Sex- and age-based disparities in statin use in patients admitted for acute myocardial infarction in France: two decades of failure ?

Background

Statins are central to cardiovascular prevention, yet women and older adults appear less likely to receive guideline-recommended therapy, potentially contributing to outcome disparities. Long-term trends in prescription of statins before acute myocardial infarction (AMI) provide a useful lens to assess equity in prevention.

Purpose

To examine sex- and age-related differences in statin prescription prior to admission for AMI in France and to evaluate how these evolved over 20 years, alongside changes in lipid-lowering therapy (LLT) use.

Methods

We pooled data from the nationwide FAST-MI periodic surveys (2005, 2010, 2015) and the FRENCHIE cohort (2019–2022), which enrolled AMI patients admitted to PCI-capable 24/7 centres across France. Pre-admission statin and LLT use were recorded on admission. Patients were stratified by prior atherosclerotic cardiovascular disease (ASCVD: coronary artery disease, peripheral arterial disease, or ischaemic stroke). Multivariable models estimated the association of sex and age with pre-AMI statin use and assessed temporal changes.

Results

Overall LLT consumption increased over time, particularly statin–ezetimibe combination therapy, with a marked shift after 2019. Marked differences persisted, with distinct patterns according to presence or absence of prior ASCVD.

In patients without known ASCVD (n=19,696), statin use prior to admission increased with age (18.1% in ≥80 years vs 5.8% in <50 years), mirroring LLT (21.7% vs 6.6%). Age remained associated with higher treatment probability (≥80 vs <50: aOR 2.48, 95% CI 2.01–3.06; p<0.001). Among patients under 50 with ≥3 risk factors, only 20.8% received statin therapy. Women showed higher unadjusted statin (14.8% vs 12.1%) and LLT use (18.0% vs 14.3%) than men, including across most risk-factor strata and with increasing risk-factor burden (notably ≥3 risk factors: 37.3% vs 34.2%). However, after adjustment women were less likely to receive statins than men (aOR 0.86, 95% CI 0.77–0.96; p=0.01), with no improvement over time.

Among patients with established ASCVD (n=7,765), women were less frequently treated than men (51.8% vs 58.6%). Statin use rose with age to 70–79 years but declined after ≥80 years. In adjusted analyses, female sex and older age were associated with lower statin use (aOR 0.79, 95% CI 0.70–0.91; p<0.001 ; ≥80 vs <50 years: aOR 0.54, 95% CI 0.42–0.70; p<0.001 respectively).

Conclusion

Over two decades in France, women were and have remained less likely to receive statins than men before AMI, regardless of prior ASCVD. Among patients without ASCVD, statin use increased with age, yet the highest-risk younger patients remained markedly undertreated. Statin use paradoxically decreased with age in those with established CVD. Targeted efforts are needed to close these dramatic and persistent sex- and age-related gaps in guideline implementation.Figure Without AtheromaFigure With Atheroma