title: Impact of the joint association between sex, age and diabetes on long-term mortality after acute myocardial infarction.
abstract: BACKGROUND
  The role of sex, and its joint effect with age and diabetes mellitus, on mortality subsequent to surviving an acute myocardial infarction (AMI) beyond 30 days are unclear. The high prevalence of diabetes mellitus in an ethnically diverse Asian population motivates this study.
  
  
  METHODS
  The study population comprised of a nationwide cohort of Asian patients with AMI, hospitalized between 2000 to 2005, who survived the first 30 days post-admission and were followed prospectively until death or 12 years.
  
  
  RESULTS
  Among the 13,389 survivors, there were fewer women (25.5%) who were older than men (median 70 vs. 58 years) and a larger proportion had diabetes mellitus at admission (51.4% vs. 31.4%). During follow-up 4,707 deaths (women 13.2%; men 22.0%) occurred, with women experiencing higher mortality than men with an averaged hazard ratio (HR): 2.08; 95% confidence interval : 1.96-2.20. However the actual adverse outcome, although always greater, reduced over time with an estimated HR: 2.23 (2.04-2.45) at 30 days to HR: 1.75; (1.47-2.09) 12 years later. The difference in mortality also declined with increasing age: HR 1.80 (1.52-2.13) for those aged 22-59, 1.26 (1.11-1.42) for 60-69, 1.06 (0.96-1.17) and 0.96 (0.85-1.09) for those 70-79 and 80-101 years. Significant two-factor interactions were observed between sex, age and diabetes (P < 0.001). Diabetic women <60 years of age had greater mortality than diabetic men of the same age (adjusted HR: 1.44; 1.14-1.84; P = 0.003), while diabetic women and men ≥60 years of age had a less pronounced mortality difference (adjusted HR: 1.12; 0.99-1.26).
  
  
  CONCLUSIONS
  One in two women hospitalized for AMI in this Asian cohort had diabetes and the sex disparity in post-MI mortality was most pronounced among these who were <60 years of age. This underscores the need for better secondary prevention in this high-risk group.
authors.affiliation: National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore. gao.fei@nhcs.com.sg.|Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857, Singapore. gao.fei@nhcs.com.sg.
authors.forename: Fei
authors.initials: F
authors.lastname: Gao
authors.affiliation: National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore. carolyn_lam@nuhs.edu.sg.
authors.forename: Carolyn Su Ping
authors.initials: CS
authors.lastname: Lam
authors.affiliation: National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore. sim.ling.ling@nhcs.com.sg.
authors.forename: Ling Ling
authors.initials: LL
authors.lastname: Sim
authors.affiliation: National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore. koh.tian.hai@nhcs.com.sg.
authors.forename: Tian Hai
authors.initials: TH
authors.lastname: Koh
authors.affiliation: Cardiac Department, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. david_foo@ttsh.com.sg.
authors.forename: David
authors.initials: D
authors.lastname: Foo
authors.affiliation: Khoo Teck Puat Hospital, 378 Alexandra Road, Singapore, 159964, Singapore. ong.hean.yee@alexandrahealth.com.sg.
authors.forename: Hean Yee
authors.initials: HY
authors.lastname: Ong
authors.affiliation: Changi General Hospital, Simei Street 3, Singapore, 529889, Singapore. khim_leng_tong@cgh.com.sg.
authors.forename: Khim Leng
authors.initials: KL
authors.lastname: Tong
authors.affiliation: National University Heart Centre Singapore, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore. huay_cheem_tan@nuhs.edu.sg.
authors.forename: Huay Cheem
authors.initials: HC
authors.lastname: Tan
authors.affiliation: Medical Statistics Group, School of Health and Related Sciences, University of Sheffield, Regents Court, 30 Regent Street, Sheffield, S1 4DA, UK. dm113@leicester.ac.uk.|Department of Cancer Studies and Molecular Medicine, Clinical Sciences Building, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 7LX, UK. dm113@leicester.ac.uk.
authors.forename: David
authors.initials: D
authors.lastname: Machin
authors.affiliation: Singapore General Hospital, 1 Hospital Drive, Singapore, 169608, Singapore. wong.kok.seng@sgh.com.sg.
authors.forename: Kok Seng
authors.initials: KS
authors.lastname: Wong
authors.affiliation: National University Heart Centre Singapore, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore. mark_chan@nuhs.edu.sg.
authors.forename: Mark Yan Yee
authors.initials: MY
authors.lastname: Chan
authors.affiliation: National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore. terrance.chua.s.j@nhcs.com.sg.
authors.forename: Terrance Siang Jin
authors.initials: TS
authors.lastname: Chua
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D044466:Asian People; D003920:Diabetes Mellitus / Q000453:epidemiology*; D005260:Female; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000401:mortality*; D015995:Prevalence; D012737:Sex Factors; D013997:Time Factors