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(Chest. 2003;124:2079-2086.)
© 2003 American College of Chest Physicians

Sex Differences in Use of Coronary Revascularization in Elderly Patients After Acute Myocardial Infarction*

A Tale of Two Therapies

Saif S. Rathore, MPH; JoAnne M. Foody, MD; Martha J. Radford, MD and Harlan M. Krumholz, MD, SM

* From the Section of Cardiovascular Medicine (Mr. Rathore and Dr. Krumholz), Department of Internal Medicine, Yale University School of Medicine, New Haven; Qualidigm (Dr. Foody), Middletown; and Center for Outcomes Research and Evaluation (Dr. Radford), Yale-New Haven Hospital, New Haven, CT.

Correspondence to: Harlan M. Krumholz, MD, Department of Internal Medicine, Yale University School of Medicine, Room I-456 SHM, 333 Cedar St, PO Box 208025, New Haven, CT 06520-8025; e-mail: harlan.krumholz{at}yale.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Objectives: To determine if there are sex differences in the use of coronary revascularization in elderly patients after acute myocardial infarction (AMI), and if sex differences vary by type of revascularization therapy.

Design: Retrospective analysis of medical record data.

Setting: US acute-care nongovernment hospitals.

Patients: A total of 66,830 Medicare patients >= 65 years old hospitalized with AMI.

Interventions: None.

Measurements and results: We assessed sex differences in the use of coronary revascularization within 60 days of hospital admission among patients who had undergone cardiac catheterization. Multivariable logistic regression models were used to derive risk-standardized rates of any coronary revascularization, coronary artery bypass graft (CABG) surgery, and percutaneous coronary intervention (PCI) adjusted for patient and hospital characteristics. Women had lower crude overall rates of coronary revascularization compared with men (65.2% vs 68.7%, p < 0.001). Multivariable adjustment reduced the sex difference in the overall coronary revascularization rate from 3.5 to 2.1% (66.0% women vs 68.1% men, p = 0.001). Sex differences in coronary revascularization use, however, varied by type of revascularization therapy. Women had lower risk-standardized rates of CABG surgery compared with men (27.0% vs 32.9%, p < 0.001), but had higher risk-standardized rates of PCI (42.0% vs 38.2%, p < 0.001), particularly among patients > 85 years old (45.8% vs 38.9%, p = 0.011).

Conclusions: Among Medicare patients hospitalized with AMI, women are slightly less likely to undergo coronary revascularization after cardiac catheterization; however, sex differences in coronary revascularization vary by type of therapy.

Key Words: aged • angioplasty • coronary artery bypass • gender • health services for the aged • myocardial infarction • myocardial revascularization


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
The literature concerning sex differences in the use of coronary revascularization after cardiac catheterization among patients with acute myocardial infarction (AMI) is inconsistent. Several studies1 2 3 4 5 6 have documented lower rates of revascularization among women compared with men after cardiac catheterization, but other studies7 8 9 10 11 12 13 14 15 16 17 18 19 20 have reported that women and men undergo revascularization at comparable rates after angiography. Different findings may be attributable to variations in the design of these studies. Although several large studies3 4 5 6 have documented sex differences in the use of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) after adjustment for selected covariates, these evaluations have been based on administrative data, and thus may have lacked necessary clinical information to exclude many potential confounders. In contrast, smaller studies7 9 10 11 13 14 16 17 18 19 have found no sex differences in the use of coronary revascularization after cardiac catheterization once accounting for sex differences in a variety of clinical factors; however, these studies were based on data obtained from single centers, clinical trials, or similarly selected patient populations. In addition, some studies1 3 4 6 7 9 14 15 21 indicate that sex differences in coronary revascularization rates vary by type of revascularization, suggesting that sex differences may be therapy specific. Thus, it is unclear whether sex differences in the use of coronary revascularization after cardiac catheterization are an artifact of limited clinical data or reflect true sex differences in the use of these cardiac procedures. In addition, the extent to which sex differences in coronary revascularization vary by type of revascularization is unknown. A recent study by Ghali and colleagues20 found sex differences in coronary revascularization use were attributable to sex differences in clinical characteristics and did not reflect a true sex effect; however, this study was based on patients treated in Alberta, Canada, and thus may not reflect practice patterns observed in the United States.

Accordingly, we undertook an evaluation of data from the Cooperative Cardiovascular Project (CCP), an initiative of the Centers for Medicare & Medicaid Services to improve the care and outcomes of elderly patients hospitalized for AMI. The CCP offers a unique methodologic advancement on prior analyses, in that it is both a large, nationally representative sample of patients, and contains extensive medical record data unavailable in prior national assessments of sex differences in revascularization use. Thus, we sought to determine if elderly men and women who had undergone cardiac catheterization underwent coronary revascularization at different rates after a myocardial infarction, and whether such differences might be explained by accounting for sex differences in clinical characteristics. In addition, we also examined whether sex variations in the use of coronary revascularization were similar for the use of CABG and PCI or varied by type of revascularization procedure.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
CCP and the Study Cohort
The CCP has been described in greater detail elsewhere.22 Briefly, Medicare fee-for-service patients hospitalized with a principal discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 410.X, with the exception of readmissions—ICD-9-CM code 410.X2)23 were sampled by state for an 8-month period between January 1994 and February 1996 (sampling was modified in Alabama, Connecticut, Iowa, Minnesota, and Wisconsin). Because we were interested in evaluating use of revascularization, we limited our analysis to patients who underwent cardiac catheterization within 60 days of hospital admission; therefore, we excluded 100,076 cases in which patients did not undergo cardiac catheterization, 34,187 cases for which Medicare Part A data (used to determine cardiac procedure use posthospitalization) were not available, and 23,773 readmissions. Of the 234,769 cases abstracted by CCP, 134,295 met one of the above-listed criteria, leaving 100,474 initial hospital admissions for patients who underwent cardiac catheterization. Cases were subsequently excluded if patients were < 65 years old (n = 9,678), were not hospitalized with a chart-confirmed myocardial infarction (n = 9,943), or had arrived by means of interhospital transfer (n = 19,500). We also excluded patients for whom American Hospital Association (n = 943) or 1990 US Census (n = 2,353) data were not available. Patients hospitalized outside of the 50 United States and the District of Columbia (n = 284), 20 patients whose race/ethnicity were unknown, and 65 patients whose mortality status was unknown at follow-up were similarly excluded. After excluding the 33,644 patients who met one or more of these criteria, 66,830 patients comprised the study cohort.

Coronary Revascularization
The principal outcome was the use of coronary revascularization within 60 days of hospital admission for an AMI, as determined by a notation in the patient’s medical record or a Medicare Part A bill listing ICD-9-CM procedure codes associated with PCI (codes 36.01, 36.02, and 36.05) or CABG (code 36.10).

Statistical Analysis
We evaluated male and female patients for differences in medical history, clinical presentation, comorbid conditions, physician, and hospital characteristics by means of {chi}2 and t test analyses. Crude rates of coronary revascularization were compared between men and women using {chi}2 analyses.

Logistic regression models were used to derive risk-standardized rates of coronary revascularization for men and women. Risk-standardized treatment rates represent treatment rates in men and women after adjusting for sex differences in sociodemographic characteristics, medical history and clinical presentation, physician characteristics, and hospital data. Patient sociodemographic characteristics included race and residential ZIP code measures of median household income, distribution of occupation types, and percentage of population with a high school education or higher as reported in the 1990 US Census.24 Patient medical history measures were drawn from previously identified predictors of coronary revascularization use and included age, left ventricular ejection fraction, prior myocardial infarction, congestive heart failure, smoking status, diabetes, cerebrovascular disease, prior revascularization, dementia, functional status, and the following characteristics ascertained at hospital admission: heart rate, Killip class, myocardial infarction location, renal dysfunction, Q-wave infarction, ST-segment elevation, anemia, and weight. Hospital data were obtained from the 1994 American Hospital Association Survey of Hospitals,25 and included level of cardiac-care facilities (none, catheterization laboratory, coronary bypass surgery suite), ownership (public, not for profit, for profit), myocardial infarction volume, rural location (location outside of a metropolitan statistical area), and US Census division. Analyses were also repeated separately for the constituent end points of CABG surgery and PCI and excluding primary PCIs (PCIs performed as a means of acute reperfusion therapy within 12 h of admission to the hospital).

Conditional logistic regression analyses were conducted to confirm that sex-associated variations in the use of revascularization were not attributable to hospital-specific variations in practice. We similarly examined possible confounding of the association of patient sex and revascularization use by center to ensure that sex differences in coronary revascularization were not attributable to the disproportionate treatment of women at centers that were less likely to provide revascularization. This was accomplished by "decomposing" the patient sex effect into a "between-hospital" effect (ie, the patient sex effect attributable to interhospital differences in patient sex composition) and a "within-hospital" effect (ie, the effect of patient sex within each hospital—or the "true" patient sex effect).26 Results were adjusted for clustering of patients by hospital using Huber-White robust estimates of SE.27 Odds ratios were converted to risk ratios (RRs) using the method outlined by Zhang and Yu.28 Statistical analyses were conducted using SAS 6.12 (SAS Institute; Cary, NC) and STATA 6.0 (Stata Corporation; College Station, TX). Use of the CCP database was approved by the Yale University School of Medicine Human Investigation Committee.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Patients were predominantly white (91.3%; mean age, 73 years), and more than half were men. Comorbid conditions including hypertension, diabetes, and prior myocardial infarction were common in the study population. Women were older, and a greater proportion were black and resided in lower-income ZIP codes compared with men. Hypertension, diabetes, and heart failure were more prevalent in women than men, but a smaller proportion of women had a prior myocardial infarction or had undergone prior cardiac procedures compared with men. Women and men did not substantially differ in the characteristics of their attending physician or hospital in which they were treated (Table 1 ).


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  		Table 1.. Patient Characteristics*

 
Crude rates of coronary revascularization were lower for women than men (65.2% vs 68.7%, p < 0.001) among patients who had undergone cardiac catheterization; however, sex differences in coronary revascularization rates were only due to lower rates of CABG use among women (26.6% vs 33.2%, p < 0.001), as women had higher crude rates of PCI than men (41.4% vs 38.5%, p < 0.001). Sex differences in rates of any coronary revascularization, CABG, and PCI were similar when stratified by race, indicating no race-sex interaction in the use of coronary revascularization (results not shown). Sex differences in overall use of coronary revascularization varied by age as women had lower rates of revascularization than men among patients < 85 years old, but underwent revascularization at a rate similar to men among patients >= 85 years old (p = 0.022 for interaction; Table 2 ).


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  		Table 2.. Patient Sex and Coronary Revascularization Rates

 
Women remained less likely than men to undergo coronary revascularization after multivariable adjustment for patient and hospital characteristics (RR, 0.97; 95% confidence interval [CI], 0.94 to 0.99). Differences by type of revascularization therapy also persisted, as women were less likely to undergo CABG (RR, 0.77; 95% CI, 0.73 to 0.81), but more likely to undergo PCI (RR, 1.16; 95% CI, 1.11 to 1.19) than men (Table 3 ).


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  		Table 3.. Patient Sex and Likelihood of Coronary Revascularization*

 
Risk-standardized rates of coronary revascularization were lower for women than men (66.0% vs 68.1%, p = 0.001); however, the size of the sex difference in revascularization rates was reduced from 3.5% in crude analysis to 2.1% when comparing risk-standardized procedure rates. Men and women’s risk-standardized rates of coronary revascularization were statistically comparable among all patients except those aged 70 to 74 years (66.5% women vs 70.0% men, p = 0.003). Sex differences in the use of CABG were similarly reduced in magnitude after multivariable adjustment, but women remained less likely to undergo CABG than men (27.0% vs 32.9%, p < 0.001). In contrast, women were still more likely to undergo PCI (42.0% vs 38.2%) than men, particularly among patients > 85 years old (45.8% vs 38.9%, p = 0.011) [Table 2 ].

Findings were unchanged when analyses were repeated using conditional logistic regression analysis, when modeling patient sex as a combination of effects due to between-hospital variation in patient sex (ie, confounding of patient sex by hospital) and within-hospital variation in patient sex (ie, the true patient sex effect), and when the end points of overall coronary revascularization and PCI use were assessed excluding primary PCIs (results not shown).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Our evaluation of elderly patients hospitalized for AMI who underwent cardiac catheterization indicates women have lower crude rates of coronary revascularization than men. Sex differences in the use of coronary revascularization were partially attenuated by accounting for sex differences in patient comorbidities and other clinical characteristics. Sex-associated differences in coronary revascularization use that persisted after multivariable adjustment varied by type of revascularization therapy. Although women were less likely than men to undergo CABG surgery, they were more likely to undergo PCI. These data, drawn from a large, population-based cohort of patients who were >= 65 years old, indicate that sex-associated differences in the use of coronary revascularization after AMI are modest in size and vary by type of revascularization therapy.

Sex differences in rates of coronary revascularization by type of therapy may be appropriate. Women hospitalized for acute coronary syndromes are less likely to have defined coronary disease or multivessel coronary disease than men, and thus may be better candidates for PCI compared with CABG surgery.14 29 Independent of the distribution of coronary disease, sex differences in the size of coronary arteries may lead physicians to believe that women are either less suited for surgical revascularization than men or more appropriate for revascularization by PCI than CABG surgery.30 Alternatively, physicians may refer fewer women for CABG surgery because of higher crude rates of short-term mortality and increased complication rates among women undergoing bypass surgery31 32 33 34 and lower rates of repeat revascularization in women undergoing PCI compared with CABG.35

Although sex is associated with the type of revascularization therapy patients undergo, women had somewhat lower rates of coronary revascularization compared with men, a finding consistent with previous reports.1 2 3 4 5 6 The cause of this relatively modest difference is not known. Women report different cardiac symptoms than men,36 37 38 even at the time of angiography,39 and these differences in presentation may complicate decision making in the absence of definitive evidence of ischemia, reinfarction, or unequivocal angiographic findings. Without definitive evidence of ischemia, physicians may use a different threshold for women when interpreting equivocal angiographic data given that women are less likely to have evidence of coronary disease, and less severe disease, than men.7 29 30 40 Although we accounted for the older age and greater comorbidity burden of female patients in our multivariable analyses, physicians may make broader age or comorbidity-associated assumptions that coronary revascularization will be less effective in women, even after viewing angiographic data. Women may also have coronary disease less suitable for coronary revascularization or be less likely to be considered appropriate candidates for coronary intervention.20 Finally, women may also undergo coronary revascularization less often because of lower rates of supplemental insurance,41 access to fewer economic resources, less social support,42 higher rates of medical therapy, or other patient preferences,43 including treatment refusal.44

One interesting facet of our study is its implications for the "Yentl syndrome" or hypothesis that sex differences in treatment are mitigated once women manifest disease "like a man."45 In the case of coronary revascularization, prior studies15 17 46 suggested sex differences in procedure use after AMI were an artifact of sex differences in initial cardiac catheterization use, and thus disappeared when sex differences in cardiac catheterization rates were considered. This pattern was interpreted as evidence of the Yentl syndrome; however, our study indicates there are sex differences in rates of coronary revascularization even among patients with an AMI who have undergone cardiac catheterization. Although part of this difference is attributable to sex differences in clinical characteristics, overall rates of coronary revascularization remain somewhat lower for women. Sex differences in treatment at different stages of coronary disease evaluation have been documented in different settings,6 47 48 suggesting that sex may continue to influence treatment decisions (appropriately or otherwise) even when successive disease burden thresholds have been crossed. Additional research is needed to better illuminate the validity of the Yentl syndrome and the clinical implications and appropriateness of sex differences in treatment at different stages of coronary disease management.

This study has certain methodologic issues to consider. In the absence of angiographic findings and a definitive standard of appropriateness for coronary revascularization, it is unclear whether sex differences in coronary revascularization use and choice of revascularization therapy reflect undertreatment, appropriate use, or overtreatment. Despite the absence of angiographic data, clinical characteristics explained much of the sex difference in coronary revascularization use in our cohort, contrary to the findings of Ghali and colleagues.20 Further, prior studies48 49 of patients undergoing CABG surgery have found that female patients generally present with more advanced coronary disease than male patients, implying undertreatment of women relative to men. In addition, we are unable to determine whether sex differences in use of CABG surgery reflect referral decisions made by cardiologists or treatment decisions made by cardiac surgeons. Our data were drawn from a cohort of elderly fee-for-service Medicare beneficiaries with an AMI and may not be applicable to younger patients, patients who undergo coronary revascularization prior to an AMI, or patients enrolled in Medicare managed-care plans. Our data reflect coronary revascularization practice patterns in the mid-1990s, and thus may not necessarily reflect current PCI or CABG surgery practices; however, our findings underscore the importance of considering detailed clinical characteristics and the need to consider type of therapy when evaluating sex differences in coronary revascularization.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Our evaluation of a large, clinically detailed data set drawn from a population-based cohort of Medicare beneficiaries hospitalized for AMI who underwent cardiac catheterization indicates that women are less likely to undergo coronary revascularization after AMI than men. Sex differences in the use of coronary revascularization, however, are mostly ameliorated after accounting for sex differences in clinical characteristics. Sex differences in coronary revascularization that persist after multivariable adjustment are solely due to lower rates of CABG surgery, as women are more likely to undergo PCI than men. Additional research is needed to determine whether sex differences in the use of revascularization among elderly patients with myocardial infarction are appropriate to optimize patient outcomes.


   Footnotes
 
Abbreviations: AMI = acute myocardial infarction; CABG = coronary artery bypass graft; CCP = Cooperative Cardiovascular Project; CI = confidence interval; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; PCI = percutaneous coronary intervention; RR = risk ratio

The analyses on which this publication is based were performed under Contract No. 500-99-CT01, entitled, "Utilization and Quality Control Peer Review Organization for the State of Connecticut," sponsored by the Centers for Medicare & Medicaid Services, United States Department of Health and Human Services. The contents of this publication do not necessarily reflect the views or policies of the United States Department of Health and Human Services, nor does mention of trade names, commercial products, or organization imply endorsement by the United States Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributors to the authors concerning experience in engaging with issues presented are welcomed.

Analyses conducted at the Yale University School of Medicine.

Received for publication January 24, 2003. Accepted for publication April 11, 2003.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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