Prevention gaps and cardiovascular outcomes in middle-aged men: A Population-Based Cohort Study

Background Cardiovascular disease remains a leading cause of death and healthcare expenditure worldwide. Although gender-related differences in cardiovascular care have often been framed around under-recognition of risk among women, men may also experience a distinct prevention gap, particularly during midlife, when modifiable cardiovascular risk factors accumulate but routine healthcare engagement is often limited. Objective To evaluate whether gender differences in preventive healthcare utilization are associated with cardiovascular risk profiles, hospitalization burden, mortality, and healthcare costs among adults aged 40–65 years, with 10-year overall survival as the primary outcome. Methods This was a retrospective cohort study of adults registered with a defined public-sector provider network within Brazil’s Public Unified Healthcare System (SUS), with deterministic linkage to national mortality data. The analytic cohort comprised 430,374 adults followed for a mean of 10.2 years; 153,483 were aged 40–65 years (63,799 men and 89,684 women). Participants were stratified by gender and age (<40, 40–65, and >65 years). Cardiovascular risk factors, outpatient consultations, emergency department admissions, hospitalizations, length of stay, cardiovascular mortality, and healthcare expenditures were analyzed. Utilization metrics were normalized per patient over a fixed 10-year window. Regression models assessed the relationship between preventive consultation intensity, defined as consultations per patient-year, and downstream healthcare resource use and costs. Results Women represented 56.8% of the cohort and men 43.2%. Across 10 years, the cohort accumulated 6,070,309 outpatient consultations, 1,905,277 emergency department admissions, 235,516 hospitalizations, and 17,282 cardiovascular deaths. Men aged 40–65 years showed the clearest adverse profile compared with women of the same age, including higher glucose (+18.6%), LDL-C (+12.9%), total cholesterol (+12.2%), triglycerides (+10.9%), systolic blood pressure (+10.9%), and diastolic blood pressure (+11.5%), and lower HDL-C (−20.7%; all pairwise comparisons p<0.001). This group had 20.0% fewer preventive consultations (95% CI −21.0 to −19.0%; p<0.001) but 22.0% more hospitalizations, longer length of stay, higher 10-year mortality (4.7% versus 2.9%), and higher healthcare costs (US$18,589 versus US$13,490, +37.8%; all p<0.001). Ten-year overall survival, the primary outcome, was 74% in men and 84% in women, corresponding to a hazard ratio of 1.62 (95% CI 1.61–1.63; log-rank p<0.001). Conclusions Middle-aged men appear to represent a high-yield target for cardiovascular prevention, characterized by reduced preventive engagement, worse cardiometabolic risk profiles, greater hospitalization burden, higher mortality, and higher costs. These findings support targeted strategies to improve cardiovascular screening, risk-factor control, and continuity of care among men entering and progressing through midlife.