Increased Mortality among Middle-Aged Women after Myocardial Infarction: Searching for Mechanisms and Solutions

• Myocardial infarction
• Sex factors
• Age factors
• Hospitalization
• Outcome and process assessment (health care)

Public and professional recognition of the prevalence and clinical impact of coronary heart disease in women has risen over the past decade, fueled in part by studies showing disparities in the use of cardiac procedures between women and men (1-4). Reacting to the previously established view of coronary heart disease as primarily a male malady (5), researchers and clinicians have increased their attention to the mechanisms, treatment, and consequences of this condition in women. Some hospitals have developed new clinical programs specifically for women with heart disease. Recent evidence has suggested that sex disparities in treatment of myocardial infarction have diminished, at least among elderly patients (6, 7).

Amid growing efforts to understand and improve the treatment of heart disease in women, Vaccarino and colleagues (8) provide sobering evidence in this issue regarding the adverse long-term consequences of acute myocardial infarction in middle-aged women. Using observational data from the Worcester Heart Attack Study, the authors analyzed a community-based cohort of nearly 7000 patients discharged alive from 16 hospitals in central Massachusetts between 1975 and 1995. Building on their previous work, which showed greater in-hospital mortality after myocardial infarction in women than in men before age 75 (9), their study in this issue has demonstrated a similar interaction between age and sex that affected 2-year mortality among patients who were discharged alive after an acute myocardial infarction.

By carefully delineating the influences of age and sex on mortality, their study has exemplified two central concepts in clinical epidemiology: confounding and effect modification. Confounding was illustrated by the finding that …