examined VIRGO data on 2,007 women and 972 men (mean age 47 years; 17.5% non-Hispanic Black; 8% Hispanic or Latino) who had an acute MI and had at least 365 days of follow-up.
Compared with men, women were more likely to report low income (47.6% vs 31.4%) and were more than twice as likely to have a history of depression (48.7% vs 24.2%). Women also were more often non-Hispanic Black, with a greater incidence of comorbidities, including obesity, chronic obstructive lung disease, congestive heart failure, prior stroke, and renal disease.
At MI presentation, women were less likely than men to have chest pain, but more likely to present more than 6 hours after symptom onset. Women also were more often diagnosed with NSTEMI and MI with nonobstructive coronary arteries (MINOCA). In addition to having longer lengths of stay for acute MI than men, women had lower rates of guideline-recommended medical therapies, including aspirin (92.6% vs 95.0%; P < 0.02), statins (67.5% vs 71.7%; P < 0.001), beta-blockers (89.6% vs 94.1%; P < 0.001), and ACE inhibitors/ARBs (61.2% vs 70.6%; P < 0.001).
At 1 year, all-cause hospitalizations had occurred in 34.8% of women and 23% of men (P < 0.001). Compared with men, women had a greater risk of coronary-related events as well as noncardiac events or stroke (P < 0.001), but similar risk of other cardiac or stroke hospitalizations.
Rates of all-cause death were 25.3% for women and 11.4% for men (P = 0.01). After adjustment for confounders, women continued to have a consistently higher risk for 1-year mortality from all causes, and coronary and noncardiac hospitalizations.
Psychosocial and Other Factors Likely at Play
In the VIRGO population, health status was assessed at baseline, 1 month postdischarge and 12 months postdischarge with the Short Form-12 score, the EQ-5D score, the Seattle Angina Questionnaire (overall and individual domain scores), the Patient Health Questionnaire-9, the ENRICHD Social Support Instrument, and the Perceived Stress Scale.
“What we know from the health questionnaires is that younger women show greater depressive states as compared to men,” Sawano added. “We haven't done a proper evaluation on this, but it is something we plan to focus on in future research.”
What we know from the health questionnaires is that younger women show greater depressive states as compared to men. Mitsuaki Sawano
According to Sawano, depression in women may be a driving factor in their rehospitalizations. He said complaints of stomach pain may add strength to that theory, since they often track with depression.
However, comorbidities, less guideline-directed therapy, and the repercussions of late initial presentation for acute MI cannot be ruled out as contributing factors to many of the hospitalizations, he added, nor can the complex interplay of sex-specific risk factors like gestational diabetes and menopause.
“Financial issues may also come into play on top of things we didn't collect in our surveys, things like [household] responsibilities for kids or parents or grandparents, that could be barriers to coming to the hospital in a timely manner [resulting in] more-frequent hospitalizations,” Sawano said.
Importantly, Gulati and colleagues point out that other analyses have identified stress as a barrier to recovery after acute Mi in young women. “Interventions designed to address social support and stress reduction would be beneficial, as well as recognition of how stressors and daily responsibilities may differ between the sexes,” they write.
The editorialists also suggest that automated prompts in electronic medical records and virtual care strategies may be a few ways of improving guideline-directed medial therapy.
But another major concern, given the greater incidence of low-income women compared with men in the study, is the projected jeopardization of healthcare access that will occur with the expiration of the COVID-19 public health emergency on May 11, 2023. For the last 3 years, the public health emergency provided individual states with funding to allow for continuous Medicaid enrollment.
When the provision ends, Gulati and colleagues add, “young women will be particularly vulnerable to losing insurance coverage and falling into a care gap.”
Sawano M, Lu Y, Caraballo C, et al. Sex difference in outcomes of acute myocardial infarction in young patients. J Am Coll Cardiol. 2023;81:1797-1806.
Gulati M, Holtzman JN, Kaur G. Increased rehospitalization in young women with acute myocardial infarction at 1 year: adding insult to infarct. J Am Coll Cardiol. 2023;81:1807-1809.
- Sawano and Gulati report no relevant conflicts of interest.