Key result
Female sex was associated with higher age-adjusted post-AMI mortality than male sex among patients aged <70 years across all ejection fraction classes, reversing in those aged ≥70 years.
Why the study?
Contemporary data describing how the female survival advantage after acute myocardial infarction is affected by age and left ventricular systolic dysfunction were lacking.
Cohort (n=167,174)
Yes
After a first-time acute myocardial infarction, young women (<60 years) face a higher long-term mortality risk than men across all ejection fraction classes, reversing the traditional female survival advantage seen in older patients (>=70 years).
Abstract Intro There is a lack of contemporary data describing how the female survival advantage is affected by age and left ventricular systolic dysfunction (LVSD) after acute myocardial infarction (AMI). Purpose This study aimed to evaluate the interaction between sex, age, and ejection fraction (EF) regarding long-term all-cause mortality in a nationwide population. We further examined sex-specific differences in baseline comorbidities and secondary prevention strategies over a 17-year period. Methods We studied a cohort of 167,174 patients from the SWEDEHEART registry, aged ≥18 years, presenting with a first-time AMI and echocardiographic assessment during hospitalisation. Relative risks were calculated using Cox proportional hazards regression models (Model 1: age-adjusted; Model 2: age + comorbidities; Model 3: age + comorbidities + discharge treatment). Analyses were stratified by age categories and four temporal periods (2005–2022). Results Women were older at presentation (median 74 vs. 67 years) and had a higher prevalence of hypertension, diabetes mellitus, and chronic kidney disease. Women were less frequently treated with percutaneous coronary intervention (PCI), P2Y12 inhibitors, and statins at discharge. Among individuals <70 years, age-adjusted mortality was consistently higher in women regardless of EF, whereas the opposite was observed in those aged ≥70 years (Figure 1). The pattern with the highest age-adjusted hazard ratio for women in those <60 years, with decreasing hazard ratios across increasing age groups, has become increasingly evident over time (Figure 2), with similar results when analyses were stratified by EF. Adjusting for comorbidities and discharge treatment did not materially change the models. Conclusion Post-AMI prognosis is characterised by a sex-dependent inversion of risk. In young women (<60 years), the traditional survival advantage is reversed, with women facing a higher mortality risk than men. This shift from protection to vulnerability is seen in all EF classes but most pronounced in those with significant LVSD. The interaction between age and sex has increased over the years which warrants more studies.
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Hamilton et al. (2026) conducted a cohort in Acute myocardial infarction with or without left ventricular systolic dysfunction (n=167,174). Female sex stratified by age and ejection fraction vs. Male sex was evaluated on Long-term all-cause mortality. Female sex was associated with higher age-adjusted post-AMI mortality than male sex among patients aged <70 years across all ejection fraction classes, reversing in those aged ≥70 years.
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