Sex, Death, and the Diagnosis Gap
Cardiovascular disease (CVD) continues to kill more women than men annually in the United States,1 a female death epidemic that emerged rapidly in 1984 and persists in 2014. This mortality shift was not accompanied by explanatory sex-specific changes in known risk factors2 and was too rapid to be caused by sex-linked genetic/genomic change. Although the aging epidemic combined with female longevity is a convenient putative explanation, CVD death rates have actually declined in older women, concomitant with the declines in older and young men, compared with an increase in younger women.2 Although overall female CVD death rates began to decline in the 2000s,1 we continue to have both a surplus of female deaths and an absence of understanding as to root causes.
Article see p 757
Ischemic heart disease (IHD) accounts for the majority of CVD death. Notably, the female-majority CVD death epidemic has occurred in the absence of a female-majority coronary heart disease (CHD) and myocardial infarction (MI) mortality epidemic.1 Said another way, although women constitute more than half of all CVD deaths, they account for only one third of the CHD and MI burden. A simple look at the daily cardiac care unit or catheterization laboratory roster tells the story: We continue to have sex ratios of 30% women to 70% men diagnosed with CHD and MI. Although higher burdens of stroke and heart failure mortality in women explain a portion of the female excess CVD mortality, it does not fully explain the gap.1 How do women die of IHD without a diagnosis of MI or CHD?
In this issue of Circulation, a new analysis by Bucholz et al3 adds to the confusion. When sex differences in 39 studies with longer-term 5- and 10-year mortality after acute MI (AMI) were …