Sex disparities in STEMI and stroke outcomes persist despite universal health care: a nationwide study in Spain (2007-2022)

INTRODUCTION AND OBJECTIVES: Sex disparities in cardiovascular disease (CVD) outcomes persist despite advances in prevention and care. We assessed sex-specific trends in CVD hospitalizations, in-hospital mortality and length of stay in Spain, a high-income country with universal health care, from 2007 to 2022. METHODS: We conducted a nationwide, retrospective, population-based study including all adults (≥ 18 years) hospitalized with a primary CVD diagnosis. Analyses focused on ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction, stroke, heart failure (HF), and aortic stenosis. Age-standardized hospitalization rates were estimated by sex. Multivariable logistic regression models assessed the association between female sex and in-hospital mortality for 2007 to 2015 and 2016 to 2022, and temporal trends were evaluated using Joinpoint regression. RESULTS: Among 6 734 967 hospitalizations, women accounted for 43.9%, were older, and had greater comorbidity than men. Men had higher crude admission rates for all conditions except HF, which predominated in women; age-standardized trends were similar between the sexes. Median length of stay declined overall and remained slightly longer in women. Crude in-hospital mortality was higher in women than in men (10.1% vs 7.6%; P < .001) among all conditions. After adjustment, female sex independently predicted higher in-hospital mortality after STEMI (OR, 1.29 and 1.25) and stroke (OR, 1.13 and 1.15) in both study periods but was slightly protective in HF (OR, 0.97 and 0.96). Risk-adjusted in-hospital mortality declined significantly over time among all cardiovascular conditions, with no significant sex differences in temporal trends. CONCLUSIONS: Persistent excess in-hospital mortality among women with STEMI and stroke suggests that universal health care alone does not ensure equity in cardiovascular outcomes.