GENESIS-PRAXY: Young Women with ACS Experience Worse Access to Care than Men

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Psychosocial characteristics including gender-based traits, income, and psychological status at presentation affect access to care of non-elderly patients with acute coronary syndromes (ACS), according to a study published online March 17, 2014, ahead of print in the Canadian Medical Association Journal. Young men are more likely to receive faster, more invasive treatment than comparably aged women, though less than half of all patients met the recommended benchmarks for timeliness.

Researchers led by Louise Pilote, MD, PhD, of the Research Institute of McGill University Health Center (Montreal, Canada), examined data on 1,123 patients (362 women, 761 men) enrolled in the GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond: PRemature Acute Coronary SYndrome) cohort study to determine the impact of sex-based (physiological/biological characteristics) and gender-related variables (ie, gender identity, social roles, socioeconomic status, and interpersonal relationships) on access to care.

Dr. Pilote and colleagues elaborate, “Unlike sex, which is a biological characteristic, gender has a wider scope, incorporating the effects of social norms and expectations for men and women.”

In the original GENESIS-PRAXY study, data were collected from 24 centers (22 Canadian, 1 American, and 1 Swiss) between January 2009 and April 2013 to investigate aspects of premature ACS in men and women with an eye to discern sociocultural, economic, biological, and anthropometric characteristics. Median patient age for men was 49 years (IQR 41-57 years) and for women 50 years (IQR 43-57 years).

In the current substudy, researchers analyzed baseline and self-reported questionnaire data including:

  • Demographic information
  • Bem Sex Role Inventory scores (to evaluate levels of masculinity and femininity)
  • Hospital Anxiety and Depression Scale scores
  • Clinical characteristics
  • Housework responsibility status
  • Time from symptom onset to emergency room presentation
  • Use of cardiac catheterization, reperfusion therapy, and nonprimary percutaneous interventions
  • Door-to-ECG, door-to-needle, and door-to-balloon times

Masculine Men and Women Treated Faster, More Invasively

Compared to men, women were more likely to have diabetes, hypertension, depression, anxiety, family and personal histories of cardiovascular disease, lower education levels, and lower income levels at baseline. Women were also more likely to be diagnosed with NSTEMI than STEMI, primarily responsible for housework, and less likely to be employed, and they reported lower levels of perceived social standing. Men tended to have higher masculinity scores than women (5.3 ± 0.9 vs 4.8 ± 0.9) from the Bem Sex Role Inventory, and women tended to have higher femininity scores than men (6.0 ± 0.8 vs 5.5 ± 0.9).

Men in the study experienced quicker time to procedure than women, with median times of 21 and 15 minutes for ECG, 36 and 28 minutes for fibrinolytic therapy, and 106 and 93 minutes for primary percutaneous intervention, respectively. More women than men did not have benchmark door-to-ECG and door-to-needle times, while a comparable percent of women and men experiencing STEMI received timely primary PCI (table 1).

Table 1. Timely Administration of Therapy

 

Men

Women

P Value

ECG ≤ 10 Minutes

38%

29%

0.02

Fibrinolytic Therapy ≤ 30 Minutes

59%

32%

0.01

Primary PCI  90 Minutesa

~47%

~48%

0.9

aBased on visual interpretation of Figure 1 in paper.

On multivariable logistic regression analysis, independent predictors of untimely therapy were absence of chest pain, higher number of risk factors for cardiovascular disease, and the presence of anxiety. Higher Bem femininity scores were found to be statistically significant determinants of untimely therapy administration, whereas higher Bem masculinity scores were associated with timely procedures.

Regression analyses also indicated the absence of chest pain at presentation, low social support, and Bem masculinity and femininity scores were associated with procedure delays to a similar extent in men and women.

In addition, women were less likely than their male counterparts to receive invasive therapies, specifically reperfusion therapy and nonprimary PCI. Both men and women underwent cardiac catheterization at similar rates.

Regardless of sex, patients who claimed responsibility for housework and/or with higher Bem femininity scores were less likely to receive catheterization and nonprimary PCI.

Patient Anxiety in Particular Tied to Delays

Contrary to the tendencies of older men and women with ACS, younger men and women with premature ACS had similar median times from symptom onset to emergency department presentation (3.5 hours and 4 hours, respectively), the authors write. The findings seemingly argue against the previous explanation given to the comparable increases in women’s times to reperfusion. 

In lieu of a substantial difference in time between symptom onset and hospital presentation, the authors include a wider breadth of variables, such as gender-related characteristics, in their study to understand what might be impacting the timeliness and type of treatment received by women and men.

Although the authors note that less than half of all patients in the sample received timely procedures, “Young men and women with no chest pain and those with anxiety, several traditional risk factors, and feminine personality traits were at particularly increased risk of poor access to care.”

The researchers postulate that because anxiety was associated with a failure to meet the benchmark 10 minute time-to-ECG in women but not men, it “suggests that triage personnel might initially dismiss a cardiac event among young women with anxiety…” As a result, they state, there is “room for improvement in the identification and treatment of ACS among younger adults, especially young women.”

The authors suggest the need for “future studies [to] assess the appropriateness of care in this population.”

 


Source:
Pelletier R, Humphries KJ, Shimony A, et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. CMAJ. 2014;Epub ahead of print.

 

 

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GENESIS-PRAXY: Young Women with ACS Experience Worse Access to Care than Men

Psychosocial characteristics including gender-based traits, income, and psychological status at presentation affect access to care of non-elderly patients with acute coronary syndromes (ACS), according to a study published
Disclosures
  • Dr. Pilote reports no relevant conflicts of interest.

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