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Original research article
Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study
  1. Chris Wilkinson1,
  2. Owen Bebb1,
  3. Tatendashe B Dondo1,
  4. Theresa Munyombwe1,
  5. Barbara Casadei2,3,
  6. Sarah Clarke4,
  7. François Schiele5,
  8. Adam Timmis6,
  9. Marlous Hall1,
  10. Chris P Gale1
  1. 1 Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  2. 2 Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, UK
  3. 3 NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4 Royal Papworth Hospital, Cambridge, UK
  5. 5 Department of Cardiology, University Hospital Jean Minjoz, Besancon, France
  6. 6 NIHR Cardiovascular Biomedical Research Unit, Barts Health Centre London, London, UK
  1. Correspondence to Professor Chris P Gale, Department of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK; c.p.gale{at}


Aim To investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.

Methods Nationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.

Results There were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3–84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9–77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%–13.1%) vs 2.3% (IQR 0.8%–7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.

Conclusion According to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap.

  • coronary artery disease
  • acute myocardial infarction
  • epidemiology
  • quality and outcomes of care
  • healthcare delivery

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  • Contributors Study conception: CPG. Study design, analysis and drafting: CPG, OJB, CW and TBD. All authors contributed to interpretation of data and critical revision of the content of the work.

  • Funding TBD and MH were funded by the British Heart Foundation (project grant PG/13/81/30474) as a research assistant and research fellow, respectively. MH is currently funded by the Wellcome Trust as a Sir Henry Wellcome Postdoctoral Fellow (206470/Z/17/Z).

  • Competing interests AT declares travel expenses from Novo Nordisk outside the submitted work. FS participated in board and symposium activities for Sanofi, Amgen, Pfizer, Bayer, Astra-Zeneka and MSD outside the submitted work. CPG declares travel expenses from Bayer, consultancy fees from AstraZeneca, Novartis and Vifor Pharma, and speaker bureau honoraria from AstraZeneca , all outside the submitted work. OJB, BC, SC, TBD, CPG, MH, TM and CW have nothing to disclose.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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