Risk for Heart Failure Higher in Women vs Men After a Heart Attack

The 5-year risk of women dying or developing heart failure following a first severe heart attack is 20% higher compared with men, according to the findings in Circulation.

The 5-year risk of women dying or developing heart failure following a first severe heart attack is 20% higher compared with men, according to study findings published today in the journal Circulation.

“Identifying when and how women may be at higher risk for heart failure after a heart attack can help providers develop more effective approaches for prevention,” said lead study author Justin A. Ezekowitz, MBBCh, MSc, a cardiologist and codirector of the Canadian VIGOUR Centre at the University of Alberta in Edmonton, Alberta, Canada, in a statement.

Ezekowitz and his fellow authors conducted their population-based cohort study on 45,064 patients admitted to an Alberta hospital between April 1, 2002, and March 31, 2016, who had a first heart attack of 1 of 2 types that required hospitalization:

  • ST-segment elevation myocardial infarction (STEMI), a life-threatening heart attack (45.1%)
  • Non–STEMI (NSTEMI), a less severe and more common heart attack (54.9%)

A second hospitalization within 24 hours of the first was “considered to be part of the same episode,” noted the authors.

The female study population was older, and despite the women having more comorbidities, the results show that 74% of them vs 87% of men had a diagnostic angiography. Following this test, however, higher rates of 1-vessel disease or nonobstructive coronary artery disease were seen in the women: 39.6% vs 29.1% (P < .0001).

STEMIs and NSTEMIs resulted in higher unadjusted rates of death in women vs men: 9.4% vs 4.5% and 4.7% vs 2.9%, respectively. Adjusting for confounders did not alter the finding that these types of heart attacks were more likely to lead to the death of female patients:

  • STEMI: adjusted odds ratio (aOR), 1.42 (95% CI, 1.24-1.64)
  • NSTEMI: aOR, 0.97 (95% CI, 0.83-1.13)

Additional analyses found:

  • Fewer women than men had an NSTEMI: 34.3% vs 65.7%. An overall 55% (n = 24,737) of patients in the study experienced this type of heart attack.
  • Fewer women than men had a STEMI: 26.5% vs 73.5%. An overall 45% (n = 20,327) experienced this type of heart attack.
  • Hypertension, diabetes, atrial fibrillation, and chronic obstructive pulmonary disease were more common risk factors among women when they had a heart attack.
  • Women were seen 15.4% less often by a cardiovascular specialist compared with men: 72.8% vs 84%.
  • Beta-blockers and cholesterol-lowering drugs were prescribed less often for women.
  • Fewer surgeries were performed among women to restore blood flow.

Overall, in the aftermath of a hospital discharge, heart failure was the more likely ultimate outcome in women compared with men after both a STEMI and an NSTEMI: 22.5% vs 14.9% and 23.2% vs 15.7%, respectively.

Clinicians need to recognize that there are gaps in care between women and men, be aware of possible biases, and be more attuned to their highest-risk patients to provide better care, said Padma Kaul, PhD, one of the study’s coauthors. Future studies also should investigate the levels of care that all patients with heart issues are receiving, as well as identify possible oversights and how to surmount them, the authors stated.

“The development of HF either in-hospital or after discharge remained higher for women compared with men, even after adjustment,” they concluded. “Given its frequency, further attention should be paid to all patients with acute coronary syndromes for the prevention of future HF outcomes.”


Ezekowitz JA, Savu A, Welsh RC, McAlister FA, Goodman SG, Kaul P. Is there a gap in surviving an acute coronary syndrome or subsequent development of heart failure? Circulation. Published online November 30, 2020. doi:10.1161/CIRCULATIONAHA.120.048015