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Sex Differences in the Management and 5-Year Outcome of Young Patients (<55 Years) with Acute Coronary Syndromes


Premature presentation of ischemic heart disease has become increasingly common. According to recent reports, patients younger than 55 years account for 23% of all patients with acute coronary syndrome.1 Premenopausal women are less likely than men of similar ages to present with acute coronary syndrome, accounting for only 17%-20%12 of cases. Studies have consistently shown that the unadjusted outcome of women following acute coronary syndrome is significantly worse as compared with men. However, this disparity in risk for mortality was greatly attenuated after adjustment for age, comorbidities, and other confounders.345 Age-specific analysis revealed that in-hospital mortality was significantly higher in young women compared with their male counterparts.4678 The difference in mortality rates between sexes decreased as age increases up to 75 years, when it was no longer significant.9

Most of these data predate the era of early invasive approach, modern antiplatelet therapy, and other current standard-of-care medications. Despite some increase in the awareness to acute coronary syndrome in women, many studies still show a tendency toward conservative rather than invasive therapy in women,1011 a fact that may affect outcome in this population. In addition, most studies examined short-term outcomes. Therefore, we aimed to study sex-related differences in the management and outcome of young (≤55) patients with acute coronary syndrome in an all-comer, contemporary national cohort.


Acute Coronary Syndrome Israeli Surveys

Acute Coronary Syndrome Israeli Surveys (ACSIS) is a national acute coronary syndrome survey conducted in all 25 cardiology departments in Israel since 1992. Details of these nationwide surveys have been previously reported.1213 Briefly, ACSIS is a 2-month nationwide survey conducted biennially, which prospectively collects data from all acute coronary syndrome admissions in each of the 25 coronary care units and cardiology wards operating in Israel. Prespecified, standard forms were used to record demographic, clinical data management and outcome during the index hospital stay and subsequent follow-up. Admission and discharge diagnoses were recorded as determined by the attending physicians based on clinical, electrocardiographic, and biochemical (elevated creatine kinase-MB or troponin levels) criteria. Definitions of type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction) and unstable angina were homogeneous and based on prespecified criteria according to accepted definitions in the specific survey period.1415 All entries were validated by the Israel Association of Cardiovascular Research by reviewing charts and discharge documents. In-hospital and 30-day outcome data were ascertained by hospital chart review, telephone contact, and clinical follow-up data. Patient management was at the discretion of the attending physicians. Mortality data during hospitalization and at 30 days were determined for all patients from hospital charts and by matching identification numbers of patients with the Israeli National Population Register. Five-year mortality data were ascertained through the use of the Israeli National Population Registry. All parameters captured by the registry were defined by protocol. Data collection was approved at each hospital by the Institutional Ethics Review Committee.

Study Population and Outcome Measures

The current study population was comprised of all patients under the age of 55 years enrolled in 7 consecutive ACSIS surveys from 2000 through 2013. All patients had a discharge diagnosis of ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina. There were no exclusion criteria from the study.

Outcome measures of the present study included in-hospital, 30-day, and 5-year all-cause mortality, as well as 30-day major adverse cardiac and cerebral events defined as recurrent myocardial infarction, stent thrombosis, ischemic stroke, urgent repeat revascularization, or death.

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-Avi Sabbag, MD, Shlomi Matetzky, MD, Avital Porter, MD, Zaza Iakobishvili, MD, Mady Moriel, MD, Donna Zwas, MD, Paul Fefer, MD, Elad Asher, MD, Roy Beigel, MD, Shmuel Gottlieb, MD, Ilan Goldenberg, MD, Amit Segev, MD

This article originally appeared in the November 2017 issue of The American Journal of Medicine.

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