Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study

Trends in the incidence, mortality and clinical outcomes in patients with ventricular septal rupture following an ST-elevation myocardial infarction

BACKGROUND

Despite improvements in outcomes of ST elevation myocardial infarction (STEMI), ventricular septal rupture (VSR) remains a known complication, carrying high mortality. The contemporary incidence, mortality, and management of post-STEMI VSR remains unclear.

METHODS

The National Inpatient Sample database (2009-2020) was used to study trends in admissions and outcomes of post-STEMI VSR over time. Survey estimation commands were used to determine weighted national estimates.

RESULTS

There were 2 315 186 ± 22 888 visits for STEMI with 0.194 ± 0.01% experiencing VSR during 2009-2020 in the USA. Patients with VSR were more often older, white, female, and presented with an anterior STEMI; there was no difference in the rates of fibrinolysis. In-hospital mortality was 73.6 ± 1.8%, but only 29.2 ± 1.9 and 10 ± 1.2% received surgical repair and transcatheter repair (TCR), respectively. TCR was associated with higher and surgical repair with lower mortality. Days to surgery were longer for those who survived (5.9 ± 2.75) compared with those who died (2.44 ± 1). In a multivariable analysis, surgical repair at greater than or equal to day 4 was associated with lower in-hospital mortality (odds ratio = 0.39, 95% confidence interval: 0.17-0.88).

CONCLUSION

Mortality in post-STEMI VSR remains high with no improvement over time. Most patients are managed conservatively, and the frequency of surgical repair has decreased, while TCR has increased over the study period. Despite design limitations and survival bias, surgical repair at greater than or equal to 4 days was associated with a lower mortality.

Sex Differences in Process-of-Care and In-Hospital Prognosis Among Elderly Patients Hospitalized With Acute Myocardial Infarction

BACKGROUND

Limited studies have demonstrated sex differences in the clinical outcomes and quality of care among elderly patients hospitalized with acute myocardial infarction (AMI).

Methods and Results

Using nationwide cardiovascular registry data collected in Japan between 2012 and 2019, we enrolled patients aged ≥45 years. The 30-day and all in-hospital mortality rates, as well as process-of-care measures, were assessed, and mixed-effects logistic regression analysis was performed. A total 254,608 patients were included and stratified into 3 age groups: middle-aged, old and oldest old. The 30-day mortality rates for females and males were as follows: 3.0% vs. 2.7%, with an adjusted odds ratio (OR) of 1.17 (95% confidence interval (CI): 1.01-1.36, P=0.030) in middle-aged patients; 7.2% vs. 5.8%, with an OR of 1.14 (95% CI: 1.09-1.21, P<0.001) in old patients; and 19.6% vs. 15.5% with an OR of 1.17 (95% CI: 1.09-1.26, P<0.001) in the oldest old patients. Moreover, significantly higher numbers of female AMI patients across all age groups died in hospital, as well as having fewer invasive procedures and cardiovascular prescriptions, compared with their male counterparts.

CONCLUSIONS

This nationwide cohort study revealed that female middle-aged and elderly patients experienced suboptimal quality of care and poorer in-hospital outcomes following AMI, compared with their male counterparts, highlighting the need for more effective management in consideration of sex-specific factors.

Influence of Organisational-Level Factors on Delayed Door-to-Balloon Time among Patients with ST-Elevation Myocardial Infarction

Objectives

This study aimed to estimate the door-to-balloon (DTB) time and determine the organisational-level factors that influence delayed DTB times among patients with ST-elevation myocardial infarction in Oman.

Methods

A cross-sectional retrospective study was conducted on all patients who presented to the emergency department at Sultan Qaboos University Hospital and Royal Hospital, Muscat, Oman, and underwent primary percutaneous coronary interventions during 2018-2019.

Results

The sample included 426 patients and the median DTB time was 142 minutes. The result of the bivariate logistic regression showed that patients who presented to the emergency department with atypical symptoms were 3 times more likely to have a delayed DTB time, when compared to patients who presented with typical symptoms (odds ratio [OR] = 3.003, 95% confidence interval [CI]: 1.409-6.400; P = 0.004). In addition, patients who presented during off-hours were 2 times more likely to have a delayed DTB time, when compared to patients who presented during regular working hours (OR = 2.291, 95% CI: 1.284-4.087; P = 0.005).

Conclusion

To meet the DTB time recommendation, it is important to ensure adequate staffing during both regular and irregular working hours. Results from this study can be used as a baseline for future studies and inform strategies for improving the quality of care.

Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative

BACKGROUND

Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries.

METHODS

We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality.

RESULTS

Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI.

CONCLUSIONS

We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.

The Importance of Gender-Sensitive Health Care in the Context of Pain, Emergency and Vaccination: A Narrative Review

So far, health care has been insufficiently organized in a gender-sensitive way, which makes the promotion of care that meets the needs of women and men equally emerge as a relevant public health problem. The aim of this narrative review was to outline the need for more gender-sensitive medical care in the context of pain, emergency care and vaccinations. In this narrative review, a selective search was performed in Pubmed, and the databases of the World Health Organization (WHO), the European Institute for Gender Equality and the German Federal Ministry of Health were searched. Study data indicate that there are differences between men and women with regard to the ability to bear pain. On the other hand, socially constructed role expectations in pain and the communication of these are also relevant. Studies indicate that women receive adequate pain medication less often than men with a comparable pain score. Furthermore, study results indicate that the female gender is associated with an increased risk of inadequate emergency care. In terms of vaccine provision, women are less likely than men to utilize or gain access to vaccination services, and there are gender-sensitive differences in vaccine efficacy and safety. Sensitization in teaching, research and care is needed to mitigate gender-specific health inequalities.

Reducing gap in pre-hospital delay between women and men presenting with ST-elevation myocardial infarction

AIMS

This study aimed to analyse changes in pre-hospital delay over time in women and men presenting with ST-elevation myocardial infarction (STEMI) in Switzerland.

METHODS AND RESULTS

AMIS Plus registry data of patients admitted for STEMI between 2002 and 2019 were analysed using multivariable quantile regression including the following covariates: interaction between sex and admission year, age, diabetes, pain at presentation, myocardial infarction (MI) history, heart failure history, hypertension, and renal disease. Among the 15,350 patients included (74.5% men), the median (interquartile range) delay between 2002 and 2019 was 150 (84; 345) min for men and 180 (100; 414) min for women. The unadjusted median pre-hospital delay significantly decreased over time for both sexes but the decreasing trend was stronger for women. Specifically, the unadjusted sex differences in delay decreased from 60 min in 2002 (P = 0.0042) to 40.5 min in 2019 (P = 0.165). The multivariable model revealed a significant interaction between sex and admission year (P = 0.038) indicating that the decrease in delay was stronger for women (-3.3 min per year) than for men (-1.6 min per year) even after adjustment. The adjusted difference between men and women decreased from 26.93 min in 2002 to -1.97 min for women in 2019.

CONCLUSION

Over two decades, delay between symptom onset and hospital admission in STEMI decreased significantly for men and women. The decline was more pronounced in women, leading to the sex gap disappearing in the adjusted analysis for 2019.

Sex-Based Differences in Rotational Atherectomy and Long-Term Clinical Outcomes

Present research on the influence of gender on the treatment of coronary artery disease (CAD) and the outcome after percutaneous coronary intervention (PCI) is inconsistent. Sex differences in the presentation of CAD and the success after treatment have been described. We intend to compare the male and female sex in the procedure and the long-term outcome of Rotational Atherectomy (RA). A total of 597 consecutive patients (20.3% female and 79.7% male, mean age 75.3 ± 8.9 years vs. 72.7 ± 9 years, p < 0.001) undergoing Rotational Atherectomy between 2015 and 2020 were enrolled in the analysis. Demographic and clinical data were registered. In-hospital, 1-year, and 3-year MACCEs (major adverse cardiac and cerebrovascular events) were calculated. Women presented more often with myocardial infarction (23.9% vs. 14.9%, p = 0.017). The intervention was mainly performed via femoral access compared to radial access (65.4% vs. 33.6%, p = 0.002). Women had a smaller diameter of the balloon predilatation compared to men (2.8 ± 0.5 mm vs. 3.15 ± 2.4 mm, p < 0.05) and a smaller maximum diameter of the implanted stent (3.5 ± 1.2 mm vs. 4.10 ± 6.5 mm, p = 0.01). In-hospital, 1-year-, and 3-year MACCEs did not differ between the sexes. After a multivariate analysis, no difference between men and women could be detected. In conclusion, this analysis shows differences between women and men in periprocedural characteristics but does not show any differences after RA regarding in-hospital, 1-year-, and 3-year MACCEs.

Sex-based Differences in Percutaneous Coronary Intervention Outcomes in Patients With Ischemic Heart Disease

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

Association of sex and age and delay predictors on the time of primary angioplasty activation for myocardial infarction patients in an emergency department

BACKGROUND

Time between Emergency Department (ED) and ST-segment elevation acute myocardial infarction (STEMI) activation time is a good indicator of ED quality. STEMI delays are of particular importance in some subgroups, such as women and the elderly.

OBJECTIVE

To determine the association of sex and age with activation time in STEMI patients admitted to the ED.

METHODS

An observational retrospective study was conducted including all patients admitted to the ED activated as a STEMI. The main variable was activation time. To evaluate the independent predictors of activation time, a multivariate logistic regression analysis was carried out, variables were sex, age, sex and age combined, chest pain, ST elevation in the electrocardiogram, and first medical contact (FMC) at the hospital's ED.

RESULTS

A total of 330 patients were included. They were classified by sex: 23.9% (78) women and 76.1% (249) men; and age: 51.1% (167) <65 yo and 48.9% (160) ≥65 yo. Women and elderly patients exhibited a more atypical presentation. Multivariate analysis shows that showed that elderly age (OR=1.976 95%; CI=1.257-3.104; p = 0.003) and FMC prior to attending the ED (OR=1.762; 95% CI=1.117-2.779; p = 0.015) were associated with a longer activation time. Women older than 65 years old showed the longest activation time.

CONCLUSION

STEMI delays are longer in women and the elderly with atypical presentation. Age ≥65 and FMC outside the ED were associated with an increase in the activation time. This highlights the need to develop strategies to improve activation time for these specific patient groups.

Trends in outcomes of women with myocardial infarction undergoing primary angioplasty-Analysis of randomized trials

Background

Sex- and gender-associated differences determine the disease response to treatment.

Aim

The study aimed to explore the hypothesis that progress in the management of STE-myocardial infarction (STEMI) overcomes the worse outcome in women.

Methods and results

We performed an analysis of three randomized trials enrolling patients treated with primary PCI more than 10 years apart. PRAGUE-1,-2 validated the preference of transport for primary PCI over on-site fibrinolysis. PRAGUE-18 enrollment was ongoing at the time of the functional network of 24/7PCI centers, and the intervention was supported by intensive antiplatelets. The proportion of patients with an initial Killip ≥ 3 was substantially higher in the more recent study (0.6 vs. 6.7%, p = 0.004). Median time from symptom onset to the door of the PCI center shortened from 3.8 to 3.0 h, p < 0.001. The proportion of women having total ischemic time ≤3 h was higher in the PRAGUE-18 (OR [95% C.I.] 2.65 [2.03-3.47]). However, the percentage of patients with time-to-reperfusion >6 h was still significant (22.3 vs. 27.2% in PRAGUE-18). There was an increase in probability for an initial TIMI flow >0 in the later study (1.49 [1.0-2.23]), and also for an optimal procedural result (4.24 [2.12-8.49], p < 0.001). The risk of 30-day mortality decreased by 61% (0.39 [0.17-0.91], p = 0.029).

Conclusion

The prognosis of women with MI treated with primary PCI improved substantially with 24/7 regional availability of mechanical reperfusion, performance-enhancing technical progress, and intensive adjuvant antithrombotic therapy. A major modifiable hindrance to achieving this benefit in a broad population of women is the timely diagnosis by health professional services.

Symptoms of Acute Myocardial Infarction as Described in Calls to Tele-Nurses and in Questionnaires: A Mixed-Methods Study

BACKGROUND

Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed.

AIM

The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis.

METHODS

A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation.

RESULTS

Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires ( P = .01 and P = .02), whereas "other" symptoms were more often mentioned in calls compared with answers given in the questionnaire ( P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets.

CONCLUSION

Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.

Prognosis Analysis of Delayed Call Time for Chest Pain in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Direct Percutaneous Coronary Intervention

To describe the impact of delayed call time for chest pain in the salvage of ST-segment elevation myocardial infarction (STEMI) patients and its associated independent risk factors, and to identify risk factors associated with cumulative morbidity and mortality in STEMI patients at 4 years after percutaneous coronary intervention (PCI). Retrospective analysis of 398 patients diagnosed with STEMI and treated with emergency PCI within 24 hours of symptom onset in Fuyang People's Hospital from April 2018 to April 2021. The enrolled patients were divided into ≤60 minutes group (193 cases), and > 60 minutes group (205 cases), according to the delayed call time of patients with chest pain. Analysis of basic clinical data, rescue time, and major cardiovascular adverse events in the 2 groups. Multifactorial logistic regression analysis of independent correlates of delayed chest pain calls and Cox proportional risk regression modeling of risk factors for cumulative morbidity and mortality at 4 years after surgery. Compared to the delayed call time ≤ 60 minutes group, the > 60 minutes group had a higher proportion of females, a history of diabetes, rural remote areas, and farmer occupation (P < .05). Binary logistic regression analysis shows the history of diabetes and female as independent risk factors for delayed call time >60 minutes for chest pain. In the delayed call time ≤60 minutes group, the time from symptom onset-to-balloon (S0-to-B) and from symptom onset-to-first medical contact (SO-to-FMC) were smaller than in the delayed call time >60 minutes group (P < .05). The sum of postinfarction angina and major cardiovascular adverse events was lower in the group with delayed call time ≤60 minutes than in the group with delayed call time >60 minutes (P < .05). The Kaplan-Meier survival curve and the survival curve without the occurrence of major adverse cardiovascular events were statistically significant in both groups (P < .05). Multifactorial Cox regression analysis showed that delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III were all risk factors for cumulative morbidity and mortality at 4 years after PCI in patients with STEMI. Delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III are all risk factors for cumulative morbidity and mortality in STEMI patients at 4 years after PCI. Reducing the delayed call time for chest pain can improve the long-term prognosis of patients.

Prevalence and associated factors of mortality after percutaneous coronary intervention for adult patients with ST-elevation myocardial infarction: A systematic review and meta-analysis

Background

There is a paucity of systematic reviews on the associated factors of mortality among ST-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention (PCI). This meta-analysis was designed to synthesize available evidence on the prevalence and associated factors of mortality after PCI for adult patients with STEMI.

Materials and Methods

Databases including the Cochrane Library, PubMed, Web of Science, Embase, Ovid, Scopus, ProQuest, MEDLINE, and CINAHL Complete were searched systematically to identify relevant articles published from January 2008 to March 2020 on factors affecting mortality after PCI in STEMI patients. Meta-analysis was conducted using Stata 12.0 software package.

Results

Our search yielded 91 cohort studies involving a total of 199, 339 participants. The pooled mortality rate for STEMI patients after PCI was 10%. After controlling for grouping criteria or follow-up time, the following 17 risk factors were significantly associated with mortality for STEMI patients after PCI: advanced age (odds ratio [OR] = 3.89), female (OR = 2.01), out-of-hospital cardiac arrest (OR = 5.55), cardiogenic shock (OR = 4.83), renal dysfunction (OR = 3.50), admission anemia (OR = 3.28), hyperuricemia (OR = 2.71), elevated blood glucose level (OR = 2.00), diabetes mellitus (OR = 1.8), chronic total occlusion (OR = 2.56), Q wave (OR = 2.18), without prodromal angina (OR = 2.12), delay in door-to-balloon time (OR = 1.72), delay in symptom onset-to-balloon time (OR = 1.43), anterior infarction (OR = 1.66), ST-segment resolution (OR = 1.40), and delay in symptom onset-to-door time (OR = 1.29).

Conclusion

The pooled prevalence of mortality after PCI for STEMI patients was 10%, and 17 risk factors were significantly associated with mortality for STEMI patients after PCI.

Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes

This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.

Clinical presentation in EMS patients with acute chest pain in relation to sex, age and medical history: prospective cohort study

OBJECTIVE

To assess symptom presentation related to age, sex and previous medical history in patients with chest pain.

DESIGN

Prospective observational cohort study.

SETTING

Two-centre study in a Swedish county emergency medical service (EMS) organisation.

PARTICIPANTS

Unselected inclusion of 2917 patients with chest pain cared for by the EMS during 2018.

DATA ANALYSIS

Multivariate analysis on the association between symptom characteristics, patients' sex, age, previous acute coronary syndrome (ACS) or diabetes and the final outcome of acute myocardial infarction (AMI).

RESULTS

Symptomology in patients assessed by the EMS due to acute chest pain varied with sex and age and also with previous ACS or diabetes. Women suffered more often from nausea (OR 1.6) and pain in throat (OR 2.1) or back (OR 2.1). Their pain was more often affected by palpation (1.7) or movement (OR 1.4). Older patients more often described pain onset while sleeping (OR 1.5) and that the onset of symptoms was slow, over hours rather than minutes (OR 1.4). They were less likely to report pain in other parts of their body than their chest (OR 1.4). They were to a lesser extent clammy (OR 0.6) or nauseous (OR 0.6). These differences were present regardless of whether the symptoms were caused by AMI or not.

CONCLUSIONS

A number of aspects of the symptom of chest pain appear to differ in unselected prehospital patients with chest pain in relation to age, sex and medical history, regardless of whether the chest pain was caused by a myocardial infarction or not. This complicates the possibility in prehospital care of using symptoms to predict the underlying aetiology of acute chest pain.

Female gender and mortality in ST-segment-elevation myocardial infarction treated with primary PCI

AIMS

To investigate gender difference in mortality among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous angioplasty (PPCI).

METHODS

We analyzed data from the prospective registries of two hub PPCI centres over a 10-year period to assess the role of female gender as an independent predictor of both all-cause and cardiac death at 30 days and 1 year. To account for all confounding variables, a propensity score (PS)-adjusted multivariable Cox regression model and a PS-matched comparison between the male and female were used.

RESULTS

Among 4370 consecutive STEMI patients treated with PPCI at participating centres, 1188 (27.2%) were women. The survival rate at 30 days and 1 year were significantly lower in women (Log-rank P-value < 0.001). At PS-adjusted multivariable Cox regression analysis, female gender was independently associated with an increased risk of 30-day all-cause death [hazard ratio (HR) = 2.09; 95% confidence interval (CI): 1.45-3.01, P < 0.001], 30-day cardiac death (HR = 2.03;95% CI:1.41-2.93, P < 0.001), 1-year all-cause death (HR = 1.45; 95% CI:1.16-1.82, P < 0.001) and 1-year cardiac death (HR = 1.51; 95% CI:1.15-1.97, P < 0.001). For the study outcome, we found a significant interaction of gender with the multivessel disease in females who were at increased risk of mortality in comparison with men in absence of multivessel disease. After the PS matching procedure, a subset of 2074 patients were identified. Women still had a lower survival rate and survival free from cardiac death rate both at 30-day and at 1-year follow-up.

CONCLUSION

As compared with men, women with STEMI treated with PPCI have higher risk of both all-cause death and cardiac mortality at 30-day and 1-year follow-up.

Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction

BACKGROUND AND HYPOTHESIS

Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients.

METHODS

Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models.

RESULTS

A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13).

CONCLUSIONS

In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Comparative study of acute coronary syndrome in postmenopausal women and age-matched men: A prospective cohort study in Southern India

Background:

Acute coronary syndrome (ACS) differs in women and men with respect to risk factors, clinical presentation, complications and outcome. The major reason for the differences has been the effect of estrogen which protects women from coronary artery disease (CAD) till menopause. Women develop CAD one decade later than men. Hence, we compared the profile of ACS in postmenopausal women with age-matched men to see, does the difference still exist.

Materials and Methods:

Comparative prospective study of 50 postmenopausal women as study group and fifty age-matched men as a control group diagnosed with ACS, who were admitted in a medical college hospital from December 2013 to September 2015. Chi-square test and Student's t-test have been used to find the significant association of study parameters between women and men.

Results:

Chest pain was the main complaint in the majority of the women (76%) and men (88%). Radiation of chest pain (60%) and sweating (72%) were significantly present in men compared to women (24% and 26%, respectively), whereas breathlessness was significantly present in women (40%) compared to men (16%). Women had later presentation to the hospital after symptom onset compared to men. Women had a higher respiratory rate (22.02 cycles/min) compared to men (20 cycles/min) and more crepitations compared to men. Men had more ventricular tachycardia (14%) and intracerebral hemorrhage (4%), whereas women had all other complications more than or same as men and higher in-hospital mortality (14%) compared to men (8%).

Conclusion:

Postmenopausal women with ACS had more atypical presentation of symptoms, later presentation to hospital, more tachypnea, more crepitations, more complications, and higher in-hospital mortality compared to men of the same age group. The difference in the profile of ACS continues to exist even after menopause and age matching.

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry

Introduction

Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD.

Methods

Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding.

Results

Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015).

Conclusions

These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score–Matched Analysis

Background

Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results.

Methods

A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared.

Results

We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups.

Conclusions

Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.

Pre hospital delay and its associated factors in acute myocardial infarction in a developing country

Background

Early revascularization and treatment is key to improving clinical outcomes and reducing mortality in acute myocardial infarction (AMI). In low- and middle-income countries such as Bangladesh, timely management of AMI is challenging, with pre-hospital delays playing a significant role. This study was designed to investigate pre-hospital delay and its associated factors among patients presenting with AMI in the capital city of Dhaka.

Methods

This retrospective cohort study was conducted on 333 patients presenting with AMI over a 3-month period at two of the largest primary reperfusion-capable tertiary cardiac care centres in Dhaka. Of the total patients, 239(71.8%) were admitted in the National Institute of Cardiovascular Diseases, Dhaka and 94(28.2%) at Ibrahim Cardiac Hospital & Research Institute, Dhaka Data were collected from patients by semi-structured interview and hospital medical records. Pre-hospital delay (median and inter-quartile range) was calculated. Statistical significance was determined by Chi-square test. Multivariate logistic regression analysis was done to determine the independent predictors of pre-hospital delay.

Results

The mean age of the respondents was 53.8±11.2 years. Two-thirds (67.6%) of the respondents were males. Median total pre-hospital delay was 11.5 (IQR-18.3) hours with median decision time from symptom onset to seeking medical care being 3.0 (IQR: 11.0) hours. Nearly half (48.9%) of patients presented to the hospital more than 12 hours after symptom onset. On multivariate logistic regression analysis, AMI patients with absence of typical chest pain [OR 5.21; (95% CI: 2.5–9.9)], diabetes [OR: 1.7 (95% CI: 1.0–2.9)], residing/staying > 30 km away from nearest hospital at the time of onset [OR: 4.3(95% CI = 2.3–7.2)] and belonged to lower and middle class [OR: 1.9(95% CI = 1.0–3.5)] were significantly associated with pre-hospital delays.

Conclusion

Acute myocardial infarction (AMI) patients with atypical chest pain, diabetes, staying far away from nearest hospital and belonged to lower and middle socioeconomic strata were significantly associated with pre-hospital delays. The findings could have immense implications for improvements about timely reaching of AMI patients to the hospital within the context of their sociodemographic status and geographic barriers of the city.

Patients' reflections on prehospital symptom recognition and timely treatment of myocardial infarction

AIMS

Early treatment is crucial to successful therapy in patients with acute myocardial infarction (MI). Prehospital delay is associated with increased morbidity and mortality. There is little empirical evidence of patients' reflections on prehospital symptoms of MI and timely treatment at the time of discharge from hospital. To explore patients' reflections on prehospital symptoms of MI and their experiences of interaction with local hospitals, general practitioners, and laypersons.

METHODS AND RESULTS

An inductive explorative design with a qualitative method approach was used to conduct in-depth interviews of patients after confirmed MI. Twenty patients were purposefully selected based on age and gender. Face-to-face, semi-structured interviews were conducted prior to hospital discharge. The interviews were organized around a set of predetermined, open-ended questions, transcribed verbatim and analysed using qualitative content analysis. There were patients who acted upon severe symptoms of MI by seeking medical assistance. Patients commonly experienced that the time from the onset of symptoms to treatment posed a transitional challenge. They did not take subtle signs of MI seriously; they underestimated symptoms of MI and delayed seeking medical assistance. Patients frequently experienced that healthcare professionals did not take them seriously, as they struggled to gain access to healthcare services.

CONCLUSION

This study highlights patients' unique experiences of the pathway from symptom onset to confirmed MI. Severe chest pain is associated with MI and triggers an immediate need for care. However, patients often underestimated moderate chest pain or subtle signs and symptoms of MI. Existing knowledge gaps concerning the misinterpretation of symptoms in primary care need to be addressed in order to reduce this clinical challenge.

Sex Differences in Prehospital Delays in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background

Women with ST‐segment–elevation myocardial infarction experience delays in reperfusion compared with men with little data on each time component from symptom onset to reperfusion. This study analyzed sex discrepancies in patient delays, prehospital system delays, and hospital delays.

Methods and Results

Consecutive patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention across 30 hospitals in the Victorian Cardiac Outcomes Registry (2013–2018) were analyzed. Data from the Ambulance Victoria Data warehouse were used to perform linkage to the Victorian Cardiac Outcomes Registry for all patients transported via emergency medical services (EMS). The primary end point was EMS call‐to‐door time (prehospital system delay). Secondary end points included symptom‐to‐EMS call time (patient delay), door‐to‐device time (hospital delay), 30‐day mortality, major adverse cardiovascular events, and major bleeding. End points were analyzed according to sex and adjusted for age, comorbidities, cardiogenic shock, cardiac arrest, and symptom onset time. A total of 6330 (21% women) patients with ST‐segment–elevation myocardial infarction were transported by EMS. Compared with men, women had longer adjusted geometric mean symptom‐to‐EMS call times (47.0 versus 44.0 minutes; P<0.001), EMS call‐to‐door times (58.1 versus 55.7 minutes; P<0.001), and door‐to‐device times (58.5 versus 54.9 minutes; P=0.006). Compared with men, women had higher 30‐day mortality (odds ratio [OR], 1.38; 95% CI, 1.06–1.79; P=0.02) and major bleeding (OR, 1.54; 95% CI, 1.08–2.20; P=0.02).

Conclusions

Female patients with ST‐segment–elevation myocardial infarction experienced excess delays in patient delays, prehospital system delays, and hospital delays, even after adjustment for confounders. Prehospital system and hospital delays resulted in an adjusted excess delay of 10 minutes compared with men.

Gender-related Disparities of Percutaneous Coronary Interventions in ST-elevation Myocardial Infarction: A Retrospective Chart Review of 500 Patients

Door-to-balloon (DTB) time of primary percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI) is a predictive indicator of outcomes and mortality. Traditional gender-related differences that existed in the provision of DTB in STEMI had been allegedly improving until recent controversial data showed re-emergence of longer DTB in females. The objective of our study was to compare circadian disparities in percutaneous coronary intervention for STEMI according to gender in our institution. We compared DTB and symptom-to-balloon (STB) as well as mortality outcomes in a registry of 514 patients. We studied 117 females and 397 males. Baseline characteristics and cardiovascular risk factors were similar among both populations. Men used more self-transportation (51% vs. 38%) compared with women. Both had similar DTB median times: males, 63 (47-79) min; and females, 61 (44-76) min. In addition, STB median times were also similar: males, 155 (116-264) min; and females, 165 (115-261) min. Mortality outcomes at 1 month were comparable at 3% in males versus 0.9% in females (P = 0.164). In a review of a tertiary care center in New York, we observed no gender differences in DTB and STB, endorsing the role of emergency medical service transportation in eliminating disparities.

Impact of STEMI Diagnosis and Catheterization Laboratory Activation Systems on Sex- and Age-Based Differences in Treatment Delay

Background

Women and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems.

Methods

This observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated “physician-blind” prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts.

Results

Five hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P = 0.04). When examining prehospital activation cohorts only, female sex (P = 0.03), off-hours presentation (P < 0.01), and physician oversight (P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 (P < 0.01), Killip class (P < 0.01), and female sex (P = 0.04) were independently associated with in-hospital mortality.

Conclusions

Automated “physician-blind” STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care.

Cardiac symptom attribution and knowledge of the symptoms of acute myocardial infarction: a systematic review

BACKGROUND

Since the knowledge of the symptoms of acute myocardial infarction (AMI) may reduce the decision time for patients to seek help in case of an AMI, we aimed to summarize evidence on the knowledge of the AMI symptoms and the symptom attribution in case of an acute coronary syndrome (ACS).

METHODS

Therefore, we systematically searched the databases PubMed, CINAHL, Embase, and Cochrane Library for relevant studies published between January 1, 2008 and 2019 (last search August 1, 2019).

RESULTS

A total of 86 studies were included, with a composite sample size of 354,497 participants. The weighted mean of the knowledge scores for the symptoms of AMI of 14,420 participants from the general population, was 42.1% (when maximum score was considered 100%) and 69.5% for 7642 cardiac patients. There was a substantially better level of knowledge for six symptoms ('chest pain or discomfort', 'shortness of breath', 'pain or discomfort in arms or shoulders', 'feeling weak, lightheaded, or faint', 'pain or discomfort in the jaw, neck, or back', and 'sweating') (49.8-88.5%) compared to the four less obvious/atypical symptoms 'stomach or abdominal discomfort', 'nausea or vomiting', 'headache', and 'feeling of anxiety' (8.7-36.7%). Only 45.1% of 14,843 patients, who experienced ACS, have correctly attributed their symptoms to a cardiac cause.

CONCLUSION

In conclusion, we found a moderate to good knowledge of "classic" and insufficient knowledge of less obvious symptoms of AMI. This might suggest that increasing knowledge about less obvious symptoms of AMI could be beneficial. It appears also important to address cardiac attribution of symptoms.

Sex Disparities in Myocardial Infarction: Biology or Bias?

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?

Sex Differences Persist in Time to Presentation, Revascularization, and Mortality in Myocardial Infarction Treated With Percutaneous Coronary Intervention

Background

Timely revascularization with percutaneous coronary intervention (PCI) reduces death following myocardial infarction. We evaluated if a sex gap in symptom‐to‐door (STD), door‐to‐balloon (DTB), and door‐to‐PCI time persists in contemporary patients, and its impact on mortality.

Methods and Results

From 2013 to 2016 the Victorian Cardiac Outcomes Registry prospectively recruited 13 451 patients (22.5% female) from 30 centers with ST‐segment–elevation myocardial infarction (STEMI, 47.8%) or non–ST‐segment–elevation myocardial infarction (NSTEMI) (52.2%) who underwent PCI. Adjusted log‐transformed STD and DTB time in the STEMI cohort and STD and door‐to‐PCI time in the NSTEMI cohort were analyzed using linear regression. Logistic regression was used to determine independent predictors of 30‐day mortality. In STEMI patients, women had longer log‐STD time (adjusted geometric mean ratio 1.20, 95% CI 1.12‐1.28, P<0.001), log‐DTB time (adjusted geometric mean ratio 1.12, 95% CI 1.05‐1.20, P=0.001), and 30‐day mortality (9.3% versus 6.5%, P=0.005) than men. Womens’ adjusted geometric mean STD and DTB times were 28.8 and 7.7 minutes longer, respectively, than were mens’ times. Women with NSTEMI had no difference in adjusted STD, door‐to‐PCI time, or early (<24 hours) versus late revascularization, compared with men. Female sex independently predicted a higher 30‐day mortality (odds ratio 1.67, 95% CI 1.11‐2.49, P=0.01) in STEMI but not in NSTEMI.

Conclusions

Women with STEMI have significant delays in presentation and revascularization with a higher 30‐day mortality compared with men. The delay in STD time was 4‐fold the delay in DTB time. Women with NSTEMI had no delay in presentation or revascularization, with mortality comparable to men. Public awareness campaigns are needed to address women's recognition and early action for STEMI.

See Editorial Gulati

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016

INTRODUCTION AND OBJECTIVES

ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI.

METHODS

This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality.

RESULTS

From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).

CONCLUSIONS

Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

Psychological and cognitive factors related to prehospital delay in acute coronary syndrome: A systematic review

BACKGROUND

In acute coronary syndrome the time elapsed between the start of symptoms and the moment the patient receives treatment is an important determinant of survival and subsequent recovery. However, many patients do not receive treatment as quickly as recommended, mostly due to substantial prehospital delays such as waiting to seek medical attention after symptoms have started.

OBJECTIVE

To conduct a systematic review with meta-analysis of the relationship between nine frequently investigated psychological and cognitive factors and prehospital delay.

DESIGN

A protocol was preregistered in PROSPERO [CRD42018094198] and a systematic review was conducted following PRISMA guidelines.

DATA SOURCES

The following databases were searched for quantitative articles published between 1997 and 2019: Medline (PubMed), Web of Science, Scopus, Psych Info, PAIS, and Open grey.

REVIEW METHODS

Study risk of bias was assessed with the NIH Quality Assessment Tool for Observational, Cohort, and Cross-Sectional Studies. A best evidence synthesis was performed to summarize the findings of the included studies.

RESULTS

Forty-eight articles, reporting on 57 studies from 23 countries met the inclusion criteria. Studies used very diverse definitions of prehospital delay and analytical practices, which precluded meta-analysis. The best evidence synthesis indicated that there was evidence that patients who attributed their symptoms to a cardiac event (n = 37), perceived symptoms as serious (n = 24), or felt anxiety in response to symptoms (n = 15) reported shorter prehospital delay, with effect sizes indicating important clinical differences (e.g., 1.5-2 h shorter prehospital delay). In contrast, there was limited evidence for a relationship between prehospital delay and knowledge of symptoms (n = 18), concern for troubling others (n = 18), fear (n = 17), or embarrassment in asking for help (n = 14).

CONCLUSIONS

The current review shows that symptom attribution to cardiac events and some degree of perceived threat are fundamental to speed up help-seeking. In contrast, social concerns and barriers in seeking medical attention (embarrassment or concern for troubling others) may not be as important as initially thought. The current review also shows that the use of very diverse methodological practices strongly limits the integration of evidence into meaningful recommendations. We conclude that there is urgent need for common guidelines for prehospital delay study design and reporting.

Few with ST-segment elevation myocardial infarction are diagnosed within 10 minutes from first medical contact, and women have longer delay times than men

Background

Previous reports have questioned the feasibility and gender equality of obtaining a prehospital ECG within 10 minutes of ambulance arrival for patients with ST-segment elevation myocardial infarction (STEMI). The main objective of this study was to investigate the proportion of STEMI patients with a prehospital ECG within 10 minutes of ambulance arrival. The secondary objective was to study the gender differences in delay times in prehospital STEMI care.

Methods

This study was a retrospective study based on 539 patients with STEMI at the investigating hospital. Ambulance and medical charts, as well as the national quality registry “SWEDEHEART”, were reviewed for each patient for demographics and time information.

Results

A prehospital ECG was obtained within 10 minutes of ambulance arrival for 99 (29%) of the men and 19 (14%) of the women, p = 0.001. Women had a 2 minutes longer delay between ambulance arrival and prehospital ECG (95% CI 0–4 min, p = 0.018) than men. Women also had a significantly longer patient delay. None of the other time intervals differed among men and women.

Conclusions

Only for a minority of patients is a prehospital ECG taken within the recommended ten minutes from ambulance arrival. Women have longer patient delay times, as well as delay times to the acquisition of a prehospital ECG than men. Improvements of prehospital ECG acquisition and adjustments of the guidelines are warranted.

Pre-hospital delay and emergency medical services in acute myocardial infarction

BACKGROUND/AIMS

Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay.

METHODS

Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center).

RESULTS

A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS.

CONCLUSION

Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.

Prehospital and in-hospital delays to care and associated factors in patients with STEMI: an observational study in 101 non-PCI hospitals in China

OBJECTIVES

To describe the prehospital and in-hospital delays to care and factors associated with the delays among patients with ST-segment elevation myocardial infarction (STEMI) in non-percutaneous coronary intervention (PCI) hospitals in China.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from a large registry-based quality of care improvement trial conducted from 2011 to 2014 among 101 non-PCI hospitals in China. A total of 7312 patients with STEMI were included. Prehospital delay was defined as time from symptom onset to hospital arrival >120 min, first ECG delay as time from arrival to first ECG >10 min, thrombolytic therapy delay as time from first ECG to thrombolytic therapy >10 min and in-hospital delay as time from arrival to thrombolytic therapy >30 min. Logistic regressions with generalised estimating equations were preformed to identify the factors associated with each delay.

RESULTS

The rates of prehospital delay, first ECG delay, thrombolytic therapy delay and in-hospital delay were 67.1%, 31.4%, 85.8% and 67.8%, respectively. Patients who were female, older than 65 years old, illiterate, farmers, onset during late night and forenoon, had heart rate ≥100 beats/m at admission were more likely and patients who had history of myocardial infarction, hypertension or SBP <90 mm Hg at admission were less likely to have prehospital delay. First ECG delay was more likely to take place in patients arriving on regular hours. Thrombolytic therapy delay rate was lower in patients who had prehospital delay or first ECG delay but higher in those with heart rate ≥100 beats/m at admission. In-hospital delay rate was lower in patients with a history of dyslipidaemia and those who arrived during regular hours.

CONCLUSION

Chinese patients with STEMI in low medical resource areas suffered severe prehospital and in-hospital delays to care. Future efforts should be made to improve the prehospital delay among vulnerable populations with low socioeconomic status.

TRIAL REGISTRATION NUMBER

NCT01398228; Post-results.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Inability to act was associated with an extended delay prior to care-seeking, in patients with an acute myocardial infarction

BACKGROUND

The out-of-hospital mortality in patients with acute myocardial infarction remains unchanged in contrast to a decrease in inhospital mortality. Interventions aiming to shorten patient delay have been largely unsuccessful. A deeper understanding is apparently needed on patients' appraisal prior to care-seeking.

AIM

To investigate whether appraisal processes influence patient delay, and if the questionnaire 'Patients' appraisal, emotions and action tendencies preceding care seeking in acute myocardial infarction' (PA-AMI) could discriminate between patients with prolonged care-seeking and those with a short delay.

METHODS

A cross-sectional study including 326 acute myocardial infarction patients filling out the validated questionnaire PA-AMI. The impact of subscales on delay was analysed by projection to latent structures regression. Discrimination opportunities between patients with short and long delays were analysed by projection to latent structures discriminant analysis.

RESULTS

The subscales 'perceived inability to act' and 'symptom appraisal' had a major impact on patient delay (P<0.0001). 'Perceived inability to act' had its main influence in patients with a delay exceeding 12 hours, and 'symptom appraisal' had its main influence in patients with a delay shorter than one hour.

CONCLUSION

Appraisal processes influence patient delay. Acute myocardial infarction patients with a prolonged delay were, besides a low perceived symptom severity and urgency to seek medical care, characterised by a perceived loss of control and ability to act. Therefore, future interventions aimed at decreasing delay should pay attention to appraisal processes, and perceived inability to act may be a sign of a health threat and therefore a signal to seek medical care.

High quality process of care increases one-year survival after acute myocardial infarction (AMI): A cohort study in Italy

Background

The relationship between guideline adherence and outcomes in patients with acute myocardial infarction (AMI) has been widely investigated considering the emergency, acute, post-acute phases separately, but the effectiveness of the whole care process is not known.

Aim

The study aim was to evaluate the effect of the multicomponent continuum of care on 1-year survival after AMI.

Methods

We conducted a cohort study selecting all incident cases of AMI from health information systems during 2011–2014 in the Lazio region. Patients’ clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. For each subject the probability to reach the hospital and the conditional probabilities to survive to 30 days from admission and to 31–365 days post discharge were estimated through multivariate logistic models. The 1-year survival probability was calculated as the product of the three probabilities. Quality of care indicators were identified in terms of emergency timeliness (time between residence and the nearest hospital), hospital performance in treatment of acute phase (number/timeliness of PCI on STEMI) and drug therapy in post-acute phase (number of drugs among antiplatelet, β-blockers, ACE inhibitors/ARBs, statins). The 1-year survival Probability Ratio (PR) and its Bootstrap Confidence Intervals (BCI) between who were exposed to the highest level of quality of care (timeliness<10', hospitalization in high performance hospital, complete drug therapy) and who exposed to the worst (timeliness≥10', hospitalization in low performance hospital, suboptimal drug therapy) were calculated for a mean-severity patient and varying gender and age. PRs for patients with diabetes and COPD were also evaluated.

Results

We identified 38,517 incident cases of AMI. The out-of-hospital mortality was 27.6%. Among the people arrived in hospital, 42.9% had a hospitalization for STEMI with 11.1% of mortality in acute phase and 5.4% in post-acute phase. For a mean-severity patient the PR was 1.19 (BCI 1.14–1.24). The ratio did not change by gender, while it moved from 1.06 (BCI 1.05–1.08) for age<65 years to 1.62 (BCI 1.45–1.80) for age >85 years. For patients with diabetes and COPD a slight increase in PRs was also observed.

Conclusions

The 1-year survival probability post AMI depends strongly on the quality of the whole multicomponent continuum of care. Improving the performance in the different phases, taking into account the relationship among these, can lead to considerable saving of lives, in particular for the elderly and for subjects with chronic diseases.

The Quality of Symptoms in Women and Men Presenting to the Emergency Department With Suspected Acute Coronary Syndrome

INTRODUCTION

More than 5.5 million patients present to emergency departments in the United States annually for potential acute coronary syndrome (ACS); however, diagnosing ACS remains a challenge in emergency departments. Our aim was to describe the quality of symptoms (chest discomfort/description of pain, location/radiation, and overall symptom distress) reported by women and men ruled-in and ruled-out for ACS in emergency departments.

METHODS

The sample consisted of 1,064 patients presenting to emergency departments with symptoms that triggered cardiac workups. Trained research staff obtained data using the ACS Patient Information Questionnaire upon patient presentation to emergency departments.

RESULTS

The sample (n = 1,064) included 474 (44.55%) patients ruled-in and 590 (55.45%) patients ruled-out for ACS. Symptom distress was significantly higher in patients ruled-in versus ruled-out for ACS (7.3 ± 2.6 vs. 6.8 ± 2.5; P = 0.002) and was a significant predictor for an ACS diagnosis in men (odds ratio [OR], 1.10; confidence interval [CI], 1.03-1.17; P = 0.003). Women also reported more chest pressure (51.75% vs. 44.65; P = 0.02) compared with men, and chest pressure was a significant predictor for a diagnosis of ACS (OR, 1.61; CI, 1.03-2.53; P = 0.02).

DISCUSSION

Higher levels of symptom distress may help ED personnel in making a decision to evaluate a patient for ACS, and the presence of chest pressure may aid in making a differential diagnosis of ACS.

Pain in emergency units: correlation with risk classification categories

Objectives:

to correlate risk classification categories with the level of pain of patients in an emergency service.

Method:

cross-sectional study carried out in the Risk Classification of 611 patients. The variables studied were: age, gender, comorbidities, complaint duration, medical specialty, signs and symptoms, outcome, color attributed in the risk classification of and degree of pain. We used Analysis of Variance, a Chi-Square test and a Likelihood Ratio test.

Results:

the average age was 42.1 years (17.8); 59.9% were women; the green (58.9%) and yellow (22.7%) risk classification prevailed and hypertension (18.3%) was the most common Comorbidity. The most frequent pain intensity was moderate (25.9%). In the red category, patients presented a higher percentage of absence of pain; in the blue, mild pain; and in the green, yellow and orange categories, there was a greater percentage of intense pain (p < 0.0001).

Conclusion:

among the patients who presented pain, the majority reported moderate intensity. Regarding risk categories, most patients in the red category did not report pain. Those who were classified as green, yellow and orange, reported mostly intense pain. On the other hand, patients in the blue category reported predominantly mild pain.

Gender differences in patient and system delay for primary percutaneous coronary intervention: current trends in a Swiss ST-segment elevation myocardial infarction population

Background:

Women with ST-segment elevation myocardial infarction (STEMI) experience greater delays for percutaneous coronary intervention-facilitated reperfusion than men. Whether women and men benefit equally from current strategies to reduce ischaemic time and whether there are gender differences in factors determining delays is unclear.

Methods:

Patient delay (symptom onset to first medical contact) and system delay (first medical contact to percutaneous coronary intervention-facilitated reperfusion) were compared between women ( n=967) and men ( n=3393) in a Swiss STEMI treatment network. Trends from 2000 to 2016 were analysed, with additional comparisons between three time periods (2000–2005, 2006–2011 and 2012–2016). Factors predicting delays and hospital mortality were determined by multivariate regression modelling.

Results:

Female gender was independently associated with greater patient delay ( P=0.02 vs. men), accounting for a 12% greater total ischaemic time among women in 2012–2016 (median 215 vs. 192 minutes, P<0.001 vs. men). From 2000–2005 to 2012–2016, median system delay was reduced by 18 and 25 minutes in women and men, respectively ( P<0.0001 for trend, P=n.s. for gender difference). Total occlusion of the culprit artery, stent thrombosis, a Killip class of 3 or greater, and presentation during off-hours predicted delays in men, but not in women. A Killip class of 3 or greater and age, but not gender or delays, were independently associated with hospital mortality.

Conclusions:

STEMI-related ischaemic time in women remains greater than in men due to persistently greater patient delays. In contrast to men, clinical signs of ongoing chest discomfort do not predict delays in women, suggesting that female STEMI patients are less likely to attribute symptoms to a condition requiring urgent treatment.