Female STEMI Patients Have Longer Prehospital Delays, Poorer Outcomes
Women with STEMI continue to have greater delays in getting to the hospital compared with men, putting them at risk for worse outcomes, according to an abstract scheduled for presentation on March 14, 2015, at the American College of Cardiology/i2 Scientific Session in San Diego, CA.
The results underscore the importance of addressing prehospital delays to improve STEMI outcomes, Raffaele Bugiardini, MD, of the University of Bologna (Bologna, Italy), said during a media briefing earlier this week. “It is time to look beyond using in-hospital quality initiatives that focus just on door-to-balloon/needle times as the only performance measures, especially in women,” he said.
Dr. Bugiardini and colleagues looked at data on 7,457 STEMI patients (30.6% female) enrolled at centers in 17 European nations participating in the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) from 2010 to 2014. Women were older than men on average (mean age 66.0 vs 59.7 years) and were more likely to have atypical symptoms and/or no chest pain (7.5% vs 5.3%; P = .001).
In the prehospital setting, women had a longer median time from symptom onset to call for help (60.0 vs 45.5 minutes) and a longer delay in getting to the hospital after contact with emergency medical services (60.0 vs 55.0 minutes) than men, with home-to-hospital intervals ranging from 5 minutes to 3 days.
Once at the hospital, women and men had similar door-to-needle times (26.0 vs 28.0 minutes) and door-to-balloon times (45.0 minutes in each group). Use of acute medications, including aspirin, clopidogrel, and unfractionated heparin, was somewhat lower for women, but the differences were not clinically meaningful, Dr. Bugiardini said. Female patients were slightly more likely to receive low molecular weight heparin (34.7% vs 33.1%).
Looking at the proportion of patients who met various goals, women were less likely than men to have a time from home to hospital admission of 60 minutes or less (29.7% vs 70.3%) and a time to treatment of 12 hours or less (76.0% vs 80.4%). They also were slightly less likely to undergo primary PCI or fibrinolysis (69.5% vs 73.5%).
Those differences appeared to add up to worse outcomes, as women were more likely to die while in the hospital (11.8% vs 6.3%).
After researchers performed multivariate adjustment that did not take into account delays, women were not less likely than men to receive reperfusion therapy (OR 0.94; 95% CI 0.81-1.10), but they continued to have greater odds of taking more than an hour to get from home to the hospital (OR 2.97; 95% CI 1.52-5.82) and of dying in the hospital (OR 1.34; 95% CI 1.01-1.77).
However, the mortality difference became nonsignificant when various prehospital delays were included in the model. For example, the odds ratio for in-hospital mortality was 0.90 (95% CI 0.31-2.56) among patients who got from their home to the hospital within an hour and 1.31 (95% CI 0.98-1.74) among those treated within 12 hours of symptom onset.
Recognizing Women’s Symptoms Could Cut Delays
Richard A. Chazal, MD, of the Lee Memorial Health System Heart and Vascular Institute (Fort Myers, FL), said during the briefing that the findings, which show that “the delays prior to the patients getting to the care of the health system [are] really crucial in terms of helping determine [outcomes],” confirm prior US data and are likely applicable to other developed countries.
Dr. Chazal, who is the current vice president of the American College of Cardiology, stressed the importance of educating the public and physicians about cardiovascular disease and the symptoms of MI in women to improve the recognition of symptoms in a timely manner.
Dr. Bugiardini agreed that education is key to reducing delays in the treatment of women with acute MI, for whom it can be more challenging to make the diagnosis. At least part of the reason for that uncertainty, he said, is that much of the early research on acute MI dealt with men and their symptoms. Some—though not all—more recent studies have suggested that women are more likely to present with atypical symptoms, including shortness of breath, nausea, vomiting, and pain in the back, neck, or jaw instead of the chest.
“It is important for physicians and for patients to recognize that the symptoms are not always that classic ‘elephant sitting on my chest’ that we hear about,” Dr. Chazal said. “They sometimes are much different.”
Bugiardini R, Ricci B, Cenko E, et al. Sex-related differences in acute coronary care among patients with myocardial infarction: the role of pre-hospital delay. Presented at: American College of Cardiology/i2 Scientific Session; March 14, 2015; San Diego, CA.
- Dr. Bugiardini reports no relevant conflicts of interest.
- Dr. Chazal reports that all of his significant holdings in healthcare equities were sold on January 27, 2014.