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Introduction: Despite evidence supporting the benefits of marriage on cardiovascular health, the impact of marital/partner status on the long-term readmission of young acute myocardial infarction (AMI) survivors is less clear. We examined the association between marital/partner status and 1-year all-cause readmission and explored sex differences among young AMI survivors., Methods: Data were from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), which enrolled young adults aged 18-55 years with AMI (2008-2012). The primary end point was all-cause readmission within 1 year of hospital discharge, obtained from medical records and patient interviews and adjudicated by a physician panel. We performed Cox proportional hazards models with sequential adjustment for demographic, socioeconomic, clinical, and psychosocial factors. Sex-marital/partner status interaction was also tested., Results: Of the 2,979 adults with AMI (2002 women [67.2%]; mean age 48 [interquartile range, 44-52] years), unpartnered individuals were more likely to experience all-cause readmissions compared with married/partnered individuals within the first year after hospital discharge (34.6% versus 27.2%, hazard ratio [HR] = 1.31; 95% confidence interval [CI], 1.15-1.49). The association attenuated but remained significant after adjustment for demographic and socioeconomic factors (adjusted HR, 1.16; 95% CI, 1.01-1.34), and it was not significant after further adjusting for clinical factors and psychosocial factors (adjusted HR, 1.10; 95%CI, 0.94-1.28). A sex-marital/partner status interaction was not significant (p = 0.69). Sensitivity analysis using data with multiple imputation and restricting outcomes to cardiac readmission yielded comparable results., Conclusions: In a cohort of young adults aged 18-55 years, unpartnered status was associated with 1.3-fold increased risk of all-cause readmission within 1 year of AMI discharge. Further adjustment for demographic, socioeconomic, clinical, and psychosocial factors attenuated the association, suggesting that these factors may explain disparities in readmission between married/partnered versus unpartnered young adults. Whereas young women experienced more readmission compared to similar-aged men, the association between marital/partner status and 1-year readmission did not vary by sex., Competing Interests: Dr. Spertus discloses providing consultative services on patient-reported outcomes and evidence evaluation to Alnylam, AstraZeneca, Bayer, Merck, Janssen, Bristol Meyers Squibb, Edwards, Kineksia, 4DT Medical, Terumo, Cytokinetics, Imbria, and United Healthcare. He holds research grants from Bristol Meyers Squibb, Abbott Vascular and Janssen. He owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire and serves on the Board of Directors for Blue Cross Blue Shield of Kansas City. No other authors report having any other disclosures to report. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Zhu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background Though associations between obstructive sleep apnea (OSA) and cardiovascular outcomes are well described, limited data exist regarding the impact of OSA on sex-specific outcomes after acute myocardial infarction (AMI). Methods and Results The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolled 3572 adults aged 18 to 55 years with AMI from the United States and Spain during 2008 to 2012. We included patients for whom the Berlin Questionnaire for OSA was scored at the time of AMI admission (3141; 2105 women, 1036 men). We examined the sex-specific association between baseline OSA risk with functional outcomes including health status and depressive symptoms at 1 and 12 months after AMI. Among both groups, 49% of patients were at high risk for OSA (1040 women; 509 men), but only 4.7% (148) of patients had a diagnosed history of OSA. Though patients with a high OSA risk reported worse physical and mental health status and depression than low-risk patients in both sexes, the difference in these functional outcomes was wider in women than men. Moreover, women with a high OSA risk had worse health status, depression, and quality of life than high-risk men, both at baseline and at 1 and 12 months after AMI. Conclusions Young women with a high OSA risk have poorer health status and more depressive symptoms than men at the time of AMI, which may place them at higher risk of poorer health outcomes over the year following the AMI. Further, the majority of patients at high risk of OSA are undiagnosed at the time of presentation of AMI.

Background Stress experienced in a marriage or committed relationship may be associated with worse patient-reported outcomes after acute myocardial infarction (AMI), but little is known about this association in young adults (≤55 years) with AMI. Methods and Results We used data from VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), an observational cohort study that enrolled individuals aged 18 to 55 years with AMI (2008-2012). Marital stress was self-reported 1 month after AMI using the Stockholm Marital Stress Scale (categorized as absent/mild, moderate, and severe). Outcomes were physical/mental health (Short Form-12 ) , generic health status (EuroQol-5 Dimensions), cardiac-specific quality of life and angina (Seattle Angina Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and all-cause readmission 1 year after AMI. Regression models were sequentially adjusted for baseline health, demographics (sex, age, race or ethnicity), and socioeconomic factors (education, income, employment, and insurance). Sex and marital stress interaction was also tested. Among 1593 married/partnered participants, 576 (36.2%) reported severe marital stress, which was more common in female than male participants (39.4% versus 30.4%, P =0.001). Severe marital stress was significantly associated with worse mental health (beta=-2.13, SE=0.75, P =0.004), generic health status (beta=-3.87, SE=1.46, P =0.008), cardiac-specific quality of life (beta=-6.41, SE=1.65, P <0.001), and greater odds of angina (odds ratio [OR], 1.49 [95% CI, 1.06-2.10], P =0.023) and all-cause readmissions (OR, 1.45 [95% CI, 1.04-2.00], P =0.006), after adjusting for baseline health, demographics, and socioeconomic factors. These associations were similar across sexes ( P -interaction all >0.05). Conclusions The association between marital stress and worse 1-year health outcomes was statistically significant in young patients with AMI, suggesting a need for routine screening and the creation of interventions to support patients with stress recovering from an AMI.

Background: Younger women experience worse health status than men after their index episode of acute myocardial infarction (AMI). However, whether women have a higher risk for cardiovascular and noncardiovascular hospitalizations in the year after discharge is unknown., Objectives: The aim of this study was to determine sex differences in causes and timing of 1-year outcomes after AMI in people aged 18 to 55 years., Methods: Data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which enrolled young patients with AMI across 103 U.S. hospitals, were used. Sex differences in all-cause and cause-specific hospitalizations were compared by calculating incidence rates ([IRs] per 1,000 person-years) and IR ratios with 95% CIs. We then performed sequential modeling to evaluate the sex difference by calculating subdistribution HRs (SHRs) accounting for deaths., Results: Among 2,979 patients, at least 1 hospitalization occurred among 905 patients (30.4%) in the year after discharge. The leading causes of hospitalization were coronary related (IR: 171.8 [95% CI: 153.6-192.2] among women vs 117.8 [95% CI: 97.3-142.6] among men), followed by noncardiac hospitalization (IR: 145.8 [95% CI: 129.2-164.5] among women vs 69.6 [95% CI: 54.5-88.9] among men). Furthermore, a sex difference was present for coronary-related hospitalizations (SHR: 1.33; 95% CI: 1.04-1.70; P = 0.02) and noncardiac hospitalizations (SHR: 1.51; 95% CI: 1.13-2.07; P = 0.01)., Conclusions: Young women with AMI experience more adverse outcomes than men in the year after discharge. Coronary-related hospitalizations were most common, but noncardiac hospitalizations showed the most significant sex disparity., Competing Interests: Funding Support and Author Disclosures The VIRGO study (NCT00597922) was supported by grant R01 HL081153 from the National Heart, Lung, and Blood Institute. In the past 3 years, Dr Krumholz has received expenses and/or personal fees from UnitedHealth, Element Science, Eyedentifeye, and F-Prime; is a co-founder of Refactor Health and HugoHealth; and is associated with contracts, through Yale New Haven Hospital, from the Centers for Medicare & Medicaid Services and through Yale University from the U.S. Food and Drug Administration, Johnson & Johnson, Google, and Pfizer. Dr. Murugiah has received support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award K08HL157727). Dr. Khera has received support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award K23HL153775) and the Doris Duke Charitable Foundation (under award, 2022060); receives research support, through Yale, from Bristol Myers Squibb and Novo Nordisk; is a coinventor of U.S. Provisional Patent Applications 63/177,117, 63/428,569, and 63/346,610, unrelated to current work; and is a founder of Evidence2Health, a precision health platform to improve evidence-based cardiovascular care. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Importance: Among younger adults, the association between Black race and postdischarge readmission after hospitalization for acute myocardial infarction (AMI) is insufficiently described., Objectives: To examine whether racial differences exist in all-cause 1-year hospital readmission among younger adults hospitalized for AMI and whether that difference retains significance after adjustment for cardiac factors and social determinants of health (SDOHs)., Design, Setting, and Participants: The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study was an observational cohort study of younger adults (aged 18-55 years) hospitalized for AMI with a 2:1 female-to-male ratio across 103 US hospitals from January 1, 2008, to December 31, 2012. Data analysis was performed from August 1 to December 31, 2021., Main Outcomes and Measures: The primary outcome was all-cause readmission, defined as any hospital or observation stay greater than 24 hours within 1 year of discharge, identified through medical record abstraction and clinician adjudication. Logistic regression with sequential adjustment evaluated racial differences and potential moderation by sex and SDOHs. The Blinder-Oaxaca decomposition quantified how much of any racial difference was explained and not explained by covariates., Results: This study included 2822 participants (median [IQR] age, 48 [44-52] years; 1910 [67.7%] female; 2289 [81.1%] White and 533 [18.9%] Black; 868 [30.8%] readmitted). Black individuals had a higher rate of readmission than White individuals (210 [39.4%] vs 658 [28.8%], P < .001), particularly Black women (179 of 425 [42.1%]). After adjustment for sociodemographic characteristics, cardiac factors, and SDOHs, the odds of readmission were 34% higher among Black individuals (odds ratio [OR], 1.34; 95% CI, 1.06-1.68). The association between Black race and 1-year readmission was positively moderated by unemployment (OR, 1.68; 95% CI, 1.09- 2.59; P for interaction = .02) and fewer number of working hours per week (OR, 1.01; 95% CI, 1.00-1.02; P for interaction = .01) but not by sex. Decomposition indicates that 79% of the racial difference in risk of readmission went unexplained by the included covariates., Conclusions and Relevance: In this multicenter study of younger adults hospitalized for AMI, Black individuals were more often readmitted in the year following discharge than White individuals. Although interventions to address SDOHs and employment may help decrease racial differences in 1-year readmission, more study is needed on the 79% of the racial difference not explained by the included covariates.

Objective: The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes., Summary Background Data: The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression., Results: A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions., Conclusion: The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Marital/Partner support is associated with lower mortality and morbidity following acute myocardial infarction (AMI) and stroke. Despite an increasing focus on the effect of patient-centered factors on health outcomes, little is known about the impact of marital/partner status on patient-reported outcome measures (PROMs)., Objective: To synthesize evidence of the association between marital/partner status and PROMs after AMI and stroke and to determine whether associations differ by sex., Methods and Analysis: We will search MEDLINE (via Ovid), Web of Science Core Collection (as licensed by Yale University), Scopus, EMBASE (via Ovid), and PsycINFO (via Ovid) from inception to July 15, 2022. Two authors will independently screen titles, abstracts, and then full texts as appropriate, extract data, and assess risk of bias. Conflicts will be resolved by discussion with a third reviewer. The primary outcomes will be the associations between marital/partner status and PROMs. An outcome framework was designed to classify PROMs into four domains (health-related quality of life, functional status, symptoms, and personal recovery). Meta-analysis will be conducted if appropriate. Subgroup analysis by sex and meta-regression with a covariate for the proportion of male participants will be performed to explore differences by sex., Ethics and Dissemination: This research is exempt from ethics approval because the study will be conducted using published data. We will disseminate the results of the analysis in a related peer-reviewed journal., Trial Registration: PROSPERO registration number: CRD42022295975., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Zhu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The relative prevalence and clinical importance of monogenic mutations related to familial hypercholesterolemia and of high polygenic score (cumulative impact of many common variants) pathways for early-onset myocardial infarction remain uncertain. Whole-genome sequencing enables simultaneous ascertainment of both monogenic mutations and polygenic score for each individual., Methods: We performed deep-coverage whole-genome sequencing of 2081 patients from 4 racial subgroups hospitalized in the United States with early-onset myocardial infarction (age ≤55 years) recruited with a 2:1 female-to-male enrollment design. We compared these genomes with those of 3761 population-based control subjects. We first identified individuals with a rare, monogenic mutation related to familial hypercholesterolemia. Second, we calculated a recently developed polygenic score of 6.6 million common DNA variants to quantify the cumulative susceptibility conferred by common variants. We defined high polygenic score as the top 5% of the control distribution because this cutoff has previously been shown to confer similar risk to that of familial hypercholesterolemia mutations., Results: The mean age of the 2081 patients presenting with early-onset myocardial infarction was 48 years, and 66% were female. A familial hypercholesterolemia mutation was present in 36 of these patients (1.7%) and was associated with a 3.8-fold (95% CI, 2.1-6.8; P<0.001) increased odds of myocardial infarction. Of the patients with early-onset myocardial infarction, 359 (17.3%) carried a high polygenic score, associated with a 3.7-fold (95% CI, 3.1-4.6; P<0.001) increased odds. Mean estimated untreated low-density lipoprotein cholesterol was 206 mg/dL in those with a familial hypercholesterolemia mutation, 132 mg/dL in those with high polygenic score, and 122 mg/dL in those in the remainder of the population. Although associated with increased risk in all racial groups, high polygenic score demonstrated the strongest association in white participants ( P for heterogeneity=0.008)., Conclusions: Both familial hypercholesterolemia mutations and high polygenic score are associated with a >3-fold increased odds of early-onset myocardial infarction. However, high polygenic score has a 10-fold higher prevalence among patients presents with early-onset myocardial infarction., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00597922.

Objectives: To evaluate community-specific nursing home performance with community-specific hospital 30-day readmissions for Medicare patients discharged with acute myocardial infarction, heart failure or pneumonia., Design: Cross-sectional study using 2009-2012 hospital risk-standardised 30-day readmission data for Medicare fee-for-service patients hospitalised for all three conditions and nursing home performance data from the Centers for Medicare & Medicaid Services Five-Star Quality Rating System., Setting: Medicare-certified nursing homes and acute care hospitals., Participants: 12,542 nursing homes and 3,039 hospitals treating 30 or more Medicare fee-for-service patients for all three conditions across 2,032 hospital service areas in the United States., Measurements: Community-specific hospital 30-day risk-standardised readmission rates. Community-specific nursing home performance measures: health inspection, staffing, Registered Nurses and quality performance; and an aggregated performance score. Mixed-effects models evaluated associations between nursing home performance and hospital 30-day risk-standardised readmission rates for all three conditions., Results: The relationship between community-specific hospital risk-standardised readmission rates and community-specific overall nursing home performance was statistically significant for all three conditions. Increasing nursing home performance by one star resulted in decreases of 0.29% point (95% CI: 0.12-0.47), 0.78% point (95% CI: 0.60-0.95) and 0.46% point (95% CI: 0.33-0.59) of risk-standardised readmission rates for AMI, HF and pneumonia, respectively. Among the specific measures, higher performance in nursing home overall staffing and Registered Nurse staffing measures was statistically significantly associated with lower hospital readmission rates for all three conditions. Notable geographic variation in the community-specific nursing home performance was observed., Conclusion: Community-specific nursing home performance is associated with community-specific hospital 30-day readmission rates for Medicare fee-for-service patients for acute myocardial infarction, heart failure or pneumonia., Implications for Practice: Coordinated care between hospitals and nursing homes is essential to reduce readmissions. Nursing homes can improve performance and reduce readmissions by increasing registered nursing homes. Further, communities can work together to create cross-continuum care teams comprised of hospitals, nursing homes, patients and their families, and other community-based service providers to reduce unplanned readmissions., (© 2017 John Wiley & Sons Ltd.)

Young women with acute myocardial infarction (AMI) have a worse prognosis than their male counterparts. We searched for differences in the electrocardiographic presentation of men and women in a large, contemporary registry of young adults with AMI that could help explain gender differences in outcomes. The qualifying electrocardiogram was blindly assessed by a central core lab in 3,354 patients (67% women) aged 18 to 55 years included in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study. Compared with men, women did not have a different frequency of sinus rhythm, and they had shorter PR and QRS intervals and longer QTc intervals. Intraventricular conduction disturbances were not different among genders. Notably, women were more likely than men to have abnormal Q waves in anterior leads and a lower frequency of Q waves in other territories. ST-segment elevation myocardial infarction (STEMI) diagnosis was less frequent in women than in men (44.6% vs 55.1%, p < 0.001). Among patients with STEMI, women had less magnitude and extent of ST-segment elevation than men. In patients with non-STEMI, the frequency, magnitude, and extent of ST-segment depression were not different among genders, but women had anterior ST-segment depression less frequently and anterior negative T waves more frequently compared with men. These differences remained statistically significant after adjusting for baseline characteristics. In conclusion, there are significant gender differences in the electrocardiographic presentation of AMI among young patients. Further studies are warranted to evaluate their impact on gender-related differences in the management and outcomes of AMI., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: Young women with acute myocardial infarction (AMI) have a higher risk of adverse outcomes than men. However, it is unclear how young women with AMI are different from young men across a spectrum of characteristics. We sought to compare young women and men at the time of AMI on six domains of demographic and clinical factors in order to determine whether they have distinct profiles., Methods and Results: Using data from Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO), a prospective cohort study of women and men aged ⩽55 years hospitalized for AMI ( n = 3501) in the United States and Spain, we evaluated sex differences in demographics, healthcare access, cardiovascular risk and psychosocial factors, symptoms and pre-hospital delay, clinical presentation, and hospital management for AMI. The study sample included 2349 (67%) women and 1152 (33%) men with a mean age of 47 years. Young women with AMI had higher rates of cardiovascular risk factors and comorbidities than men, including diabetes, congestive heart failure, chronic obstructive pulmonary disease, renal failure, and morbid obesity. They also exhibited higher levels of depression and stress, poorer physical and mental health status, and lower quality of life at baseline. Women had more delays in presentation and presented with higher clinical risk scores on average than men; however, men presented with higher levels of cardiac biomarkers and more classic electrocardiogram findings. Women were less likely to undergo revascularization procedures during hospitalization, and women with ST segment elevation myocardial infarction were less likely to receive timely primary reperfusion., Conclusions: Young women with AMI represent a distinct, higher-risk population that is different from young men.

Background: Young women (≤55 years of age) with acute myocardial infarction (AMI) have higher mortality risk than similarly aged men. Elevated inflammatory markers are associated with an increased risk of cardiovascular outcomes after AMI, but little is known about whether young women have higher inflammatory levels after AMI compared with young men., Methods and Results: We assessed sex differences in post-AMI inflammatory markers and whether such differences account for sex differences in 12-month health status, using data from 2219 adults with AMI, 18 to 55 years of age, in the United States. Inflammatory markers including high-sensitivity C-reactive protein (hsCRP) and lipoprotein-associated phospholipase A2 were measured 1 month after AMI. Overall, women had higher levels of hsCRP and lipoprotein-associated phospholipase A2 after AMI compared with men, and this remained statistically significant after multivariable adjustment. Regression analyses showed that elevated 1-month hsCRP was associated with poor health status (symptom, function, and quality of life) at 12 months. However, the association between hsCRP and health status became nonsignificant after adjustment for sociodemographics, comorbidities, and treatment factors. Half of these patients had residual inflammatory risk (hsCRP >3 mg/L) compared with a third who had residual cholesterol risk (Low-density lipoprotein cholesterol >100 mg/dL)., Conclusions: Young women with AMI had higher inflammatory levels compared with young men. Elevated 1-month hsCRP was associated with poor health status at 12 months after AMI, but this was attenuated after adjustment for patient characteristics. Targeted anti-inflammatory treatments are worthy of consideration for secondary prevention in these patients if ongoing trials of anti-inflammatory therapy prove effective., (© 2017 American Heart Association, Inc.)

Objective: The aim of the study was to examine how psychological stress changes over time in young and middle-aged patients after experiencing an acute myocardial infarction (AMI) and whether these changes differ between men and women., Methods: We analyzed data obtained from 2358 women and 1151 men aged 18 to 55 years hospitalized for AMI. Psychological stress was measured using the 14-item Perceived Stress Scale (PSS-14) at initial hospitalization and at 1 month and 12 months after AMI. We used linear mixed-effects models to examine changes in PSS-14 scores over time and sex differences in these changes, while adjusting for patient characteristics and accounting for correlation among repeated observations within patients., Results: Overall, patients' perceived stress decreased over time, especially during the first month after AMI. Women had higher levels of perceived stress than men throughout the 12-month period (difference in PSS-14 score = 3.63, 95% confidence interval = 3.08 to 4.18, p < .001), but they did not differ in how stress changed over time. Adjustment for patient characteristics did not alter the overall pattern of sex difference in changes of perceived stress over time other than attenuating the magnitude of sex difference in PSS-14 score (difference between women and men = 1.74, 95% confidence interval = 1.32 to 2.16, p < .001). The magnitude of sex differences in perceived stress was similar in patients with versus without post-AMI angina, even though patients with angina experienced less improvement in PSS-14 score than those without angina., Conclusions: In young and middle-aged patients with AMI, women reported higher levels of perceived stress than men throughout the first 12 months of recovery. However, women and men had a similar pattern in how perceived stress changed over time.

Background: Young women with acute myocardial infarction (AMI) have higher mortality risk than similarly aged men. An adverse lipid profile is an important risk factor for cardiovascular outcomes after AMI, but little is known about whether young women with AMI have a higher-risk lipid pattern than men. We characterized sex differences in lipid profiles and treatment utilization among young adults with AMI., Methods: A total of 2,219 adults with AMI (1,494 women) aged 18-55 years were enrolled from 103 hospitals in the United States (2008-2012). Serum lipids and lipoprotein subclasses were measured 1 month after discharge., Results: More than 90% of adults were discharged on a statin, but less than half received a high-intensity dose and 12% stopped taking treatments by 1 month. For both men and women, the median of low-density lipoprotein (LDL) cholesterol was reduced to <100 mg/dL 1 month after discharge for AMI, but high-density lipoprotein (HDL) cholesterol remained <40 mg/dL. Multivariate regression analyses showed that young women had favorable lipoprotein profiles compared with men: women had higher HDL cholesterol and HDL large particle, but lower total cholesterol-to-HDL cholesterol ratio and LDL small particle., Conclusions: Young women with AMI had slightly favorable lipid and lipoprotein profiles compared with men, suggesting that difference in lipid and lipoprotein may not be a major contributor to sex differences in outcomes after AMI. In both men and women, statin remained inadequately used, and low HDL cholesterol level was a major lipid abnormality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: Most younger adults who experience an acute myocardial infarction (AMI) are sexually active before the AMI, but little is known about sexual activity or sexual function after the event., Objective: To describe patterns of sexual activity and function and identify indicators of the probability of loss of sexual activity in the year after AMI., Design, Setting, and Participants: Data from the prospective, multicenter, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study (conducted from August 21, 2008, to January 5, 2012) were assessed at baseline, 1 month, and 1 year. Participants were from US (n = 103) and Spanish (n = 24) hospitals and completed baseline and all follow-up interviews. Data analysis for the present study was conducted from October 15, 2014, to June 6, 2016. Characteristics associated with loss of sexual activity were assessed using multinomial logistic regression analyses., Main Outcomes and Measures: Loss of sexual activity after AMI., Results: Of the 2802 patients included in the analysis, 1889 were women (67.4%); median (25th-75th percentile) age was 49 (44-52) years (range, 18-55 years). At all time points, 637 (40.4%) of women and 437 (54.9%) of men were sexually active. Among people who were active at baseline, men were more likely than women to have resumed sexual activity by 1 month (448 [63.9%] vs 661 [54.5%]; P < .001) and by 1 year (662 [94.4%] vs 1107 [91.3%]; P = .01) after AMI. Among people who were sexually active before and after AMI, women were less likely than men to report no sexual function problems in the year after the event (466 [40.3%] vs 382 [54.8%]; P < .01). In addition, more women than men (211 [41.9%] vs 107 [30.5%]; P < .01) with no baseline sexual problems developed 1 or more incident problems in the year after the AMI. At 1 year, the most prevalent sexual problems were lack of interest (487 [39.6%]) and trouble lubricating (273 [22.3%]) among women and erectile difficulties (156 [21.7%]) and lack of interest (137 [18.8%]) among men. Those who had not communicated with a physician about sex in the first month after AMI were more likely to delay resuming sex (adjusted odds ratio [AOR], 1.51; 95% CI, 1.11-2.05; P = .008). Higher stress levels (AOR, 1.36; 95% CI, 1.01-1.83) and having diabetes (AOR, 1.90; 95% CI, 1.15-3.13) were significant indicators of the probability of loss of sexual activity in the year after the AMI., Conclusions and Relevance: Impaired sexual activity and incident sexual function problems were prevalent and more common among young women than men in the year after AMI. Attention to modifiable risk factors and physician counseling may improve outcomes.

Background: Return to work after acute myocardial infarction (AMI) is an important outcome and is particularly relevant to young patients. Women may be at a greater risk for not returning to work given evidence of their worse recovery after AMI than similarly aged men. However, sex differences in return to work after AMI has not been studied extensively in a young population (≤ 55 years)., Methods and Results: We analyzed data from 1680 patients with AMI aged 18 to 55 years (57% women) participating in the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study who were working full time (≥ 35 hours) before the event. Data were obtained by medical record abstraction and patient interviews. We conducted multivariable regression analyses to examine sex differences in return to work at 12 months after AMI, and the association of patient characteristics with return to work. When compared with young men, young women were less likely to return to work (89% versus 85%; 85% versus 89%, P=0.02); however, this sex difference was not significant after adjusting for patient sociodemographic characteristics, psychosocial factors, and health measures. Being married, engaging in a professional or clerical type of work, having more favorable physical health, and having no previous coronary disease or hypertension were significantly associated with a higher likelihood of return to work at 12 months., Conclusions: Among a young population, women are less likely to return to work after AMI than men. This disadvantage is explained by differences in demographic, occupational, and health characteristics., (© 2016 American Heart Association, Inc.)

Aims: We assessed gender differences in pre-event health status (symptoms, functioning, quality of life) in young patients with acute myocardial infarction and whether or not this association persists following sequential adjustment for important covariates. We also evaluated the interaction between gender and prior coronary artery disease, given that aggressive symptom control is a cornerstone of care in those with known coronary disease., Methods and Results: A total of 3501 acute myocardial infarction patients (2349 women) aged 18-55 years were enrolled from 103 US/24 Spanish hospitals (2008-2012). Clinical/health status information was obtained by medical record abstraction and patient interviews. Pre-event health status was measured by generic (Short Form-12, EuroQoL) and disease-specific (Seattle Angina Questionnaire) measures. T-test/chi-square and multivariable linear/logistic regression analysis was utilized, sequentially adjusting for covariates. Women had more co-morbidities and significantly lower generic mean health scores than men (Short Form-12 physical health = 43 ± 12 vs. 46 ± 11 and mental health = 44 ± 13 vs. 48 ± 11); EuroQoL utility index = 0.7 ± 0.2 vs. 0.8 ± 0.2 and visual analog scale = 63 ± 22 vs. 67 ± 20, P < 0.0001 for all. Their disease-specific health status was also worse, with more angina (Seattle Angina Questionnaire angina frequency = 83 ± 22 vs. 87 ± 18), worse physical function (physical limitation = 78 ± 27 vs. 87 ± 21) and poorer quality of life (55 ± 25 vs. 60 ± 22, P<0.0001 for all). In multivariable analysis, the association between female gender and worse generic physical/mental health persisted, as well as worse disease-specific physical limitation and quality of life. The interaction between gender and prior coronary artery disease was not significant in any of the health status outcomes., Conclusion: Young women have worse pre-event health status as compared with men, regardless of their coronary artery disease history. While future studies of gender differences should adjust for baseline health status, an opportunity may exist to better address the pre-event health status of women at risk for acute myocardial infarction., (© The European Society of Cardiology 2015.)

This prospective study assessed whether gender differences in health insurance help explain gender differences in delay in seeking care for patients in the US, with acute myocardial infarction (AMI). We also assessed gender differences in such prehospital delay for AMI in Spain, a country with universal insurance. We used data from 2,951 US and 496 Spanish patients aged 18 to 55 years with AMI. US patients were grouped by insurance status: adequately insured, underinsured, or uninsured. For each country, we assessed the association between gender and prehospital delay (symptom onset to hospital arrival). For the US cohort, we modeled the relation between insurance groups and delay of >12 hours. US women were less likely than men to be uninsured but more likely to be underinsured, and a larger proportion of women than men experienced delays of >12 hours (38% vs 29%). We found no association between insurance status and delays of >12 hours in men or women. Only 17.3% of Spanish patients had delays of >12 hours, and there were no significant gender differences. In conclusion, women were more likely than men to delay, although it was not explained by differences in insurance status. The lack of gender differences in prehospital delays in Spain suggests that these differences may vary by health care system and culture., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Differences between sexes in cardiac risk factors, perceptions of cardiac risk, and health care provider discussions about risk among young patients with acute myocardial infarction (AMI) are not well studied., Objectives: This study compared cardiac risk factor prevalence, risk perceptions, and health care provider feedback on heart disease and risk modification between young women and men hospitalized with AMI., Methods: We studied 3,501 AMI patients age 18 to 55 years enrolled in the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study in U.S. and Spanish hospitals between August 2008 and January 2012, comparing the prevalence of 5 cardiac risk factors by sex. Modified Poisson regression was used to assess sex differences in self-perceived heart disease risk and self-reported provider discussions of risk and modification., Results: Nearly all patients (98%) had ≥1 risk factor, and 64% had ≥3. Only 53% of patients considered themselves at risk for heart disease, and even fewer reported being told they were at risk (46%) or that their health care provider had discussed heart disease and risk modification (49%). Women were less likely than men to be told they were at risk (relative risk: 0.89; 95% confidence interval: 0.84 to 0.96) or to have a provider discuss risk modification (relative risk: 0.84; 95% confidence interval: 0.79 to 0.89). There was no difference between women and men for self-perceived risk., Conclusions: Despite having significant cardiac risk factors, only one-half of young AMI patients believed they were at risk for heart disease before their event. Even fewer discussed their risks or risk modification with their health care providers; this issue was more pronounced among women., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Excess dosing of anticoagulant agents has been linked to increased risk of bleeding after percutaneous coronary intervention (PCI) for women compared with men, but these studies have largely included older patients. We sought to determine the prevalence and gender-based differences of excess dosing of anticoagulants including glycoprotein IIb/IIIa inhibitors, bivalirudin, and unfractionated heparin in young patients with acute myocardial infarction who underwent PCI and to examine its association with bleeding. Of 2,076 patients enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young Acute Myocardial Infarction Patients study who underwent PCI, we abstracted doses of unfractionated heparin, bivalirudin, and glycoprotein IIb/IIIa inhibitors administered during PCI from the medical records. At least 47.2% received at least 1 excess dose of an anticoagulant, which did not differ by gender. We used logistic regression to determine the predictors of excess dosing and the association of excess dosing with bleeding. In multivariable analysis, only lower body weight and younger age were significant predictors of excess dosing. Bleeding was higher in young women who received excess dosing versus those who did not (9.3% vs 6.0%, p = 0.03) but was comparable among men (5.2% vs 5.9%, p = 0.69) in univariate analysis. In multivariable analysis, there was a trend to an association between excess dosing and bleeding (odds ratio 1.33, 95% confidence interval 0.92 to 1.91) although not statistically significant. In conclusion, approximately half of the patients received excess dosing of anticoagulant drugs during PCI, which did not vary based on gender. There was a trend toward an association between excess dosing and increased bleeding, although not statistically significant., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Despite the excess risk of mortality in young women (≤55 years of age) after acute myocardial infarction (AMI), little is known about young women's health status (symptoms, functioning, quality of life) during the first year of recovery after an AMI. We examined gender differences in health status over time from baseline to 12 months after AMI., Methods and Results: A total of 3501 AMI patients (67% women) 18 to 55 years of age were enrolled from 103 US and 24 Spanish hospitals. Data were obtained by medical record abstraction and patient interviews at baseline hospitalization and 1 and 12 months after AMI. Health status was measured by generic (Short Form-12) and disease-specific (Seattle Angina Questionnaire) measures. We compared health status scores at all 3 time points and used longitudinal linear mixed-effects analyses to examine the independent effect of gender, adjusting for time and selected covariates. Women had significantly lower health status scores than men at each assessment (all P values <0.0001). After adjustment for time and all covariates, women had Short Form-12 physical/mental summary scores that were -0.96 (95% confidence interval [CI], -1.59 to -0.32) and -2.36 points (95% CI, -2.99 to -1.73) lower than those of men, as well as worse Seattle Angina Questionnaire physical limitations (-2.44 points lower; 95% CI, -3.53 to -1.34), more angina (-1.03 points lower; 95% CI, -1.98 to -0.07), and poorer quality of life (-3.51 points lower; 95% CI, -4.80 to -2.22)., Conclusion: Although both genders recover similarly after AMI, women have poorer scores than men on all health status measures, a difference that persisted throughout the entire year after discharge., (© 2015 American Heart Association, Inc.)

Background: Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men., Methods and Results: We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33)., Conclusions: Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy., (© 2015 American Heart Association, Inc.)

Background: Depression was recently recognized as a risk factor for adverse medical outcomes in patients with acute myocardial infarction (AMI). The degree to which depression is present among younger patients with an AMI, the patient profile associated with being a young AMI patient with depressive symptoms, and whether relevant sex differences exist are currently unknown., Methods and Results: The Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study enrolled 3572 patients with AMI (67.1% women; 2:1 ratio for women to men) between 2008 and 2012 (at 103 hospitals in the United States, 24 in Spain, and 3 in Australia). Information about lifetime history of depression and depressive symptoms experienced over the past 2 weeks (Patient Health Questionnaire; a cutoff score ≥10 was used for depression screening) was collected during index AMI admission. Information on demographics, socioeconomic status, cardiovascular risk, AMI severity, perceived stress (14-item Perceived Stress Scale), and health status (Seattle Angina Questionnaire, EuroQoL 5D) was obtained through interviews and chart abstraction. Nearly half (48%) of the women reported a lifetime history of depression versus 1 in 4 in men (24%; P<0.0001). At the time of admission for AMI, more women than men experienced depressive symptoms (39% versus 22%, P<0.0001; adjusted odds ratio 1.64; 95% CI 1.36 to 1.98). Patients with more depressive symptoms had higher levels of stress and worse quality of life (P<0.001). Depressive symptoms were more prevalent among patients with lower socioeconomic profiles (eg, lower education, uninsured) and with more cardiovascular risk factors (eg, diabetes, smoking)., Conclusions: A high rate of lifetime history of depression and depressive symptoms at the time of an AMI was observed among younger women compared with men. Depressive symptoms affected those with more vulnerable socioeconomic and clinical profiles., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population., Methods and Results: We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease., Conclusions: Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population., (© 2015 American Heart Association, Inc.)

Background: Younger age and female sex are both associated with greater mental stress in the general population, but limited data exist on the status of perceived stress in young and middle-aged patients presenting with acute myocardial infarction., Methods and Results: We examined sex difference in stress, contributing factors to this difference, and whether this difference helps explain sex-based disparities in 1-month recovery using data from 3572 patients with acute myocardial infarction (2397 women and 1175 men) 18 to 55 years of age. The average score of the 14-item Perceived Stress Scale at baseline was 23.4 for men and 27.0 for women (P<0.001). Higher stress in women was explained largely by sex differences in comorbidities, physical and mental health status, intrafamily conflict, caregiving demands, and financial hardship. After adjustment for demographic and clinical characteristics, women had worse recovery than men at 1 month after acute myocardial infarction, with mean differences in improvement score between women and men ranging from -0.04 for EuroQol utility index to -3.96 for angina-related quality of life (P<0.05 for all). Further adjustment for baseline stress reduced these sex-based differences in recovery to -0.03 to -3.63, which, however, remained statistically significant (P<0.05 for all). High stress at baseline was associated with significantly worse recovery in angina-specific and overall quality of life, as well as mental health status. The effect of baseline stress on recovery did not vary between men and women., Conclusions: Among young and middle-aged patients, higher stress at baseline is associated with worse recovery in multiple health outcomes after acute myocardial infarction. Women perceive greater psychological stress than men at baseline, which partially explains women's worse recovery., (© 2015 American Heart Association, Inc.)

Background: Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade., Methods: To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010., Results: We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P < .001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke., Conclusions: From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients' experience with counseling about sexual activity after AMI., Methods and Results: The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03-1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02-1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08-1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11-1.66)., Conclusions: Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT00597922., (© 2014 American Heart Association, Inc.)

Background: Social support is an important predictor of health outcomes after acute myocardial infarction (AMI), but social support varies by sex and age. Differences in social support could account for sex differences in outcomes of young patients with AMI., Methods and Results: Data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, an observational study of AMI patients aged ≤55 years in the United States and Spain, were used for this study. Patients were categorized as having low versus moderate/high perceived social support using the ENRICHD Social Support Inventory. Outcomes included health status (Short Form-12 physical and mental component scores), depressive symptoms (Patient Health Questionnaire), and angina-related quality of life (Seattle Angina Questionnaire) evaluated at baseline and 12 months. Among 3432 patients, 21.2% were classified as having low social support. Men and women had comparable levels of social support at baseline. On average, patients with low social support reported lower functional status and quality of life and more depressive symptoms at baseline and 12 months post-AMI. After multivariable adjustment, including baseline health status, low social support was associated with lower mental functioning, lower quality of life, and more depressive symptoms at 12 months (all P<0.001). The relationship between low social support and worse physical functioning was nonsignificant after adjustment (P=0.6). No interactions were observed between social support, sex, or country., Conclusion: Lower social support is associated with worse health status and more depressive symptoms 12 months after AMI in both young men and women. Sex did not modify the effect of social support., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Various national campaigns launched in recent years have focused on young women with acute myocardial infarctions (AMIs). Contemporary longitudinal data about sex differences in clinical characteristics, hospitalization rates, length of stay (LOS), and mortality have not been examined., Objectives: This study sought to determine sex differences in clinical characteristics, hospitalization rates, LOS, and in-hospital mortality by age group and race among young patients with AMIs using a large national dataset of U.S. hospital discharges., Methods: Using the National Inpatient Sample, clinical characteristics, AMI hospitalization rates, LOS, and in-hospital mortality were compared for patients with AMI across ages 30 to 54 years, dividing them into 5-year subgroups from 2001 to 2010, using survey data analysis techniques., Results: A total of 230,684 hospitalizations were identified with principal discharge diagnoses of AMI in 30- to 54-year-old patients from Nationwide Inpatient Sample data, representing an estimated 1,129,949 hospitalizations in the United States from 2001 to 2010. No statistically significant declines in AMI hospitalization rates were observed in the age groups <55 years or stratified by sex. Prevalence of comorbidities was higher in women and increased among both sexes through the study period. Women had longer LOS and higher in-hospital mortality than men across all age groups. However, observed in-hospital mortality declined significantly for women from 2001 to 2010 (from 3.3% to 2.3%, relative change 30.5%; p for trend < 0.0001) but not for men (from 2% to 1.8%, relative change 8.6%; p for trend = 0.60)., Conclusions: AMI hospitalization rates for young people have not declined over the past decade. Young women with AMIs have more comorbidity, longer LOS, and higher in-hospital mortality than young men, although their mortality rates are decreasing., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Modification of traditional cardiac risk factors is an important goal for patients after an acute myocardial infarction (AMI). Risk factor prevalence and secondary prevention efforts at discharge are well characterized among older patients; however, research is limited for younger and minority AMI populations, particularly among women., Methods: Among 2369 AMI patients enrolled in a 19-center prospective study, we compared the prevalence and cumulative number of five cardiac risk factors (hypertension, hypercholesterolemia, current smoking, diabetes, obesity) by age, sex, and race. We also compared secondary prevention strategies at discharge for these risk factors, including prescription of antihypertensive or lipid-lowering medications and counseling on preventive behaviors (smoking cessation, diabetes management, diet/weight management)., Results: Approximately 93% of patients had ≥1 risk factor, 72% had ≥2 factors, and 40% had ≥3 factors. The prevalence of multiple risk factors was markedly higher for blacks than for whites within each age-sex group; black women had the greatest risk factor burden of any subgroup (60% of older black women and 54% of younger black women had ≥3 risk factors). Secondary prevention efforts for smoking cessation were less common for black compared with white patients, and younger black patients were less often prescribed antihypertensive and lipid-lowering medications compared with younger white patients., Conclusions: Multiple cardiac risk factors are highly prevalent in AMI patients, particularly among black women. Secondary prevention efforts, however, are less common for blacks compared to whites, especially among younger patients. Our findings highlight the need for improved risk factor modification efforts in these high-risk subgroups.

Objective: To examine changes in social support during early recovery after acute myocardial infarction (AMI) and determine whether these changes influence outcomes within the first year., Methods: Among 1951 AMI patients enrolled in a 19-center prospective study, we examined changes in social support between baseline (index hospitalization) and 1 month post-AMI to longitudinally assess their association with health status and depressive symptoms within the first year. We further examined whether 1-month support predicted outcomes independent of baseline support. Hierarchical repeated-measures regression evaluated associations, adjusting for site, baseline outcome level, baseline depressive symptoms, sociodemographic characteristics, and clinical factors., Results: During the first month of recovery, 5.6% of patients had persistently low support, 6.4% had worsened support, 8.1% had improved support, and 80.0% had persistently high support. In risk-adjusted analyses, patients with worsened support (vs. persistently high) had greater risk of angina (relative risk=1.46), lower disease-specific quality of life (β=7.44), lower general mental functioning (β=4.82), and more depressive symptoms (β=1.94) (all p≤.01). Conversely, patients with improved support (vs. persistently low) had better outcomes, including higher disease-specific quality of life (β=6.78), higher general mental functioning (β=4.09), and fewer depressive symptoms (β=1.48) (all p≤.002). In separate analyses, low support at 1 month was significantly associated with poorer outcomes, independent of baseline support level (all p≤.002)., Conclusion: Changes in social support during early AMI recovery were not uncommon and were important for predicting outcomes. Intervening on low support during early recovery may provide a means of improving outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Emotional support and depression may influence adherence to risk factor management instructions after acute myocardial infarction (AMI), but their role requires further investigation., Purpose: To examine the longitudinal association between perceived emotional support and risk factor management adherence and assess depressive symptoms as a moderator of this association., Methods: Among 2,202 AMI patients, we assessed adherence to risk factor management instructions over the first recovery year. Modified Poisson mixed-effects regression evaluated associations, with adjustment for demographic and clinical factors., Results: Patients with low baseline support had greater risk of poor adherence over the first year than patients with high baseline support (relative risk [RR] = 1.20, 95% confidence interval [CI] = 1.02-1.43). In stratified analyses, low support remained a significant predictor of poor adherence for non-depressed (RR = 1.41, 95% CI = 1.23-1.61) but not depressed (RR = 1.01, 95% CI = 0.78-1.30) patients (p for interaction < 0.001)., Conclusions: Low emotional support is associated with poor risk factor management adherence after AMI. This relationship is moderated by depression, with a significant relationship observed only among non-depressed patients.

Background: Somatic depressive symptoms and certain biomarkers are each associated with worse acute myocardial infarction (AMI) prognosis, but the relationship between depressive symptom domains and inflammatory, neurohormonal, and coagulation markers is unknown., Methods: We examined the relationship between depressive symptoms and 1-month biomarker levels (high-sensitivity C-reactive protein [hs-CRP], N-terminal pro-brain natriuretic peptide [NT-proBNP], white blood cell [WBC], platelet counts) in 1265 AMI patients. Depressive symptoms (9-item Patient Health Questionnaire) were assessed during index hospitalization and categorized as somatic or cognitive. Using median regression models, the upper quartile of somatic and cognitive depression scores and each biomarker were compared with the lower three quartiles, adjusting for site, demographics, and clinical characteristics., Results: Although hs-CRP values were higher in patients with somatic symptoms, this association was attenuated after adjustment (B(per SD increase) = .02, 95% confidence interval: .00; .05, p = .07). WBC count was independently associated with somatic depressive symptoms (B(per SD increase) = .28, 95% confidence interval: .12; .44, p < .001). Cognitive depressive symptoms were not associated with hs-CRP or WBC count. Neither dimension was associated with NT-proBNP or platelet levels. For each biomarker, the depression dimensions explained <1% of their variation., Conclusions: Neither somatic nor cognitive depressive symptoms were meaningfully associated with hs-CRP, NT-proBNP, WBC, or platelet counts 1 month after AMI, suggesting that the association between depression and long-term outcomes may be unrelated to these biomarkers. Future research should explore other biomarkers to better illuminate pathways by which depression adversely impacts AMI prognosis., (Copyright © 2012 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies., Methods and Results: Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors; to determine whether there are sex differences in the quality of care received by young AMI patients; and to determine how these factors contribute to sex differences in outcomes (including mortality, hospitalization, and health status). Blood serum and DNA for consenting participants will be stored for future studies., Conclusions: VIRGO will seek to identify novel and prognostic factors that contribute to outcomes in this young AMI population. Results from the study will be used to develop clinically useful risk-stratification models for young AMI patients, explain sex differences in outcomes, and identify targets for intervention.

Background: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists., Methods: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality., Results: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia., Conclusions: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality., (2010 Massachusetts Medical Society)

Background: Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex., Methods and Results: Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [beta]=-3.33; 95% CI, -5.25, -1.41), lower mental functioning (beta=-1.72; 95% CI, -2.65, -0.79), and more depressive symptoms (beta=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (beta=-0.87; 95% CI, -1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P<0.02)., Conclusions: Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.

Context: During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates., Objective: To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI., Design, Setting, and Patients: Observational study using administrative data and a validated risk model to evaluate 3,195,672 discharges in 2,755,370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI., Main Outcome Measure: Hospital-specific 30-day all-cause RSMR., Results: At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%., Conclusion: Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.

Background: Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction., Methods: We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic., Results: The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes)., Conclusions: Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

Background: We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time., Methods: Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time., Results: In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively., Conclusions: Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Background: Acute myocardial infarction may be accompanied by acute, severe, concomitant, noncardiac conditions, but their prevalence and prognostic importance is not well defined. We sought to evaluate the prevalence of acute, severe, noncardiac conditions present at the time of hospital admission with acute myocardial infarction and to assess the association of these conditions with in-hospital mortality., Methods and Results: A total of 3907 patients admitted with an acute myocardial infarction were prospectively enrolled in 19 US centers between January 2003 and June 2004. Acute noncardiac conditions present at admission with imminent threat to life were identified from medical record review within 24 hours of admission. Using multivariable analyses, we evaluated the relationship between these conditions and in-hospital mortality. We documented a concomitant acute, severe, noncardiac condition in 6.8% (n=267) of the study sample. The most common concomitant conditions were severe pneumonia (potentially requiring intubation; 18.4%), severe gastrointestinal bleeding/anemia (15.7%), stroke (9.7%), and sepsis (9.4%). These patients were less likely to be ideal for or to receive evidence-based therapies at the time of admission. The in-hospital mortality was 21.3% (57 of 267) for patients with concomitant conditions versus 2.7% (100 of 3640) for those without these conditions. The presence of an acute noncardiac condition was associated with an increased risk of in-hospital mortality after adjustment for demographic and clinical characteristics and disease severity (odds ratio, 5.0; 95% confidence interval, 3.3 to 7.7)., Conclusions: Concomitant, acute, noncardiac conditions are common and associated with a marked increase in the risk of in-hospital mortality.

Background: The ranking of "America's Best Hospitals" by U.S. News & World Report for "Heart and Heart Surgery" is a popular hospital profiling system, but it is not known if hospitals ranked by the magazine vs nonranked hospitals have lower risk-standardized, 30-day mortality rates (RSMRs) for patients with acute myocardial infarction (AMI)., Methods: Using a hierarchical regression model based on 2003 Medicare administrative data, we calculated RSMRs for ranked and nonranked hospitals in the treatment of AMI. We identified ranked and nonranked hospitals with standardized mortality ratios (SMRs) significantly less than the mean expected for all hospitals in the study., Results: We compared 13 662 patients in 50 ranked hospitals with 254 907 patients in 3813 nonranked hospitals. The RSMRs were lower in ranked vs nonranked hospitals (16.0% vs 17.9%, P<.001). The RSMR range for ranked vs nonranked hospitals overlapped (11.4%-20.0% vs 13.1%-23.3%, respectively). In an RSMR quartile distribution of all hospitals, 35 ranked hospitals (70%) were in the lowest RSMR or best performing quartile, 11 (22%) were in the middle 2 quartiles, and 4 (8%) were in the highest RSMR or worst performing quartile. There were 11 ranked hospitals (22%) and 28 nonranked hospitals (0.73%) that each had an SMR significantly less than 1 (defined by a 95% confidence interval with an upper limit of <1.0)., Conclusions: On average, admission to a ranked hospital for AMI was associated with a lower risk of 30-day mortality, although about one-third of the ranked hospitals fell outside the best performing quartile based on RSMR. Although ranked hospitals were much more likely to have an SMR significantly less than 1, many more nonranked hospitals had this distinction.

Objective: To determine if psychosocial status influences treatment satisfaction, a quality-of-care indicator, of patients who were hospitalized for acute myocardial infarction (AMI)., Methods: Psychosocial variables (social support, dispositional optimism, and depression) were assessed in 1847 AMI patients who completed a 1-month assessment in Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), a multicenter, prospective cohort study. Patients' treatment satisfaction was determined using the Treatment Satisfaction scale of the Seattle Angina Questionnaire. The association between psychosocial variables and treatment satisfaction-adjusted for site, sociodemographics, medical history, clinical presentation, and treatment procedures-was evaluated using a censored normal model., Results: Study participants were primarily white (77.6%) and male (68.8%), with a mean age of 60.6 +/- 12.7 (SD) years. Satisfaction with posthospitalization treatment following AMI increased as social support (Wald chi(2) = 35.02, p < .001) and dispositional optimism (beta = 1.42; 95% CI 0.24, 2.60) increased. Participants with mild (-3.10, 95% CI -5.77, -0.44), moderate (-4.77, 95% CI -8.16, -1.38), moderately severe (-8.49, 95% CI -13.47, -3.52), and severe (-11.65, 95% CI -18.77, -4.53) depression had significantly worse treatment satisfaction compared with the nondepressed participants., Conclusion: Assessing psychosocial variables, such as social support, dispositional optimism, and depression severity before hospital discharge, may indicate who is likely to be more satisfied with posthospitalization cardiac care 1 month following AMI. Without controlling for psychosocial status, treatment satisfaction may be a biased indicator of quality. Future studies should evaluate whether psychosocial intervention after AMI can improve satisfaction.

Background: Although much attention has been given to survival after myocardial infarction (MI), little is known about sex differences in health status (symptoms, function, and quality of life). A particularly critical moment to assess health status following an MI is early after discharge when patients have resumed routine activities and when additional treatments may be offered to those with residual angina or quality of life limitations., Methods: We used multivariable Poisson and linear regression models to examine differences in 30-day health status by sex in a cohort of 2096 MI patients enrolled in a 19-center Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER)., Results: Women (32% of the cohort) were older and less likely to be white, married, or treated with coronary revascularization. They were more likely to have had a non-ST segment elevation MI, diabetes, hypertension, heart failure, chronic lung disease, and worse health status at admission. Risk-adjusted multivariable models suggest women were slightly more likely to have angina (RR 1.06, 95% CI 1.0, 1.14, p = 0.06), worse quality of life (difference in SAQ score = -4.36 points, 95% CI -5.44, -3.27 points, p = <0.001) and poorer physical functioning (difference in SF-12 PCS = -2.55 points, 95%CI = -3.62, -1.48 points, p = <0.001) at 30 days than men., Conclusions: One in four patients experienced angina 1 month after their MI, and women had a slightly greater prevalence than men. The physical function and quality of life of women 30 days after an MI is similar to or worse than that of men.

Safety-net hospitals are experiencing increasing financial strains, possibly affecting their quality of care. We compare quality at safety-net and non-safety-net urban hospitals for Medicare beneficiaries admitted with acute myocardial infarction (AMI). Although safety-net hospitals had modestly higher risk-standardized thirty-day all-cause mortality rates and modestly lower adherence to quality-of-care performance measures than non-safety-net hospitals, there was much heterogeneity among safety-net hospitals and substantial overlap with non-safety-net hospitals. We examine the implications of these findings for the millions of vulnerable Americans who rely on safety-net hospitals for their care.

Purpose: The study's purpose was to determine the prevalence and prognostic importance of acute, severe, noncardiac conditions present at the time of an acute myocardial infarction (AMI)., Methods: We identified consecutive patients with AMI who were discharged from Yale-New Haven Hospital between January 1, 1997, and June 30, 2000. Acute, noncardiac conditions that were present at admission were abstracted from patient records and graded by severity (imminent threat to life; other significant condition that would warrant admission). We examined the prognostic importance of these conditions on hospital mortality in multivariable logistic models. The study included 1145 patients with AMI, of whom 8.5% (n=97) presented with an acute, life-threatening, noncardiac condition at admission and 19.5% (n=223) presented with another significant noncardiac condition., Results: Hospital mortality was 25.8% and 9.0%, respectively, for patients who presented with life-threatening and other significant noncardiac conditions, compared with 4.6% for patients without either of these conditions. In multivariable analysis, life-threatening noncardiac conditions were associated with increased hospital mortality after adjusting for demographic factors, medical history, clinical presentation, cardiac severity, and initial therapy (odds ratio 2.5; 95% confidence interval [CI], 1.2-5.2). No increased hospital mortality risk was found for other significant noncardiac conditions in the risk-adjusted analyses (odds ratio 1.0; 95% CI, 0.5-1.7)., Conclusions: A subgroup of patients with AMI presented with a life-threatening noncardiac condition, which was associated with a marked increase in the risk of death during the hospitalization. Despite the excessive mortality risk associated with concomitant noncardiac conditions, this subset of patients with AMI are poorly described in current literature.

Background: Depression is common in patients hospitalized with acute myocardial infarction (AMI). In the community, younger women are uniquely prone to depression. Whether younger women are also more likely to have depression during hospitalization with AMI is unknown., Methods: A total of 2498 AMI patients (1284 patients

Background: Stroke is an important outcome after acute myocardial infarction. Studies that have examined this relationship have largely excluded older patients, even though half of stroke admissions occur among patients 75 years of age and older., Methods and Results: Among 111 023 medicare patients discharged with a principal diagnosis of acute myocardial infarction during an 8-month period in 1994 to 1995, we identified hospital admissions for ischemic stroke within 6 months of discharge. The rate of admission was 2.5% within 6 months. Independent predictors of ischemic stroke were age greater-than-or-equal 75 years, black race, no aspirin at discharge, frailty, prior stroke, atrial fibrillation, diabetes, hypertension, and history of peripheral vascular disease. To identify individuals at increased risk for stroke, a risk stratification score was constructed from identified factors. The 6-month stroke admission rate for patients with a score of 4 or higher (approximately 20% of the total sample) was approximately 4%., Conclusions: The risk of stroke after myocardial infarction is substantial, with about 1 in 40 patients suffering an ischemic stroke within 6 months of discharge. Simple clinical factors can predict the risk of stroke and, based on these factors, we identified 20% of older patients who have a 1 in 25 chance of being hospitalized for a stroke within 6 months of discharge.

Aims Little is known about the relationship between marital/partner status and patient-reported outcome measures (PROMs) following myocardial infarction (MI). We conducted a systematic review/meta-analysis and explored potential sex differences. Methods and results We searched five databases (Medline, Web of Science, Scopus, EMBASE, and PsycINFO) from inception to 27 July 2022. Peer-reviewed studies of MI patients that evaluated marital/partner status as an independent variable and reported its associations with defined PROMs were eligible for inclusion. Results for eligible studies were classified into four pre-specified outcome domains [health-related quality of life (HRQoL), functional status, symptoms, and personal recovery (i.e. self-efficacy, adherence, and purpose/hope)]. Study quality was appraised using Newcastle–Ottawa Scale, and data were synthesized by outcome domains. We conducted subgroup analysis by sex. We included 34 studies (n = 16 712), of which 11 were included in meta-analyses. Being married/partnered was significantly associated with higher HRQoL {six studies [ n = 2734]; pooled standardized mean difference, 0.37 [95% confidence interval (CI), 0.12–0.63], I 2 = 51%} but not depression [three studies (n = 2005); pooled odds ratio, 0.72 (95% CI, 0.32–1.64); I 2 = 65%] or self-efficacy [two studies (n = 356); pooled β , 0.03 (95% CI, −0.09 to 0.14); I 2 = 0%]. The associations of marital/partner status with functional status, personal recovery outcomes, and symptoms of anxiety and fatigue were mixed. Sex differences were not evident due to mixed results from the available studies. Conclusions Married/partnered MI patients had higher HRQoL than unpartnered patients, but the associations with functional, symptom, and personal recovery outcomes and sex differences were less clear. Our findings inform better methodological approaches and standardized reporting to facilitate future research on these relationships. [ABSTRACT FROM AUTHOR]