Elsevier

Resuscitation

Volume 155, October 2020, Pages 119-124
Resuscitation

Review
Association between sex and mortality in adults with in-hospital and out-of-hospital cardiac arrest: A systematic review and meta-analysis

https://doi.org/10.1016/j.resuscitation.2020.07.031Get rights and content

Abstract

Objectives

Conflicting data exists regarding the association between sex and mortality in adults with in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA). We therefore conducted a meta-analysis to investigate the association between sex and mortality in adults with IHCA and OHCA.

Methods

We systematically searched MEDLINE and Cochrane databases to identify studies reporting sex-specific mortality in adults following IHCA or OHCA from inception to April 2020. Data were pooled using random-effects models. The primary outcome of interest was in-hospital (or 30-day) all-cause mortality.

Results

We included 21 observational studies with a total of 1,029,978 adult patients – 622,085 men and 407,893 women. Seven studies included patients only with IHCA and 14 studies included patients only with OHCA. Female sex was associated with significantly higher mortality following OHCA [odds ratio (OR) 1.56, 95% confidence interval (CI) 1.32–1.84, p < 0.001) and a trend toward higher mortality following IHCA (OR 1.10, 95%CI 1.00–1.20, p = 0.052).

Conclusions

In adults with cardiac arrest, female sex was associated with significantly higher mortality following OHCA and a trend toward higher mortality following IHCA.

Introduction

query>Cardiac arrest (CA), a leading cause of death worldwide, claims the lives of an over 300,000 Americans annually.1, 2 Despite advances in resuscitative and post-resuscitative care, rates of survival and favorable neurologic outcomes remain low for in-hospital cardiac arrest (IHCA), and even lower for out-of-hospital cardiac arrest (OHCA).1 While data exists regarding sex-related disparities in outcomes following IHCA3, 4, 5, 6, 7, 8, 9 and OHCA,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 these studies have yielded conflicting results. A recent meta-analysis of 13 observational studies of patients with sudden cardiac arrest reported higher survival to hospital discharge in women compared to men,24 however, multiple studies involving patients less than 18 years of age were included in the quantitative analysis. Furthermore, since publication of this meta-analysis, several subsequent observational studies evaluating sex-related differences in outcomes have been published demonstrating contradictory results.10, 11, 12, 13, 14, 15, 16, 17, 18 Accordingly, we conducted a systematic review and meta-analysis of studies to specifically investigate the association between sex and mortality in adults with IHCA and OHCA.

Section snippets

Methods

We report this systematic review in accordance with the Preferred Reporting of Items for Systematic Reviews And Meta-Analyses (PRISMA) statement.25

Systematic search

Database search yielded 9916 citations. A total of 9833 citations were excluded given the titles and/or abstracts were not relevant to the proposed review. The remaining 83 articles were examined in greater detail for relevance. Eleven of these citations were excluded due to absence of data on sex-specific in-hospital or 30-day mortality. Another 51 citations were excluded as these were either case reports, review articles or involved inappropriate study populations. Overall, there were 21

Discussion

The principal findings of this systematic review and meta-analysis of observational clinical studies of adult patients with cardiac arrest are that female sex was associated with over 50% higher mortality following OHCA and a trend toward higher mortality following IHCA compared to male sex. To our knowledge, this is the first meta-analysis to examine sex-related disparities in outcomes in the setting of IHCA and the largest meta-analysis to date to examine outcomes in the setting of OHCA.

The

Conclusions

In adults with cardiac arrest, female sex was associated with over 50% higher mortality following OHCA compared to male sex and a trend toward higher mortality following IHCA. Further large-scale studies examining sex-related disparities in clinical presentation, management, and clinical outcomes in adults with OHCA and IHCA are warranted.

Funding support

Stony Brook Department of Medicine.

Conflict of interest statement

None.

References (31)

Cited by (8)

  • A more conservative test of sex differences in the treatment and outcome of in-hospital cardiac arrest

    2023, Heart and Lung
    Citation Excerpt :

    Regarding sudden cardiac arrest (CA), research has clearly shown that racial minorities and individuals with lower socioeconomic status (SES), such as uneducated and poor people, receive inferior treatment and are less likely to survive a sudden cardiac arrest both outside (of-hospital cardiac arrest=OHCA) and inside (in-hospital cardiac arrest=IHCA) the hospital.1-7 Regarding sex disparities, individual studies have produced rather divergent findings,8-10 although recent meta-analyses11,12 suggest that men show a survival advantage after OHCA compared to women, particularly when it comes to survival to discharge and to 30 days. Various empirically supported explanations have been provided for this disparity.

  • Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study

    2022, Mayo Clinic Proceedings
    Citation Excerpt :

    Several studies report that sex is not an independent predictor of mortality in OHCA patients.23-27 In contrast, the studies that reported higher risk of death in women attributed it to the differences in patients’ characteristics, prehospital management, and inpatient management.14-20 In one study, women presenting with OHCA were older, had lower rates of shockable rhythm,14 and experienced disparities in the prehospital management of OHCA.

  • Sex-related disparities in the in-hospital management of patients with out-of-hospital cardiac arrest

    2022, Resuscitation
    Citation Excerpt :

    Women experiencing cardiac arrest are less likely to receive bystander cardiopulmonary resuscitation (CPR)5,12–14 and less frequently present with a shockable rhythm.15,16 Conflicting results regarding sex disparities in survival and prognosis after OHCA were noted.16–28 However, the extent of sex disparities in OHCA remains unclear.

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