title: Paradoxical lower postmyocardial infarction mortality among veteran women--does a sex bias exist in the Veterans Affairs medical system?
abstract: BACKGROUND
  Outcomes after acute coronary disease are reportedly worse among women in general and more so among women with diabetes compared with men. Sex differences were evaluated in postmyocardial infarction (MI) mortality among veterans (who are predominantly male) to determine whether evaluation and treatment in Veterans Affairs hospitals amplifies sex differences in outcome.
  
  
  METHODS
  All patients discharged with the primary diagnosis of acute MI from any Veterans hospitals in the United States between October 1990 and September 1997 were identified. Demographic, comorbidity, inpatient, outpatient, mortality and readmission data were extracted. Mortality, revascularization and readmissions were compared between male and female patients using Cox regression models.
  
  
  RESULTS
  The authors identified 67,889 patients with MI, 17,756 (26%) of whom had diabetes. There were 951 women, 280 (29%) of whom had diabetes, and 66,938 men, 17,476 (26%) of whom had diabetes. Over the entire follow-up period, adjusted mortality was higher in men than women (hazard ratio [HR] 1.5, 95% CI 1.3 to 1.7). Cardiac procedures were significantly higher among men: HR for coronary bypass surgery was 2.1 (95% CI 1.6 to 2.8; P<0.001) for all men, while HR for catheterization and percutaneous coronary intervention were higher for men among nondiabetics only--1.5 (95% CI 1.2 to 1.8; P<0.001) and 2.0 (95% CI 1.4 to 2.9; P<0.001). Interaction between sex and diabetes was not significant.
  
  
  CONCLUSIONS
  Contrary to previous observations in the nonveteran population, long-term mortality post-MI was lower among veteran women, despite higher procedure rates in men. The present study also failed to show increased mortality in women with diabetes.
authors.affiliation: Indiana University School of Medicine, Indianapolis, USA.
authors.forename: Masoor
authors.initials: M
authors.lastname: Kamalesh
authors.forename: Usha
authors.initials: U
authors.lastname: Subramanian
authors.forename: Anahita
authors.initials: A
authors.lastname: Ariana
authors.forename: George J
authors.initials: GJ
authors.lastname: Eckert
authors.forename: Stephen
authors.initials: S
authors.lastname: Sawada
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003920:Diabetes Mellitus / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality*; D010359:Patient Readmission / Q000706:statistics & numerical data; D012737:Sex Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000706:statistics & numerical data*
references.citation: Circulation. 2004 Feb 10;109(5):558-60
references.pmid: 14769673
references.citation: Circulation. 2002 May 7;105(18):2231-9
references.pmid: 11994261
references.citation: Circulation. 1996 Mar 15;93(6):1170-6
references.pmid: 8653838
references.citation: J Gen Intern Med. 2002 Aug;17(8):604-11
references.pmid: 12213141
references.citation: Circulation. 2003 Sep 2;108(9):1041-3
references.pmid: 12952825
references.citation: JAMA. 1988 Dec 16;260(23):3456-60
references.pmid: 2974889
references.citation: J Am Coll Cardiol. 1993 Dec;22(7):1788-94
references.pmid: 8245329
references.citation: Lancet. 2002 Jun 22;359(9324):2140-4
references.pmid: 12090978
references.citation: Am J Med. 1996 Sep 30;101(3A):10S-21S
references.pmid: 8876471
references.citation: N Engl J Med. 2000 Dec 28;343(26):1934-41
references.pmid: 11136265
references.citation: N Engl J Med. 1997 May 22;336(21):1500-5
references.pmid: 9154770
references.citation: Circulation. 1999 Mar 9;99(9):1165-72
references.pmid: 10069784
references.citation: JAMA. 1999 Apr 14;281(14):1291-7
references.pmid: 10208144
references.citation: Med Care. 1999 Jun;37(6):529-37
references.pmid: 10386565
references.citation: Diabetes Care. 1998 Jan;21(1):69-75
references.pmid: 9538972
references.citation: JAMA. 1991 Feb 6;265(5):627-31
references.pmid: 1987413
references.citation: Int J Epidemiol. 1996 Oct;25(5):948-52
references.pmid: 8921479
references.citation: JAMA. 1994 Apr 20;271(15):1175-80
references.pmid: 8151875
references.citation: Arch Intern Med. 1996 Mar 11;156(5):505-9
references.pmid: 8604956
references.citation: Am J Health Promot. 2001 Jan-Feb;15(3):149-66
references.pmid: 11265579
references.citation: Med Care. 1992 May;30(5):377-91
references.pmid: 1583916
references.citation: Arch Intern Med. 2003 Jul 28;163(14):1735-40
references.pmid: 12885690
references.citation: Am J Epidemiol. 1995 Feb 1;141(3):242-50
references.pmid: 7840098
references.citation: Diabetes Care. 1998 Sep;21(9):1414-31
references.pmid: 9727886