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Biology and bias: do we have the will to improve cardiovascular disease outcomes for women?
  1. Janet Wei1,
  2. Timothy D Henry2,
  3. C Noel Bairey Merz1
  1. 1 Barbara Streisand Women’s Heart Center, Cedars-Sinai Smdit Heart Institute, Los Angeles, California, USA
  2. 2 Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
  1. Correspondence to Dr C Noel Bairey Merz, Barbara Streisand Women’s Heart Center, Smidt Cedars-Sinai Heart Institute, Los Angeles CA 90048, USA; Noel.BaireyMerz{at}

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Sex differences in acute myocardial infarction (AMI): biology and bias

Women with AMI have higher mortality than men with AMI, but multiple factors contribute to this sex difference, including biological variables related to sex such as older age at presentation and increased cardiovascular risk profile, as well as gender bias including disparities in reperfusion time and AMI treatment in women. Notably, the largest sex discrepancy in AMI survival is among young women <65 years when compared with similarly aged men1; younger women are the only group with rising cardiovascular disease (CVD) death rates compared with declines in all others.2 3 Understanding both biological sex differences and gender bias in AMI treatment is essential to improve CVD outcomes for all.

New findings

A new report4 using the recently developed and validated European Society of Cardiology Acute Cardiovascular Care Association (ACCA) Quality Indicators (QIs) for AMI offers insight into improving outcomes for women. These investigators found that women in England and Wales less frequently received guideline-indicated AMI care and had significantly higher mortality than men. Specifically, among 691 290 patients in the UK Myocardial Ischaemia National Audit Project, women less likely received timely reperfusion therapy for ST-Elevation Myocardial Infarction (STEMI), coronary angiography for Non-ST-elevation Myocardial Infarction (NSTEMI), dual antiplatelet therapy and secondary prevention therapies. Notably, this suboptimal care existed despite a more adverse biological 30-day Global Registry of Acute Coronary Events (GRACE) risk score adjusted mortality in women compared with men. The authors estimated that 8243 deaths in women were potentially preventable had care been equal between sexes.

Why is AMI care unequal? Biology drives bias

Biological sex differences in AMI likely drive differences in administration of and response to guidelines-based therapy. For example, compared with men, women are less likely to have a culprit lesion identified at the time of angiography and more likely to …

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