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Gender Differences in Acute Non–ST-Segment ElevationMyocardial Infarction

Tobias Heer, MDa,*, Anselm K. Gitt, MDa, Claus Juenger, MDa, Rudolf Schiele, MDa,Harm Wienbergen, MDa, Frank Towae, MDa, Martin Gottwitz, MDb, Ralph Zahn, MDb,

Uwe Zeymer, MDa, and Jochen Senges, MDa, for the ACOS Investigators

To assess gender-based differences in presentation and outcome after non–ST-elevationmyocardial infarction (NSTEMI) in clinical practice, this study examined data from theAcute Coronary Syndrome registry, which enrolled 16,817 patients from 2000 through theend of 2002, 6,358 of them with NSTEMIs (34.1% women). Women with NSTEMIs were7.5 years older, had a history of myocardial infarction and percutaneous coronary inter-vention or coronary artery bypass graft less often, and were less likely to have smoked.They more often had a history of systemic hypertension and diabetes mellitus, but thisdifference was due to their older age. Reperfusion therapy was performed less often inwomen, which still was significant after adjustment for baseline variables (odds ratio 0.71,95% confidence interval 0.63 to 0.80). Clopidogrel was given less often in women (43.4% vs56%). After adjustment for age, gender differences in medical therapy with statins, aspirin,and � blockers were not significant. Hospital mortality was 1.7 times greater in women.This difference was not significant after adjustment for age (odds ratio 1.07, 95% confi-dence interval 0.84 to 1.35). Women had greater crude long-term mortality, but after ageadjustment, this difference was no longer significant (odds ratio 0.92, 95% confidenceinterval 0.76 to 1.11). In conclusion, women with NSTEMIs were older than men and thusmore often had concomitant diseases but less often had a history of myocardial infarctionor coronary artery bypass grafts. They less often received acute percutaneous coronaryintervention and less often were treated with clopidogrel. However, there was no differencein age-adjusted mortality in women. © 2006 Elsevier Inc. All rights reserved. (Am J
Cardiol 2006;98:160–166)
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n 2000, the Joint Committee of the European Society ofardiology and the American College of Cardiology pub-

ished a new definition of myocardial infarction, with aedefinition of non–ST-elevation myocardial infarctionNSTEMI). It was based on the biomarkers troponin T androponin I, with nearly absolute myocardial tissue specific-ty.1 Yet data are sparse regarding gender differences inospital and long-term outcomes after acute NSTEMI. Theurpose of this subanalysis of the Acute Coronary Syn-rome (ACOS) registry was to examine gender differencesn presentation, acute therapy, and hospital and long-termortality in patients with confirmed NSTEMIs according to

he new definition.

ethodsThe ACOS registry: The ACOS registry was a prospec-

ive German multicenter registry investigating the current

aHerzzentrum Ludwigshafen, Department of Cardiology, Ludwig-hafen; and bKlinikum Nuernberg, Department of Cardiology, Nuernberg,ermany. Manuscript received September 10, 2005; revised manuscript

eceived and accepted January 25, 2006.This study was supported by a grant from MSD Sharp & Dohme, Haar,

ermany.* Corresponding author: Tel: 49621-503-4000; fax: 49621-503-4044.

rE-mail address: [email protected] (T. Heer).

002-9149/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.oi:10.1016/j.amjcard.2006.01.072

reatment of acute coronary syndromes. The 155 participat-ng hospitals were located in Germany and included universityospitals, community hospitals, and tertiary care centers, allroviding intensive care units and medical reperfusion ther-py, some with facilities for cardiac catheterization andalloon angioplasty. During the entire study, all patientsith acute coronary syndromes were registered prospec-

ively over 12 months and followed during their clinicalourses.

From June 2000 to December 2002, a total of 16,817onsecutive patients with acute coronary syndromes werenrolled into the ACOS registry. For the present analysis,nly patients with acute NSTEMIs were included. All par-icipating centers were committed to use criteria accordingo the new definition of acute coronary syndromes publishedy the Joint Committee of the European Society of Cardi-logy and the American College of Cardiology.1,2

Data collection: Data on patient characteristics on ad-ission were recorded. Data on electrocardiographicndings, biochemical markers, reperfusion treatment,harmacologic treatment, and interventional proceduresere documented. At discharge outcome and major ad-erse cardiovascular and cerebrovascular events were
ecorded.
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161Coronary Artery Disease/Gender Differences in NSTEMI

Every participating center was committed by writtenonsent to include every consecutive patient with acuteoronary syndrome. All patients gave informed consent torocess their anonymous data. Data were collected on 3ecord forms by the treating physicians. Completed dataheets were sent to the central data processing center, Insti-ut für Herzinfarktforschung Ludwigshafen, for uniformonitoring and registration. Source data verification was

erformed by comparison of the registry data with hospitalecords in randomly selected patients in 20 randomly se-ected participating centers. The study was approved by thethics committee of Landesärztekammer Mainz.

One year after discharge from the hospital, telephoneollow-up was performed by Institut für Herzinfarktfors-hung Ludwigshafen to document mortality, adverse events,edical therapy, and long-term treatment.

Definitions: According to the new definition of myocar-ial infarction, NSTEMI was diagnosed in the presence ofhe 2 following criteria: persistent angina pectoris �20

inutes and elevation of troponin T or troponin I.1,2 Elec-rocardiography could show ST depression or T-wave in-ersion or could even have “normal” results.

Statistical analysis: Data are presented as proportions,edians, or mean � SD as appropriate. Whenever possible,

ates are used to describe patient populations. The frequen-ies of categorical variables in the 2 populations were com-ared using the chi-square test and by calculating oddsatios (ORs) and 95% confidence intervals (CIs). Continu-us variables were compared using the 2-tailed Wilcoxon’sank-sum test. Variables influencing in-hospital and long-erm mortality were assessed with the aid of multiple logis-ic regression models. The following variables were includedn the logistic regression model: age, gender, previous myo-ardial infarction, previous percutaneous coronary interventionPCI), previous coronary bypass grafting, previous stroke, re-

able 1aseline characteristics of the patients (n � 6,358)

ariable Women(n � 2,168) (

ge (yrs) (mean � SD) 72.8 � 11.0 6ge �70 yrs 64.0%revious myocardial infarction 22.6%revious coronary angioplasty or bypass 13.7%revious stroke/transient ischemic attack 10.0%ystemic hypertension 77.5%iabetes mellitus 38.0%ypercholesterolemia† 63.3%moker 13.1%besity (body mass index �30 kg/m2) 23.1%enal failure (creatinine �2 mg/dl) 4.3%rehospital delay �3 h 70.3%eart rate �100 beats/min 23.6%trial fibrillation 11.3%

* Comparing women with men.† Low-density lipoprotein cholesterol �130 mg/dl, history of hyperchol

al failure, diabetes mellitus, hypertension, and hypercholes- i

erolemia. Kaplan-Meier curves were calculated to describe theong-term mortality of men and women. The survival func-ions were compared using the log-rank test. A multivariateox regression model with the independent variables fe-ale gender and age was used to estimate the effects. Thisas used to calculate the survival curve of patients aged70 years. A p value �0.05 was considered significant. Allvalues are the results of 2-tailed tests. The analysis was

erformed with SAS version 8.2 (SAS Institute Inc., Cary,orth Carolina) on a personal computer.

esultsBaseline characteristics: From June 2000 to December

002, a total of 6,358 consecutive patients with NSTEMIsere admitted to 154 participating hospitals. One third of allatients were women (n � 2,168). Women were 7.5 yearslder than men. Women less often had a history of myo-ardial infarction, PCI, coronary artery bypass grafting, andenal failure. They less often were smokers compared withen. Systemic hypertension, diabetes mellitus, and obesityere more often present in women. After age adjustment,

here was no gender difference in rate of previous stroke,revious transient ischemic attack, and hypercholesterol-mia (Table 1). Absolute cholesterol levels were higher inomen than men (total cholesterol 212 vs 201 mg/dl inen, univariate p �0.001; low-density lipoprotein cho-

esterol 131 vs 127 mg/dl, univariate p � 0.002; high-ensity lipoprotein cholesterol 49 vs 43 mg/dl, univariate�0.001).

Presenting symptoms and signs: Prehospital delay wasonger in women than men (374 vs 306 minutes, univariate

�0.001; Table 1). Heart rate on admission was higher inomen (median 80.0 vs 77.0 beats/min in men, univariate�0.001; Table 1). After adjustment for age, we found no

ender difference in the percentage of atrial fibrillation in the

90)Univariate p Value* Age-Adjusted OR (95% CI)

2.0 �0.001�0.001

0.003 0.65 (0.57–0.74)�0.001 0.55 (0.47–0.64)

0.005 0.89 (0.73–1.07)�0.001 1.41 (1.25–1.60)�0.001 1.42 (1.26–1.59)

0.042 1.06 (0.95–1.19)�0.001 0.53 (0.46–0.62)

0.017 1.47 (1.28–1.70)0.59 0.67 (0.52–0.87)

�0.001 1.20 (1.06–1.35)�0.001 1.38 (1.21–1.58)�0.001 0.96 (0.80–1.15)

mia, and/or actual medication for hypercholesterolemia.

Menn � 4,1

5.3 � 137.9%26.0%20.6%7.9%

66.2%26.8%65.8%31.8%20.4%

4.6%65.1%16.3%7.9%

nitial electrocardiogram.

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162 The American Journal of Cardiology (www.AJConline.org)

Treatment: PCI �48 hours was performed in 24.5% ofomen and 37.6% of men. After adjusting for age, this differ-

nce in acute reperfusion therapy was reduced but still signif-cant (Table 2). Even after adjustment for baseline parametersn a multiple logistic regression model, the gender differenceersisted, with less use of acute reperfusion therapy in womenmultivariate OR 0.72, 95% CI 0.64 to 0.81; Figure 1). Womeness often were treated with glycoprotein IIb/IIIa antagonistsnd clopidogrel (Table 2). After adjustment for age alonend in the multivariate model, women were treated lessggressively (multivariate OR for glycoprotein IIb/IIIa an-agonists 0.80, 95% CI 0.71 to 0.90; multivariate OR forlopidogrel 0.77, 95% CI 0.69 to 0.86). Unfractionatedeparin was used in 70.3% of women and 75.1% of men.fter age adjustment, this difference was still significant

Table 2).As for � blockers and statins, a gender difference with

ess therapy with these 2 agents in the univariate analysisisappeared after age adjustment. No gender differencesould be seen in therapy with acetylsalicylic acid and an-

Hospital mortality

Reperfusion

GP IIb/IIIa antagonist

Clopidogrel

Beta-blocker

Statin

ACE inhibitor

0 0.2 0.4 0.6 0.8 1 1.2 1.4

0.95

0.98

0.77

Chance in women lower < OR> higher compared tomen

0.97

0.97

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0.72

igure 1. The influence of gender on acute therapy and hospital mortalityf NSTEMI adjusted for 4 parameters (age, diabetes mellitus, heart rate100 beats/min, systolic blood pressure �100 mm Hg) (logistic regressionodel). ACE � angiotensin-converting enzyme.

able 2cute treatment

ariable Women(n � 2,168)

eperfusion therapyPCI �48 h 24.5%oncomitant medical therapy (�48 h)Acetylsalicylic acid 88.5%Unfractionated heparin 70.3%Low-molecular-weight heparin 31.5%Clopidogrel 40.1%Glycoprotein IIb/IIIa antagonist 28.8%� blocker 76.2%Angiotensin-converting enzyme inhibitor 63.7%Statin 57.3%

* Comparing women with men.

iotensin-converting enzyme inhibitors. There was a non- i

ignificant trend toward more use of low-molecular-weighteparin in women.

Angiographic findings: Coronary angiography was donen 60.7% of women and 76.9% of men with NSTEMIs. Noifference could be found in the severity of coronary arteryisease concerning the number of affected vessels (Table 3).

Hospital outcomes: Mortality in women was 1.7 timesreater than in men (6.8% vs 4.1%). After adjustment forge, this difference was no longer significant (Table 4). Inhe multiple logistic regression model, the OR for hospitalortality in women was 0.97 (95% CI 0.75 to 1.24; Figure

). There was no gender difference in nonfatal hospitaleinfarction. In a univariate analysis, women more often hadonfatal stroke and cardiogenic shock. Yet these differencesere no longer significant after adjustment for age. Regard-

ng hospital major adverse cerebrovascular and cardiovas-ular events, no differences between men and women coulde found when the difference in age was considered. Peakreatine kinase was greater in men than women, but thisay have been partly due to the different normal values inen and women. No differences could be found in the rate

f reduced and severely reduced left ventricular functionetween the 2 genders (Table 4).

Comparing hospital mortality in different age groups,here was a nonsignificant trend for greater mortality inomen aged 55 to 64 years compared with men in the same

ge group. In contrast, no women �54 years old died,hereas 4 men with NSTEMIs who died during their indexospital stays were 50 to 54 years old, and 4 were �50 yearsld (Figure 2).

Medical therapy at discharge and long-term fol-ow-up (median 12 months): At discharge, women withSTEMIs were treated less often with statins, acetylsalicylic

cid, clopidogrel, and � blockers. No gender differences coulde found in therapy with angiotensin-converting enzyme in-ibitors. After adjustment for age, only the difference in ther-py with clopidogrel was significant (Table 5). In a multivar-

n,190)

Univariate p Value* Age-Adjusted OR (95% CI)

% �0.001 0.71 (0.63–0.80)

% 0.21 0.97 (0.82–1.15)% �0.001 0.84 (0.74–0.95)% �0.001 1.12 (0.99–1.26)% �0.001 0.75 (0.67–0.84)% �0.001 0.78 (0.69–0.88)% 0.002 0.96 (0.84–1.09)% 0.14 0.97 (0.87–1.09)% �0.001 0.91 (0.81–1.02)

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ate model with adjustment for 9 parameters (age, diabetes

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ellitus, heart rate �100 beats/min, blood pressure �100 mmg, reperfusion, therapy with statins, � blockers or angio-

ensin-converting enzyme inhibitors at discharge, and ejec-ion fraction �40%), the underuse of clopidogrel in womenemained significant (OR 0.85, 95% CI 0.72 to 0.94).

Long-term mortality in women was 1.4 times greatern women (13.6%) than men (9.7%) (Table 5, Figure 3).his difference was not significant after adjusting for age

Table 5 and Figure 3). Likewise, in a multiple logisticegression model, the gender difference in long-termortality was not significant (OR 0.87, 95% CI 0.71 to

.06). A subgroup analysis of the influence of gender andherapy on mortality at follow-up revealed a gender dif-erence in the subgroup with no statins at discharge.

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Deathduringhospitalization(%)

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igure 2. Hospital mortality in women and men with NSTEMIs accordingo age.

able 3ngiographic findings during index hospital stay


oronary angiography done 60.7%- or 3-vessel disease 63.6%ulprit stenosis left anterior descending artery 45.4%ulprit stenosis right circumflexus artery 28.7%


able 4ospital outcome


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ospital mortality 6.8% 4.1einfarction, nonfatal 4.2% 3.8troke, nonfatal 1.5% 0.6ACCE 11.9% 8.3ardiogenic shock 3.5% 2.4jection fraction �40% 20.7% 19.3jection fraction �30% 6.7% 7.6eak creatine kinase (U/L)† 215.4 303.5

* Comparing women with men.† Normal value for men �171 U/L; normal value for women �145 U/MACCE � major adverse cardiovascular and cerebrovascular events (d

omen in this group had a chance for lower long-term w

ortality than men (OR 0.63, 95% CI 0.44 to 0.90). In allther subgroups, no significant gender difference coulde found, although there was for a trend for a lowerong-term mortality in women, except for the subgroupith statins at discharge (Figure 4).

iscussion

fter correction for age, there was no difference in hospitalnd long-term mortality for NSTEMI between men andomen, although acute PCI was performed less often inomen and women less often were treated with glycopro-

ein IIb/IIIa antagonists and clopidogrel.In accordance with studies of acute coronary syn-

romes,3–11 our study showed that women and men withSTEMIs were different in their risk profiles: women werelder than men by an average of 7.5 years and had a greaterncidence of systemic hypertension, diabetes mellitus, andbesity. They were less likely to be smokers and less likelyo have had previous infarctions. Comparing NSTEMI andT-elevation myocardial infarction, we found that pa-

ients with NSTEMIs were about 3 to 4 years older3,7,12

nd therefore more often had concomitant diseases suchs diabetes mellitus, hyperlipidemia, and hypertension,nd they more often had a history of myocardial infarc-ion or PCI. Gender differences on initial electrocardio-raphic changes in the ACOS population were describedy Wienbergen et al.13

Women with NSTEMIs were treated less aggressivelyhan men. After adjustment for age and clinical variables

en4,190)


.9% �0.001 0.46 (0.41–0.52)

.9% 0.86 0.99 (0.86–1.14)

.9% �0.001 1.31 (1.13–1.51)

.4% 0.001 0.77 (0.65–0.90)


�0.001 1.07 (0.84–1.35)0.51 1.04 (0.79–1.39)

�0.001 1.67 (0.96–2.88)�0.001 1.11 (0.93–1.33)

0.01 1.11 (0.81–1.53)0.22 1.09 (0.95–1.25)0.19 0.87 (0.70–1.1)

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erence was reduced but remained significant. Bavry et al14

ublished a meta-analysis of 5 studies in patients withnstable angina and NSTEMIs who were randomized toither routine invasive or conservative therapy. They foundhat men benefited from invasive therapy, as did troponin-ositive patients. The results for women and troponin-egative patients were equivocal.14 They suggested en-anced risk stratification in women, but nothing was saidbout troponin T–positive women. B-type natriuretic pep-ide and high-sensitivity C-reactive protein are 2 promisingarkers for risk stratification in patients with unstable an-

ina or NSTEMI, especially in women. In a Treat Anginaith Aggrastat and Determine Cost of Therapy With an

nvasive or Conservative Strategy–Thrombolysis In Myo-ardial Infarction-18 substudy, Wiviott et al15 reported thatomen without positive biomarkers were even more likely

o have death, myocardial infarction, or rehospitalization forcute coronary syndromes with the invasive strategy.10,16

able 5edical therapy at discharge and follow-up


oncomitant medical therapy at dischargeStatin 70.0%Acetylsalicylic acid 85.5%Clopidogrel 43.4%� blocker 82.8%Angiotensin-converting enzyme inhibitor 76.3%ollow-up (13 mo), meanMortality 13.6%Reinfarction, nonfatal 4.3%Stroke, nonfatal 1.5%PCI 7.6%Coronary artery bypass graft 8.5%Readmission rate 39.3%


Survival after NSTEMI

0.80

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0.95

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Days after Discharge

Women Men

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igure 3. (A) Empirical survival function for men versus women, medianegression).

elty et al17 showed that women had greater mortality �24 o

ours after PCI and before discharge because of a higherate of noncardiac death. These points favor a well-consid-red, troponin-conducted indication for PCI in women. Inur study, concomitant medical therapy with glycoproteinIb/IIIa antagonists and clopidogrel was administered lessften in women. Because these drugs are usually givenithin the scope of acute PCI, this may explain the lowerse in women, because PCI is performed less often inomen.Crude hospital mortality in women with NSTEMIs was

.7 times greater than in men. Similar to this finding werehe results for long-term mortality. Crude long-term mor-ality was about 1.4 times greater in women than in men.fter adjustment for age, neither the difference in hospitalortality nor that in long-term mortality was significant.ence, there was no difference in mortality that was due todistinction between the 2 genders. Differences in hospital

nd long-term mortality could be attributed to the older age

n Univariate p Value* Age-Adjusted OR (95% CI),190)

% �0.001 0.90 (0.79–1.02)% �0.001 0.85 (0.72–1.01)% �0.001 0.72 (0.64–0.81)% 0.001 0.93 (0.80–1.08)% 0.31 0.94 (0.83–1.08)

% �0.001 0.92 (0.76–1.11)% 0.02 1.59 (1.10–2.31)% 0.44 1.05 (0.58–1.89)% �0.01 0.73 (0.57–0.92)% �0.01 0.72 (0.57–0.90)% 0.88 1.01 (0.88–1.15)

Adjusted survival after NSTEMI

.8

5

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Women, 70 Men, 70

p = 0.30

ths (Kaplan-Meier curve) and (B) adjusted survival after NSTEMI (Cox

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f women. This finding is in accordance with those of

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arlier studies using the old NSTEMI definition. Hochmant al3 analyzed data from the Global Use of Strategies topen Occluded Coronary Arteries in Acute Coronary Syn-romes IIb trial and found that the adjusted risk for death oreinfarction at 30 days after NSTEMI was similar betweenomen and men (OR 0.93, 95% CI 0.72 to 1.21). In this

tudy, the old definition of NSTEMI was used. Lloyd-Jonest al18 used the new definition of NSTEMI and extendedollow-up in a preexisting database of unselected patientsith primary unstable angina pectoris and NSTEMI admit-

ed in 1991 and 1992. In this retrospective analysis, men hadworse prognosis after adjustment for age. However, gen-

er was not a significant predictor of long-term prognosisfter further adjustment for other covariates. Mueller et al6

xamined a very early aggressive reperfusion of NSTEMInd unstable angina with coronary stenting of the culpritesion. Female gender independently reduced the risk foreath or myocardial infarction by 49%. A limitation of thistudy is that only 50% of the population had a positiveroponin T results, and there was no analysis of this high-isk group. It is well known that women with unstable anginaectoris more often have less severe or no coronary arteryisease compared with men.3 This fact may account for theetter prognosis of women in the study of Mueller et al.6 Annalysis of the Euro Heart Survey of Acute Coronary Syn-romes by Hasdai et al7 found that female gender was notndependently associated with worse hospital mortality, ir-espective of the type of acute coronary syndrome.

As suspected, mortality rates in patients with ST-eleva-ion myocardial infarctions were higher than in patients withSTEMIs in our population. Patients with ST-elevationyocardial infarctions had a hospital mortality of 16% to

1% (women) and 8% to 12% (men), compared with 7%women) and 4% (men) of those with NSTEMIs.4,12 As forong-term mortality, this difference was attenuated. Long-erm mortality after ST-elevation myocardial infarction was

Long-termmortalityReperfusionNo reperfusion

Clopidogrel at dischargeNo clopidogrel at discharge

Statin at dischargeNo statin at discharge

Beta-blocker at discharge

No beta-blocker at discharge

ACE inhibitor at discharge

No ACE inhibitor at discharge

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6

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Long-term mortality in women lower < OR> higher compared tomen

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igure 4. The influence of gender and therapy on mortality at follow-upmedian 13 months) adjusted for age, diabetes mellitus, heart rate �100eats/min, blood pressure �100 mm Hg, acute reperfusion, statins, �lockers, angiotensin-converting enzyme (ACE) inhibitors at discharge,nd ejection fraction �40% (logistic regression model).

6% to 25% (women) and 10% to 18% (men), compared

ith mortality after NSTEMI of 14% (women) and 10%men).12

In almost all subgroups, there were no significant differ-nces between men and women. Only in the group with notatins at discharge was long-term mortality in womenower than in men. It seems paradoxical that withholding aherapy should be beneficial. A possible explanation coulde that statin therapy after NSTEMI is very effective in menut less effective in women, so withholding statin therapy inen results in adverse outcomes. In the other subgroups

except for those with statins at discharge), there was alight but not significant trend toward lower long-term mor-ality in women.

Because the ACOS registry is confined to Germany, ourata may be not representative of other countries. No datare available regarding the severity of presenting chest pain.he presence of atypical symptoms in women may have

educed the initial index of suspicion and therefore the usef reperfusion.19 In this observational study, the treatmentecisions were not randomized and were left to the discre-ion of the treating physician.

ppendix

he participants of the ACOS registry are listed else-here.20

1. Joint European Society of Cardiology/American College of Cardiol-ogy Committee. Myocardial infarction redefined—a consensus docu-ment of the Joint European Society of Cardiology/American Collegeof Cardiology Committee for the redefinition of myocardial infarction.Eur Heart J 2000;21:1502–1513.

2. Bertrand ME, Simoons ML, Fox KAA, Wallentin LC, Hamm CW,McFadden E, De Feyter PJ, Specchia G, Ruzyllo W. Management ofacute coronary syndromes: acute coronary syndromes without persis-tent ST segment elevation; recommendations of the Task Force of theEuropean Society of Cardiology. Eur Heart J 2000;21:1406–1432.

3. Hochman JS, Tamis JE, Thompson TD, Weaver WD, White HD, Vande Werf F, Aylward P, Topol EJ, Califf RM, for the Global Use ofStrategies to Open Occluded Coronary Arteries in Acute CoronarySyndromes IIb Investigators. Sex, clinical presentation, and outcomein patients with acute coronary syndromes. N Engl J Med 1999;341:226–232.

4. Carraba N, Santoro GM, Balzi D, Barchielli A, Marchionni N, FabianiP, Landini C, Scarti L, Santoro G, Valente S, et al, for the AMI-Florence Working Group. In-hospital management and outcome inwomen with acute myocardial infarction (data from the AMI-Florenceregistry). Am J Cardiol 2004;94:1118–1123.

5. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM, forthe National Registry of Myocardial Infarction 2 Participants. Sex-based differences in early mortality after myocardial infarction. N EnglJ Med 1999;341:217–225.

6. Mueller C, Neumann FJ, Roskamm H, Buser P, Hodgson JM, PerruchoudAP, Buettner HJ. Women do have an improved long-term outcome afternon-ST-elevation acute coronary syndromes treated very early and pre-dominantly with percutaneous coronary intervention. J Am Coll Cardiol2002;40:245–250.

7. Hasdai D, Porter A, Rosengren A, Behar S, Boyko V, Battler A. Effectof gender on outcomes of acute coronary syndromes. Am J Cardiol
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Heer Gender differences in NSTEMI Am J Cardiol 2006