Sex gaps in clinical care, left ventricular remodeling, and mortality after ST-elevation myocardial infarction in an Eastern European cohort

Background Ischemic heart disease disproportionately affects Eastern Europe and is the leading cause of death in Romania. Despite this, sex-specific outcomes after ST-elevation myocardial infarction (STEMI) remain underreported in the region. Purpose To explore sex differences in clinical care, ventricular remodeling, and clinical outcomes among Romanian patients with STEMI. Methods We examined the characteristics of 777 men and 308 women prospectively enrolled in the Romanian Registry for Post-myocardial Infarction Left Ventricular Remodeling and Heart Failure Prevention (REDEFINE-HF) from 2020 to 2023. Cardiac magnetic resonance (CMR) was performed in 130 patients at baseline and 6-month follow-up. The primary outcome was all-cause mortality. Results Women had a higher prevalence of cardiovascular risk factors, longer total ischemic time, and larger infarctions than men (p<0.05). Percutaneous coronary intervention (PCI) restored TIMI 3 flow in 78% of women vs 86% of men, and 23% of women vs 15% of men developed significant ischemic mitral regurgitation (p<0.01). Female sex, diabetes, and the extent of acute myocardial injury were associated with larger 6-month scars on CMR (p<0.01). In Kaplan-Meier analysis, the 3-year mortality was 27% in women vs 17% in men (Figure, p<0.001). In Cox regression analysis, women and men had comparable survival after adjustment for age, diabetes, hypertension, smoking, baseline troponin T, kidney function and glycemia, and restored epicardial flow at PCI (p=0.28). Conclusions Substantial sex gaps in risk factor management and STEMI care contribute to excess mortality among Romanian women after STEMI. These findings underscore the need for targeted population interventions and sex-specific follow-up for patients at risk of, or with established, ischemic heart disease in the region.