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Background: Many studies have found that women are less likely than men to have cardiac catheterization after an acute myocardial infarction; however, it is unknown whether sex differences reflect inappropriate treatment. Objective: To ascertain whether cardiac catheterization use after acute myocardial infarction in men and women varied by sex and the appropriateness of the procedure, as determined by clinical guidelines. Design: Retrospective analysis of chart-abstracted data. Setting: U.S. acute-care hospitals. Patients: 143 444 Medicare patients who were hospitalized for acute myocardial infarction between 1994 and 1996. Measurements: Cardiac catheterization use within 60 days of hospitalization for acute myocardial infarction. Results: Women had lower crude rates of cardiac catheterization than men (35.7% for women vs. 46.5% for men [P0.2]; difference, 0.5 percentage point). Rates of cardiac catheterization use among patients with weak indications did not significantly differ between men and women (16.5% for women vs. 18.0% for men [P=0.096]; difference, 1.5 percentage points). Sex differences in cardiac catheterization use were largest for patients with equivocal indications (39.4% for women vs. 42.5% for men [P Conclusions: Among elderly persons, women have lower rates of cardiac catheterization use after an acute myocardial infarction than men. However, this difference was attenuated after multivariable adjustment, and it occurred primarily in patients with equivocal indications. We found no sex variations in procedure use among patients who had strong indications for cardiac catheterization.

The article targets the need for older patients to be included in heart attack medical care quality measurements, as they are currently an under-represented patient group.

Background: A paced rhythm can mask the electrocardiographic features of an acute myocardial infarction, complicating timely recognition and treatment. Objective: To evaluate characteristics, treatment, and outcomes among patients presenting with paced rhythms during myocardial infarction. Design: Retrospective cohort study. Setting: U.S. acute care hospitals. Patients: 102 249 Medicare beneficiaries at least 65 years of age who were treated for acute myocardial infarction between 1994 and 1996. Measurements: Provision of three treatments for acute myocardial infarction (emergent reperfusion, aspirin, and [Beta]-blockers), death at 30 days, and long-term follow-up. Results: 1954 patients (1.9%) presented with paced rhythms during myocardial infarction. These patients were older; were predominantly male; and had higher rates of congestive heart failure, diabetes, and previous infarction. They were significantly less likely to receive emergent reperfusion (relative risk [RR], 0.27 [95% CI, 0.22 to 0.33]), aspirin (RR at admission, 0.91 [CI, 0.88 to 0.94]; RR at discharge, 0.87 [CI, 0.83 to 0.92]), and [Beta]-blockers at admission (RR, 0.89 [CI, 0.82 to 0.96]). In addition, there was a trend toward decreased use of [Beta]-blockers at discharge (RR, 0.91 [CI, 0.76 to 1.06]). Crude mortality rates were higher among patients with paced rhythms than among those without at 30 days (25.8% vs. 21.3%; P = 0.001) and at 1 year (47.1% vs. 36.1%; P = 0.001). Among patients with paced rhythms, risk for death at 30 days decreased after adjustment for illness severity and decreased use of therapy (RR, 1.03 [CI, 0.93 to 1.14]). Patients with paced rhythms remained at additional risk for long-term mortality (hazard ratio, 1.12 [CI, 1.06 to 1.18]). Conclusions: Patients with paced rhythms were less likely than those without to receive treatment for acute myocardial infarction and had poorer short- and long-term outcomes. However, this mortality risk diminished after adjustment for treatment. This suggests that improved recognition and treatment of myocardial infarction may improve outcomes, particularly in the short term. Ann Intern Med. 2001;134:644-651. www.annals.org