Sex-specific survival after stress echocardiography: trends over two decades

Background Sex-related differences in outcomes after stress echocardiography (SE) are well recognized. However, their long-term evolution in real-world clinical practice remains insufficiently studied. Aim To evaluate short- and long-term survival stratified by sex over two decades following SE. Methods We retrospectively analysed data from 21,063 prospectively enrolled consecutive patients undergoing SE between 2002 and 2023 at a single centre. The cohort was stratified into three approximately 7-year calendar periods. One-year survival was assessed using administrative censoring. For long-term comparisons between the first two periods, follow-up was uniformly censored at 6.7 years. Cox proportional hazards models were used to identify independent predictors of all-cause mortality and were performed in the complete-case cohort (n=13,398). Results One-year survival remained high across all periods. Women demonstrated higher short-term survival than men in the earlier eras, particularly after negative SE, whereas in the most recent period sex differences were small. Long-term survival was significantly higher in women compared with men (p<0.001). When analysis was restricted to the first two calendar periods with uniform 6.7-year follow-up, long-term survival remained stable over time in women after both negative and positive SE, whereas men exhibited significant improvement across periods in both groups. In age-adjusted analysis, male sex was associated with increased mortality (HR 2.12, 95% CI 1.96–2.30; p<0.001), and this association persisted after multivariable adjustment (HR 1.72, 95% CI 1.58–1.89; p<0.001). Conclusion Women demonstrated better short- and long-term survival than men following SE. Although long-term survival improved over time in men, male sex remained independently associated with mortality after adjustment for clinical risk factors.