title: Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting.
abstract: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.
  
  
  
  Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.
  
  
  
  Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.
  
  
  
  Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.
authors.affiliation: School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Fitzroy, Victoria, 3065, Australia. George.Mnatzaganian@acu.edu.au.
authors.forename: George
authors.initials: G
authors.lastname: Mnatzaganian
authors.affiliation: Department of Medicine, The University of Melbourne, Parkville, Victoria, 3010, Australia.|Department of Emergency Medicine, Royal Melbourne Hospital, Parkville, Victoria, 3010, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Braitberg
authors.affiliation: School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, 3122, Australia.|Discipline of Public Health, School of Population Health, The University of Adelaide, Adelaide, South Australia, 5000, Australia.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Hiller
authors.affiliation: School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, Victoria, 3220, Australia.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kuhn
authors.affiliation: School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, 6102, Australia.
authors.forename: Rose
authors.initials: R
authors.lastname: Chapman
mesh_terms: D000328:Adult; D000368:Aged; D003325:Coronary Care Units / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000628:therapy; D010343:Patient Admission; D012189:Retrospective Studies; D012307:Risk Factors; D017678:Sex Distribution; D012737:Sex Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014218:Triage; D014739:Victoria / Q000453:epidemiology
keywords: Attributable risk; Hospital setting; In-hospital mortality; Myocardial infarction; Sex disparity