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Ethnic variations in female vulnerability after an acute coronary event
  1. K H Mak1,
  2. J D Kark2,
  3. K S Chia3,
  4. L L Sim1,
  5. B H Foong4,
  6. Z P Ding1,
  7. R Kam1,
  8. S K Chew4
  1. 1Department of Cardiology, National Heart Centre, Singapore
  2. 2Epidemiology Unit, Hebrew University-Hadassah School of Public Health and Community Medicine, Jerusalem, Israel
  3. 3Department of Community, Family and Occupational Medicine, National University of Singapore
  4. 4Division of Epidemiology and Disease Control, Ministry of Health, Singapore
  1. Correspondence to:
    Dr K H Mak
    Department of Cardiology, National Heart Centre, 17 Third Hospital Avenue, Singapore 168752;


Objective: To determine the ethnic variation of short and long term female vulnerability after an acute coronary event in a population of Chinese, Indians, and Malays.

Design: Population based registry.

Patients: Residents of Singapore between the ages of 20–64 years with coronary events. Case identification and classification procedures were modified from the MONICA (monitoring trends and determinants in cardiovascular disease) project.

Main outcome measures: Adjusted 28 day case fatality and long term mortality.

Results: From 1991 to 1999, there were 16 320 acute coronary events, including 3497 women. Age adjusted 28 day case fatality was greater in women (51.5% v 38.6%, p < 0.001), with a larger sex difference evident among younger Malay patients. This inequality between the sexes was observed in both the pre-hospitalisation and post-admission periods. Among hospitalised patients, women were older, were less likely to have suffered from a previous Q wave or anterior wall myocardial infarction, and had lower peak creatine kinase concentrations. Case fatality was higher among women, with adjusted hazard ratios of 1.64 (95% confidence interval (CI) 1.43 to 1.88) and 1.50 (95% CI 1.37 to 1.64) for 28 day and mean four year follow up periods. There were significant interactions of sex and age with ethnic group (p  =  0.017). The adjusted hazards for mortality among Chinese, Indian, and Malay women versus men were 1.30, 1.71, and 1.96, respectively. The excess mortality among women diminished with age.

Conclusion: In this multiethnic population, both pre-hospitalisation and post-admission case fatality rates were substantially higher among women. The sex discrepancy in long term mortality was greatest among Malays and in the younger age groups.

  • case fatality rate
  • epidemiology
  • ethnic variations
  • sex gap
  • registries
  • CI, confidence interval
  • MI, myocardial infarction
  • MONICA, monitoring trends and determinants in cardiovascular disease
  • NRMI-2, National Registry of Myocardial Infarction 2
  • SMIR, Singapore Myocardial Infarction Register

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