Worse LV Function After Primary PCI in Women May Be Due to Delay in Presentation

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Compared with men, women who undergo primary percutaneous coronary intervention (PCI) for anterior wall ST-segment elevation myocardial infarction (STEMI) have increased risk of moderate or worse left ventricular (LV) function. But the role of patient sex disappears after adjustment for pretreatment characteristics, reports a study published online August 26, 2014, ahead of print in the American Journal of Cardiology.

The authors suggest that women’s worse prognosis may be partially due to presentation delay and recommend greater efforts to raise their awareness of cardiac symptoms.

Clear Gender Differences Seen

Women presented at an older age than men and were more likely to have diabetes, hypertension, renal failure, and Killip class > 1 but less likely to have a history of smoking. Time from symptom onset to arrival at the emergency department (ED) was longer for women, as was total ischemic time. However, there were no differences between the sexes in door-to-balloon time (table 1).

Table 1. Presentation Characteristics by Gender

TIMI flow grades were similar between men and women prior to PCI, but after the procedure men had better angiographic results with higher rates of TIMI flow grade 3 compared with women (96% vs 89.6%; P = .006).

Additionally, during the first 48 hours after PCI, more women than men had moderate or worse LV dysfunction (LVEF < 40%) as assessed by transthoracic echocardiogram (61.6% vs 48%; P = .002). This association was confirmed by multivariate analysis, which also linked female sex with total ischemic time > 3.5 hours, pre-PCI TIMI flow grade < 2, white blood cell count >10.0 x 10⁹/L, diabetes, and renal failure. However, after accounting for variable baseline risk profiles between the 2 groups using multivariate and propensity score techniques, female sex remained predictive of all but moderate or worse LV dysfunction.

At 2 years, women had higher MACE rates than men (36.5% vs 24.3%; P = .003) driven by higher mortality and recurrent MI, although 30-day mortality did not differ (P = .5). Multivariate analysis did not show patient sex to be an independent predictor of mortality.

More Education, Awareness Needed

According to the study authors, most previous studies on gender differences among patients undergoing primary PCI have focused more on mortality and MACE than on LV function.

They observe that women’s longer total ischemic time compared with men was driven by delays from symptom onset to presentation at the ED. This finding, they say, suggests that “delay in presentation might be explained by the low awareness of cardiovascular disease amongst women and/or by atypical symptoms, which are more common in women compared with men and might be related to different pain perception, older age, and diabetes.”

They note that “there were neither delays nor other differences in the treatment of women compared to men,” and conclude that more efforts should be devoted to increasing women’s awareness of cardiac symptoms.

Source:
Weissler-Snir A, Kornowski R, Sagie A, et al. Gender differences in left ventricular function following percutaneous coronary intervention for first anterior wall ST-segment elevation myocardial infarction. Am J Cardiol. 2014;Epub ahead of print.

Disclosures:

• The study contains no information regarding conflicts of interest.

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