Background
Previous studies have shown that women with acute coronary syndrome (ACS) are less likely to receive in-hospital care such as revascularisation procedures and secondary prevention medications. Therefore, the aim was to determine if the rate of secondary preventive care and outcomes also differ by sex in patients with ACS at 6 and 12 months after discharge.
Methods
Of ACS patients recruited from 43 hospitals between 2009 to 2018, 9,283 were discharged alive and followed up at 6 months as part of the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) registry. Multivariable logistic regression models within the framework of generalised estimating equations were used to compare the rate of medication use, smoking, cardiac rehabilitation participation, major adverse cardiovascular event (MACE: myocardial infarction, heart failure or stroke) and all-cause death at 6 and 12 months after discharge between female and male patients.
Results
Of 9,283 ACS patients, 2,676 (29%) were women. At 6-month post discharge, women were more likely to have comorbidities than men. After adjusting for clinical characteristics, women had lower odds of attending cardiac rehabilitation than men (OR [95% CI]: 0.87 [0.78, 0.98]) and no sex difference in the odds of using ≥75% of the indicated medications or smoking. Women had higher odds of having a MACE compared to men (1.35 [1.03, 1.77]) but there was no difference for all-cause death between women and men. Moreover, at 12 months after discharge, women were less likely to be on ≥75% of the indicated medications (0.84 [0.75, 0.95]) but no difference was found in the odds of smoking, MACE and all-cause death.
Conclusion
Our findings from a large contemporary Australian registry dataset suggest that women attend cardiac rehabilitation programs less often and are more likely to have a MACE at 6 months of surviving ACS. At 12 months post discharge, women were less likely to use the indicated secondary prevention medications. Development of effective secondary prevention methods tailored to women are needed.
Keywords
Introduction
Ischaemic heart disease is the leading cause of death globally [
[1]
]. In 2016, 9.4 million deaths were due to ischaemic heart disease, where 47% of these were women [[1]
]. Acute coronary syndromes (ACS) form a large subset of ischaemic heart disease and include ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA) [[2]
]. The rate of repeat events is considerably high for people with ACS. In Australia, a report from 2011 has estimated between 29% and 43% of total ACS events to be repeat events [[3]
]. A recent systematic review of the Australian literature from 2000 to 2016 reported that the readmission rate for acute myocardial infarction was 13–17% [[4]
]. In Canada, a large, multicentre (six centres) registry found that 33% of ACS patients who survived to discharge were readmitted for a cardiac reason [[5]
]. A large number of these repeat events can be prevented by following the recommended guidelines for secondary prevention. A combination of adherence to cardioprotective medication, lifestyle modification to minimise risk factors, including smoking cessation and being active, and attending cardiac rehabilitation programs are important in decreasing the likelihood of secondary events [[6]
].In recent years, substantial evidence has suggested that sex disparity exists in ACS and cardiovascular disease management. Past studies have found that women presenting to hospital with ACS had more comorbidities, yet were less likely to undergo coronary angiography or revascularisation [
7
, 8
, 9
]. At discharge, women were less likely to be prescribed the recommended secondary prevention medications [10
, 11
, 12
, 13
] and given fewer referrals to cardiac rehabilitation [14
, 15
, 16
]. Furthermore, among people with a history of coronary heart disease or cardiovascular disease, studies have also found poorer risk factor assessment for secondary prevention for female patients, especially young women, than their male counterparts in general practices [- Redfern J.
- Hyun K.
- Chew D.P.
- Astley C.
- Chow C.
- Aliprandi-Costa B.
- et al.
Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand.
Heart (British Cardiac Society). 2014; 100: 1281-1288
[15]
,[17]
]. These findings raise questions regarding how well women are supported in obtaining and adhering to the guideline-recommended secondary prevention care. The objective of this study was to explore whether sex differences exist in adherence to secondary preventive care and its effect on clinical events for those who have survived ACS.Methods
Study Design and Data
For this study, data from the Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) registry were used [
[18]
]. CONCORDANCE is a prospective, observational study that provides continuous real-time reporting on the clinical characteristics, management and outcomes of patients admitted to Australian public hospitals with ACS. Patients aged 18 years or older, who presented to a hospital with symptoms of an ACS together with significant electrocardiographic changes, elevated cardiac enzyme levels, or newly documented coronary heart disease were recruited from 2009 to 2018 from 43 public hospitals nationwide. The 43 hospitals are representative of regional and metropolitan acute care facilities, with a range of clinical and treatment characteristics, procedural services and hospital systems. The study was approved by the Sydney Local Health District Concord Human Research Ethics Committee (CH62/6/2008-141), and opt-out consent granted.Data were collected from medical records and entered into a web-based electronic case report form. The data collected included details of pre-hospital assessment and management, medical history, demographics, in-hospital investigations and management, and in-hospital morbidity and mortality. Patients were followed up at 6 and 12 months post discharge via mail, telephone, primary care provider and/or hospital database to collect data regarding the vital status, hospital admissions due to a clinical event, medication use and lifestyle factors such as risk factor measurements, cardiac rehabilitation attendance, dietary advice provided and the number of visits to a general practitioner. The clinical events data collected at 12 months were any new or repeat event that happened since the 6-month follow-up. All patients were followed up at 6 months, and 12-month follow-up was introduced to the patients who were enrolled in the registry from 2013.
Outcomes
The rates of secondary preventive care adherence and clinical events at 6 and 12 months post discharge were compared between women and men who had survived ACS. Secondary preventive care was assessed by evaluating how many subjects used ≥75% of the indicated secondary prevention medications (aspirin, second antiplatelet, statin, beta blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker), smoking status and cardiac rehabilitation participation. The method of defining the criteria for the use of ≥75% of the indicated secondary prevention medications for STEMI, NSTEMI and UA has been described previously [
[19]
]. Seventy-five per cent (75%) or more of the indicated medications could be four or five of five medications or three or four of four medications (if five were not indicated):- 1.Aspirin for all.
- 2.Lipid-lowering therapy for all.
- 3.Antiplatelet for all patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) or undergoing percutaneous coronary intervention. For patients with unstable angina, a second antiplatelet is generally indicated if the patient is aged >60 years, has had a previous myocardial infarction or undergone coronary artery bypass graft surgery, has multivessel coronary artery disease, previous stroke or transient ischaemic attack or peripheral vascular disease, or has chronic kidney disease. A second antiplatelet is not indicated for patients on a vitamin K antagonist or non-vitamin K oral anticoagulant unless the patient is not on aspirin.
- 4.Beta blocker for all patients unless they have heart block or unstable angina and their left ventricular function is normal.
- 5.Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for all patients unless they are allergic to the medication or have unstable angina and their left ventricular function is normal.
Cardiac rehabilitation participation was only collected at 6-months follow-up as the rehabilitation programs are generally offered during the first 6 months of discharge. The clinical outcomes were major adverse cardiovascular event (MACE: myocardial infarction, stroke or heart failure) and all-cause death at 6 months and between 6 and 12 months post discharge.
Statistical Analysis
Baseline demographic and clinical characteristics and the outcomes were compared between women and men. All analyses were corrected for the hospital clustering effect. For univariable comparison, Rao-Scott Chi-squared test was used for categorical variables. For normally distributed continuous variables, unadjusted linear regression model within the framework of generalised estimating equation (GEE) was used and for skewed continuous variables, Wilcoxon rank-sum test was used. For the adjusted analyses of the outcomes, the multivariable logistic regression model within the framework of GEE was used to estimate the adjusted odds ratios (ORs) and the corresponding 95% confidence intervals (CIs). The covariates included in the adjusted models were sex (women vs. men); the Global Registry of Acute Coronary Events (GRACE) risk score groups (≤84, 85–104, 105–126 and >126); current smoker (yes vs. no); ACS diagnosis (STEMI, NSTEMI vs. UA); at least one vessel disease (≥50% stenosis) found in angiogram (yes vs. no); and socioeconomic status (Index of Relative Socio-economic Disadvantage [IRSD] quintiles). Missing binary data regarding medical history, in-hospital investigations, medication prescriptions and clinical events were assumed not to have occurred if not recorded in the medical records. For the remaining missing data (i.e. other categorical and continuous variables) listwise deletion method, which is the method to exclude any observation with any single value included in the analysis missing.
Results
Of 10,745 patients with ACS enrolled in the CONCORDANCE registry, 9,283 (86%) were followed up at 6 months, of whom 29% were women. Of 5,333 patients who were eligible to be followed up at 12 months, 4,974 (93%) were followed up, of whom 29% were women. The characteristics of those who were and were not followed up were comparable, with the exception that followed patients were slightly older with a higher risk of myocardial infarction or death (i.e. higher GRACE risk scores) than those who were not (Appendices 1 and 2). Among those who were followed-up at 6 months post discharge, there were differences in baseline characteristics between women and men. Women were older (mean (standard deviation [SD]): 67.0 [13.7] years vs. 63.7 [12.6] years, p<0.001), had a higher risk of myocardial infarction or death at 6 months post discharge (median GRACE risk score (interquartile interval [IQI]): 108 [85, 130] vs. 103 [84, 124], p<0.001). Women were more likely to have a history of atrial fibrillation, hypertension and diabetes, however, were less likely to smoke and have a history of myocardial infarction and revascularisation compared to men (Table 1). In hospital, women were less likely to have documented coronary disease (i.e. at least one vessel disease with ≥50% stenosis found in angiogram) and present with STEMI but more likely to present with NSTEMI and UA than men.
Table 1Baseline characteristics, in-hospital management and outcomes.
| Variable | Level | Women n (%) n=2,676 | Men n (%) n=6,607 | Overall n (%) N=9,283 | P-value |
|---|---|---|---|---|---|
| Age (yr), mean (SD) | 67 (14) | 64 (13) | 65 (13) | <0.0001 | |
| Grace Risk Score (Fox), median (IQI) | 108 (85, 130) | 103 (84, 124) | 105 (84, 126) | <0.0001 | |
| Indigenous (Aboriginal/TSI) | 258 (10) | 384 (6) | 642 (7) | <0.0001 | |
| Prior myocardial infarction | 678 (25) | 2,024 (31) | 2,702 (29) | <0.0001 | |
| Prior heart failure | 196 (7) | 465 (7) | 661 (7) | 0.6717 | |
| Prior percutaneous coronary intervention | 461 (17) | 1,482 (22) | 1,943 (21) | <0.0001 | |
| Prior coronary artery bypass graft | 212 (8) | 840 (13) | 1,052 (11) | <0.0001 | |
| Chronic renal failure | 243 (9) | 526 (8) | 769 (8) | 0.1591 | |
| Prior stroke/transient ischaemic attack | 200 (7) | 436 (7) | 636 (7) | 0.0303 | |
| Diabetes | 847 (32) | 1,754 (27) | 2,601 (28) | 0.0026 | |
| Hypertension | 1,773 (66) | 3,970 (60) | 5,743 (62) | <0.0001 | |
| Dyslipidaemia | 1,485 (56) | 3,707 (56) | 5,192 (56) | 0.5559 | |
| Current smoker | 660 (25) | 1,903 (29) | 2,563 (28) | <0.0001 | |
| Peripheral arterial disease | 141 (5) | 383 (6) | 524 (6) | 0.3577 | |
| Body mass index (kg/m2), median (IQI) | 28 (24, 33) | 28 (25, 32) | 28 (25, 32) | 0.2393 | |
| Angiographically significant disease (≥1 VD) | 1,488 (71) | 5,035 (89) | 6,523 (84) | <0.0001 | |
| Diagnosis | STEMI | 664 (25) | 2,103 (32) | 2,767 (30) | <0.0001 |
| NSTEMI | 1,432 (54) | 3,261 (49) | 4,693 (51) | – | |
| UA | 580 (22) | 1,243 (19) | 1,823 (20) | – | |
| Discharge therapies | |||||
| Aspirin | 2,350 (88) | 6,134 (93) | 8,484 (91) | <0.0001 | |
| Second antiplatelet (clopidogrel/ticagrelor/prasugrel) | 1,768 (66) | 4,932 (75) | 6,700 (72) | <0.0001 | |
| Beta blocker | 1,953 (73) | 5,213 (79) | 7,166 (77) | <0.0001 | |
| ACE/ARB | 1,881 (70) | 4,847 (73) | 6,728 (72) | 0.0212 | |
| Statin/other lipid lowering therapy | 2,362 (88) | 6,211 (94) | 8,573 (92) | <0.0001 | |
| ≥75% of indicated medications | 2,505 (94) | 6,277 (95) | 8,782 (95) | 0.0025 | |
| Referral to cardiac rehabilitation | 1,599 (60) | 4,626 (70) | 6,225 (67) | <0.0001 | |
| Hospital procedures and complications | |||||
| Cardiac catheterisation | 2,094 (78) | 5,626 (85) | 7,720 (83) | <0.0001 | |
| Percutaneous coronary intervention | 996 (37) | 3,423 (52) | 4,419 (48) | <0.0001 | |
| Coronary artery bypass graft | 138 (5) | 701 (11) | 839 (9) | <0.0001 | |
| Renal failure | 109 (4) | 296 (5) | 405 (4) | 0.3304 | |
| Myocardial Infarction | 45 (2) | 124 (2) | 169 (2) | 0.4575 | |
| Stroke | 13 (0) | 22 (0) | 35 (0) | 0.3576 | |
| Major bleeding | 197 (7) | 431 (7) | 628 (7) | 0.1242 | |
| Congestive failure | 199 (8) | 465 (7) | 664 (7) | 0.4660 | |
| MACE (myocardial infarction/stroke/congestive failure) | 250 (10) | 588 (9) | 838 (9) | 0.4837 |
Denominator: ACS who were discharged alive and followed up at 6 months.
Abbreviations: SD, standard deviation; IQI, interquartile interval; TSI, Torres Strait Islander; ACE, angiotensin converting enzyme inhibitors; ARB, angiotensin-receptor blockers; MACE, major adverse cardiovascular disease; ACS, acute coronary syndrome.
Secondary Prevention and Outcomes at 6 Months Post Discharge
At 6 months post discharge, women were less likely to use secondary prevention care and more likely to have worse outcomes than men before adjustment (Table 2). The unadjusted results suggested that women were less likely to use ≥75% of the indicated secondary prevention medications (71% vs. 78%, p<0.001) and participate in cardiac rehabilitation (35% vs. 45%, p<0.001). However, there was no difference in the proportion of smokers between the sexes (13% vs. 14%, p=0.230). Further, women were more likely to visit a general practitioner (median [IQI]: 4 [2, 6] vs. 3 [2, 6], p<0001) but less likely to receive dietary advice (52% vs. 57%, p=0.032) than men. After adjusting for the baseline characteristics, the odds of women attending a cardiac rehabilitation program continued to be lower than men (OR [95% CI]: 0.87 [0.78, 0.98]), but the use of ≥75% of the indicated secondary prevention medications was no longer significant between the sexes (Table 2).
Table 2Unadjusted and adjusted comparison of outcomes at 6 months after discharge by gender.
| Outcome | Unadjusted | Adjusted | ||||
|---|---|---|---|---|---|---|
| Women n (%) n=2,517 | Men n (%) n=6,244 | Overall n (%) n=8,761 | P-value | Odds Ratio (95% CI) Women vs. Men | P-value | |
| ≥75% of indicated medications | 1,777 (71) | 4,852 (78) | 6,629 (76) | <0.0001 | 0.94 (0.85, 1.03) | 0.2008 |
| Current smokers | 308 (13) | 860 (14) | 1,168 (14) | 0.1127 | 0.94 (0.79, 1.13) | 0.5365 |
| Cardiac rehabilitation | 836 (35) | 2,670 (45) | 3,506 (42) | <0.0001 | 0.87 (0.78, 0.98) | 0.0310 |
| N=2,676 | N=6,607 | N=9,283 | ||||
| MACE | 191 (7) | 336 (5) | 527 (6) | 0.0002 | 1.35 (1.03, 1.77) | 0.0482 |
| All-cause death | 101 (4) | 192 (3) | 293 (3) | 0.0228 | 1.26 (0.93, 1.71) | 0.1411 |
Abbreviations: MACE, major adverse cardiovascular events; CI, confidence interval; ACS, acute coronary syndrome.
a Denominator: ACS who were discharged alive, followed up and alive at 6 months.
b Denominator: ACS who were discharged alive, followed up at 6 months.
Before adjustment, a greater proportion of women had MACE and all-cause death than men at 6 months (7% vs. 5%, p<0.001 and 4% vs. 3%, p=0.023, respectively) (Table 2). The significant difference in the odds of MACE remained after adjustment and women had a 35% higher odds of experiencing a MACE than men (OR [95% CI]: 1.35 [1.03, 1.77]), whereas the odds of death were not significantly different (Table 2).
Secondary Prevention and Outcomes at 12 Months Post Discharge
The comparison of the unadjusted rate of the secondary care showed that women were less likely to use ≥75% of the indicated medications (66% vs. 74%, p<0.001) and the rate of smoking was not significantly different (Table 3). The results were similar after adjustment with women 16% less likely than men to be taking ≥75% of the indicated medications (OR [95% CI]: 0.84 [0.75, 0.95]) (Table 3). The rates of MACE and all-cause death between 6 and 12 months post discharge were not statistically significantly different between women and men (Table 3).
Table 3Unadjusted and adjusted comparison of outcomes between 6 and 12 months after discharge by gender.
| Outcome | Unadjusted | Adjusted | ||||
|---|---|---|---|---|---|---|
| Women n (%) n=1,375 | Men n (%) n=3,486 | Overall n (%) n=4,861 | P-value | Odds Ratio (95% CI) Women vs. Men | P-value | |
| ≥75% of indicated medications | 909 (66) | 2,587 (74) | 3,496 (72) | <0.0001 | 0.84 (0.75, 0.95) | 0.0234 |
| Current smokers | 170 (12) | 437 (13) | 607 (13) | 0.8648 | 1.19 (0.91, 1.55) | 0.2400 |
| N=1,411 | N=3,563 | N=4,974 | ||||
| MACE | 60 (4) | 119 (3) | 179 (4) | 0.0707 | 1.07 (0.77, 1.5) | 0.6763 |
| All-cause death | 27 (2) | 55 (2) | 82 (2) | 0.4153 | 0.6 (0.32, 1.15) | 0.0905 |
Abbreviations: MACE, major adverse cardiovascular events; CI, confidence interval; ACS, acute coronary syndrome.
a Denominator: ACS who were discharged alive, followed up and alive at 6 months and followed up and alive at 12 months.
b Denominator: ACS who were discharged alive, followed up and alive at 6 months and followed up at 12 months.
Discussion
The sex disparities in the use of secondary preventive care and clinical outcomes were explored using a large national contemporary data of patients who survived ACS. This study has found that at 6 months of hospital discharge, women attended cardiac rehabilitation less often than men but the use of the indicated secondary prevention medications and cigarette smoking were not different. Women visited their general practitioner more often but were less likely to receive dietary advice. Further, women were significantly more likely to have MACE compared to men even though there was no difference in the rate of all-cause death. At 12-month follow-up, women were less likely to use medications than men. There were no sex differences in the odds of smoking, MACE and all-cause death between 6 and 12 months post discharge.
These findings are supported by prior studies that women are less likely to utilise secondary preventive care. Although the fact that women are being referred to a cardiac rehabilitation program less often in the first place may contribute to the lower attendance rate compared to men, women were also reported to have greater dropout rates from the programs than men in past studies [
[12]
,20
, 21
, 22
]. Local and international studies have also found a sex difference in the use of secondary prevention medications [[13]
,[23]
,[24]
]. While we observed gender discrepancies in the use of the indicated medications at 12 months after the hospital discharge, an Australian study found that women from the state of Victoria with myocardial infarction who had undergone percutaneous coronary intervention and have left ventricular ejection fraction >44% were less likely to receive the indicated medications at 30-day follow-up compared to their male counterparts [[13]
]. This finding was driven by a vast difference in the use of lipid-lowering therapy between women and men, which was also found in international studies [[23]
,[24]
].There are several reasons that may have attributed to the lack of use of secondary prevention care by women. As found in the current study, women are less likely to be prescribed secondary prevention medications and referred to cardiac rehabilitation programs at discharge compared to men [
[8]
,[25]
]. Also, a combination of financial, social and psychological reasons may have discouraged participation to cardiac rehabilitation and medication adherence. Lower socioeconomic status in women may have led to difficulties in adhering to the secondary prevention care due to the out-of-pocket cost that exist, even with Medicare, in addition to the hospital medical fees related to assessment and management of ACS [[26]
,[27]
]. Smith et al., Yohannes et al., and Sanderson and Bittner suggested that the barriers to women’s participation in cardiac rehabilitation programs include psychological distress, pressure as the primary caretaker of the family, the lack of financial resources and social or emotional support [[21]
,[26]
,[28]
]. As these studies also stress, there need to be secondary prevention methods tailored for women to address the above barriers.In Australia, after hospital discharge, primary health care services oversee the support for the management of secondary prevention of ischaemic heart disease. Although in this study, the self-reported response suggested that sex difference in the use of indicated medications does not exist until about a year after discharge, data extracted from the general practice records indicate otherwise [
[15]
,[17]
]. Despite the finding that women are more likely to visit general practitioners after surviving acute coronary syndrome, previous studies have found that women are less likely to be prescribed the guideline-recommended medications and have their cardiovascular disease risk factors assessed in primary care than men [[15]
,[17]
,[29]
]. Whether this can partially explain the greater likelihood of women experiencing MACE post discharge than men cannot be certain but seems plausible.While it is important to reduce the sex disparity in the use of secondary preventive care, the poor overall use of this care as recommended by the guidelines is also to be highlighted. Even though 95% (94% women and 95% men) have been discharged on indicated medications, only 76% (71% women and 78% men) were on the indicated medications at 6 months and at 12 months the rate of the indicated medication use decreased further for both women and men (66% women and 74% men). The smoking rate had reduced from 28% (25% women and 29% men) to 14% (13% women and 14% men) from in-hospital to 6 months post discharge but 13% (12% women and 13% men) continued to smoke at 12 months. For cardiac rehabilitation, 67% (60% women and 70% men) were referred at discharge yet only 42% (35% women and 45% men) attended the program. Therefore, there is a need to induce both women and men to adhere to the secondary preventive care.
There are limitations to this study that require mention. First, CONCORDANCE follow-up data at 6 and 12 months were partly self-reported as the follow-ups were conducted by mailing out the case report forms and/or phone calls as well as searching through the primary health care and hospital medical records. Therefore, the data are subjected to recall bias. Second, there has been a 14% loss to follow-up at 6 months, however, the follow-up rate of 86% is considered substantially high in observational studies. Moreover, although only a subset of patients (i.e. recruited from 2013 onwards) was followed up at 12 months, the follow-up rate was very high of 93%.
Conclusion
Despite current efforts to provide equitable care and follow-up support to all patients with ACS, our findings suggest that there continue to be sex discrepancies. Compared to men, women attend cardiac rehabilitation less often and have a higher risk of MACE at 6 months of discharge. At 12 months of discharge, fewer women take indicated medications than men. This calls for an assessment of the current secondary preventive care being provided with the aim of developing and delivering programs that are specifically tailored to women’s needs.
Funding
KH is funded by the National Heart Foundation Postdoctoral Fellowship. JR is funded by a National Health and Medical Research Council Career Development Fellowship co-funded.
Competing Interests
The CONCORDANCE registry has been funded by grants to the Sydney Local Health District from Sanofi-Aventis, AstraZeneca, Eli Lilly, Boehringer Ingelheim, the Merck Sharp and Dohme/Schering Plough joint venture, and the National Heart Foundation of Australia. The current paper was not funded and the sponsors played no role in the design, analysis or preparation of this article.
Acknowledgements
We thank all the investigators and study coordinators who contributed to the CONCORDANCE Registry.
Appendices. Supplementary Data
- Appendices 1 and 2
Reference
- Global Health Estimates 2016: Disease burden by cause, age, by country and by region, 2000-2016.2018
- Acute coronary syndromes: diagnosis and management, part I.Mayo Clin Proc. 2009; 84: 917-938
- ACS in Perspective: The importance of secondary prevention.2011
- Readmissions following hospitalisations for cardiovascular disease: a scoping review of the Australian literature.Aust Health Rev. 2019;
- Reliability of predicting early hospital readmission after discharge for an acute coronary syndrome using claims-based data.Am J Cardiol. 2016; 117: 501-507
- National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016.Med J Aust. 2016; 205: 128-133
- Acute coronary syndromes in women: recent treatment trends and outcomes.Clin Med Insights Cardiol. 2016; 10: 1-10
- Differences in management and outcomes for men and women with ST-elevation myocardial infarction.Med J Aust. 2018; 209: 118-123
- Sex differences persist in time to presentation, revascularization, and mortality in myocardial infarction treated with percutaneous coronary intervention.J Am Heart Assoc. 2019; 8: e012161
- Sex differences in in-hospital management and outcomes of patients with acute coronary syndrome: findings from the CCC Project.Circulation. 2019; 139: 1776-1785
- Tailoring and targeting interventions for women with heart disease: the need for gender-based approaches.Evid Based Nurs. 2013; 16: 45-46
- Cardiovascular disease in women.Circ Res. 2016; 118: 1273-1293
- Sex differences in optimal medical therapy following myocardial infarction according to left ventricular ejection fraction.Eur J Prev Cardiol. 2020; (2047487319900875)
- Achieving coordinated secondary prevention of coronary heart disease for all in need (SPAN).Int J Cardiol. 2011; 146: 1-3
- Sex disparities in the management of coronary heart disease in general practices in Australia.Heart. 2019; 105: 1898-1904
- Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand.Heart (British Cardiac Society). 2014; 100: 1281-1288
- Gender inequalities in cardiovascular risk factor assessment and management in primary healthcare.Heart. 2017; 103: 492-498
- The design and rationale of the Australian Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events (CONCORDANCE).Heart Lung Cir. 2013; 22: 533-541
- Secondary prevention therapies in acute coronary syndrome and relation to outcomes: observational study.Heart Asia. 2019; 11: e011122
- Cardiac rehabilitation past, present and future: an overview.Cardiovasc Diagn Ther. 2012; 2: 38-49
- Predictors of drop-out from an outpatient cardiac rehabilitation programme.Clin Rehabil. 2007; 21: 222-229
- Sex and racial disparities in cardiac rehabilitation referral at hospital discharge and gaps in long-term mortality.J Am Heart Assoc. 2018; 7: e008088
- Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge.J Manag Care Pharm. 2008; 14: 271-280
- Sex differences in high-intensity statin use following myocardial infarction in the United States.J Am Coll Cardiol. 2018; 71: 1729-1737
- Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study.Heart. 2019; 105: 516
- ‘Betwixt and between health and illness’ – women's narratives following acute coronary syndrome.J Clin Nurs. 2017; 26: 3457-3470
- The household economic burden for acute coronary syndrome survivors in Australia.BMC Health Serv Res. 2016; 16: 636
- Women in cardiac rehabilitation: Outcomes and identifying risk for dropout.Am Heart J. 2005; 150: 1052-1058
- Sex differences in cardiovascular medication prescription in primary care: a systematic review and meta-analysis.J Am Heart Assoc. 2020; : e014742
Article info
Publication history
Published online: August 15, 2020
Accepted:
June 15,
2020
Received in revised form:
June 11,
2020
Received:
January 31,
2020
Identification
Copyright
© 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
