Gender differences in presentation, management, and cardiac event-free survival in patients with syncope.

In a MEDLINE search of published English studies (1966 to 1996), no prior study was identified that examined gender-based differences in the management and prognosis of patients admitted with syncope. We studied 109 consecutive patients (48 women) admitted with syncope at the Massachusetts General Hospital (1989 to 1990). All patients underwent Holter monitoring, signal-averaged electrocardiography, and echocardiography according to study protocol. Follow-up was 100% complete (10 +/- 4 months). Women were older (74 +/- 2 vs 66 +/- 2 years, p <0.01) and less likely to have premonitory symptoms when compared with men (46% vs 66%, p <0.05). A greater proportion of men had left ventricular ejection fractions of <0.40 (18% vs 0%, p <0.01), abnormal signal-averaged electrocardiograms (28% vs 8%, p <0.01), and a cardiac cause for syncope (49% vs 25%, p <0.01). Although referral for diagnostic electrophysiologic testing was >3 times as frequent for men compared with women (20% of men vs 6% of women, p <0.05), this difference was not significant after adjustment for age, ventricular arrhythmia, and referral for coronary angiography. During follow-up, 21% of men versus 6% of women (p <0.05) had cardiac events (recurrent syncope, myocardial infarction, or sudden death). Cardiac event-free survival rates were worse for men (p = 0.045). Thus, we have identified gender-based differences in the clinical presentation of syncope for hospital admission. Left ventricular dysfunction and an abnormal signal-averaged electrocardiogram occur more frequently in men. Men are more likely to have cardiac syncope and worse cardiac event-free survival when compared with women.

Geriatric patients with acute myocardial infarction: Cardiac risk factor profiles, presentation, thrombolysis, coronary interventions, and prognosis.

Elderly patients have a higher mortality after acute myocardial infarction (MI) yet are treated less aggressively than younger patients. To determine (l) the risk-factor profiles, (2) presentation, (3) management, and (4) hospital outcomes for the elderly (> or = 75 years) compared with middle aged (66 to 74 years) and younger (< or = 65 years) patients in the 1990s, we studied 561 consecutive patients with acute MI. Compared with younger patients, the elderly more frequently had congestive heart failure (40 percent vs 14 percent; p < 0.00001) and non-Q wave infarctions (76 percent vs 56 percent; p < 0.005), received thrombolysis (9 percent vs 34 percent; p < 0.0001), and underwent catheterization (35 percent vs 73 percent; p < 0.00001), percutaneous transluminal coronary angioplasty (9 percent vs 31 percent; p < 0.0002), and coronary artery bypass grafting (5 percent vs 15 percent; p < 0.03) less frequently. Those who did not receive thrombolysis all had contraindications. Mortality was higher in the elderly (19 percent vs 5 percent; p < 0.004), especially among those who did not receive thrombolysis (20 percent vs 7 percent; p < 0.03). Multivariate predictors of mortality included age, and congestive heart failure. In addition, when clinical course and management variables were considered, use of the intraaortic balloon pump was a predictor of mortality, whereas undergoing coronary angiography was a negative predictor (relative risk, 0.3; 95 percent confidence intervals, 0.1 to 0.6).

Do gender-based differences in presentation and management influence predictors of hospitalization costs and length of stay after an acute myocardial infarction?

Previous studies have reported conflicting results on gender differences in the management of acute myocardial infarction (AMI) and have not evaluated hospital length of stay or costs. To determine gender-based differences in presentation, management, length of stay, costs, and prognosis after AMI, we studied 561 patients with AMI. Women were older, had systemic hypertension, diabetes mellitus, and a non-Q-wave AMI more frequently, whereas more men smoked cigarettes. Predictors of coronary angiography were: male gender (RR 1.9; 95% CI 1.2 to 3.1), chest pain at presentation (RR 1.8; 95% CI 1.0 to 3.3), recurrent angina (RR 4.1; 95% CI 2.5 to 6.8), admission via the emergency room (RR 0.2; 95% CI 0.1 to 0.3), and younger age. Gender did not predict mortality. Among presenting features, the predictors of length of stay were diabetes, prior coronary bypass and prior coronary angioplasty in men, and age alone in women. Pulmonary edema and need for coronary bypass during the hospital course were predictors of length of stay in men only. Among presenting features, predictors of cost were diabetes in men and congestive heart failure in women. Predictors of cost during hospitalization for men were pulmonary edema, coronary angiography, intraaortic balloon pump use, and coronary bypass; for women, they were peak levels of creatine kinase and coronary bypass. Thus, predictors of length of stay and hospitalization costs differ based on gender. Efforts at cost containment may need to be gender-specific.