Sex, Death, and the Diagnosis Gap

• Editorials
• diagnosis
• myocardial infarction
• sex

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 …