Sex disparities in pre-hospital and hospital treatment of ST-segment elevation myocardial infarction

Implementation of a Novel Prehospital Clinical Decision Tool and ECG Transmission for STEMI Significantly Reduces Door-to-Balloon Time and Sex-Based Disparities

BACKGROUND

An important method employed to reduce door to balloon time (DTBT) for ST segment elevation Myocardial Infarctions (STEMIs) is a prehospital MI alert. The purpose of this retrospective study was to examine the effects of an educational intervention using a novel decision support method of STEMI notification and prehospital electrocardiogram (ECG) transmission on DTBT.

METHODS

An ongoing database (April 4, 2000 - present) is maintained to track STEMI alerts. In 2007, an MI alert program began; emergency medicine physicians could activate a "prehospital MI alert". In October 2015, modems were purchased for Emergency Medical Services personnel to transmit ECGs. There was concurrent implementation of a decision support tool for identifying STEMI. Sex was assigned as indicated in the medical record. Data were analyzed in two groups: Pre-2016 (PRE) and 2016-2022 (POST).

RESULTS

In total, 3,153 patients (1,301 PRE; 1,852 POST) were assessed; the average age was 65.2 years, 32.6% female, 87.7% white with significant differences in age and race between the two cohorts. Of the total 3,153 MI alerts, 239 were false activations, leaving 2,914 for analysis. 2,115 (72.6%) had cardiac catheterization while 16 (6.7%) of the 239 had a cardiac catheterization. There was an overall decrease in DTBT of 27.5% PRE to POST of prehospital ECG transmission (p < 0.001); PRE median time was 74.5 min vs. 55 min POST. There was no significant difference between rates of cardiac catheterization PRE and POST for all patients. After accounting for age, race, and mode of arrival, DTBT was 12.2% longer in women, as compared to men (p < 0.001) PRE vs. POST. DTBT among women was significantly shorter when comparing PRE to POST periods (median 77 min vs. 60 min; p = 0.0001). There was no significant sex difference in the proportion of those with cardiac catheterization between the two cohorts (62.5% vs. 63.5%; p = 0.73).

CONCLUSION

Introduction of a decision support tool with prehospital ECG transmission with prehospital ECG transmission decreased overall DTBT by 20 min (27.5%). Women in the study had a 17-minute decrease in DTBT (22%), but their DTBT remained 12.2% longer than men for reasons that remain unclear.

Disparities in Emergency Medical Services Care Delivery in the United States: A Scoping Review

BACKGROUND

Emergency medical services (EMS) often serve as the first medical contact for ill or injured patients, representing a critical access point to the health care delivery continuum. While a growing body of literature suggests inequities in care within hospitals and emergency departments, limited research has comprehensively explored disparities related to patient demographic characteristics in prehospital care.

OBJECTIVE

We aimed to summarize the existing literature on disparities in prehospital care delivery for patients identifying as members of an underrepresented race, ethnicity, sex, gender, or sexual orientation group.

METHODS

We conducted a scoping review of peer-reviewed and non-peer-reviewed (gray) literature. We searched PubMed, CINAHL, Web of Science, Proquest Dissertations, Scopus, Google, and professional websites for studies set in the U.S. between 1960 and 2021. Each abstract and full-text article was screened by two reviewers. Studies written in English that addressed the underrepresented groups of interest and investigated EMS-related encounters were included. Studies were excluded if a disparity was noted incidentally but was not a stated objective or discussed. Data extraction was conducted using a standardized electronic form. Results were summarized qualitatively using an inductive approach.

RESULTS

One hundred forty-five full-text articles from the peer-reviewed literature and two articles from the gray literature met inclusion criteria: 25 studies investigated sex/gender, 61 studies investigated race/ethnicity, and 58 studies investigated both. One study investigated sexual orientation. The most common health conditions evaluated were out-of-hospital cardiac arrest (n = 50), acute coronary syndrome (n = 36), and stroke (n = 31). The phases of EMS care investigated included access (n = 55), pre-arrival care (n = 46), diagnosis/treatment (n = 42), and response/transport (n = 40), with several studies covering multiple phases. Disparities were identified related to all phases of EMS care for underrepresented groups, including symptom recognition, pain management, and stroke identification. The gray literature identified public perceptions of EMS clinicians' cultural competency and the ability to appropriately care for transgender patients in the prehospital setting.

CONCLUSIONS

Existing research highlights health disparities in EMS care delivery throughout multiple health outcomes and phases of EMS care. Future research is needed to identify structured mechanisms to eliminate disparities, address clinician bias, and provide high-quality equitable care for all patient populations.

Gender differences in clinical characteristics and in-hospital and one-year outcomes of young patients with ST-segment elevation myocardial infarction under the age of 40

Introduction: Although the incidence of acute ST-segment elevation myocardial infarction (STEMI) in the elderly population has decreased in recent years, this is not the case for young people. At the same time, no reduction in hospitalization rate after STEMI was shown in young people. Clinical characteristics, risk factors, angiographic findings, in-hospital and one-year outcomes of patients under the age of 40 and their gender differences were investigated. Methods: This study has been performed retrospectively in two centers. Between January 2015 and April 2019, 212 patients aged 18-40 years with STEMI and who underwent reperfusion therapy were included. The gender differences were compared. Results: The median age of (male 176; 83.0% and female 36; 17.0%) patients included in the study was 36 (33-38) for men and 36 (34-38) for women. Chest pain was the most common complaint for both genders (96.0% vs. 94.4%; P = 0.651). While men presented more often with Killip class 1,women presented more often with Killip class 2. The anterior myocardial infarction (MI) was the most common MI type and it was higher in women than in man (P = 0.027). At one year of follow-up, the prevalence of all-cause hospitalization was 24%, MI 3.8%, coronary angiography 15.1%, cardiovascular death 1.4%, and all-cause death 0.47%, there was no gender difference. Conclusion: Anterior MI was the most common type of MI and it was more common in women than in men. Left anterior descending artery was the most common involved coronary artery. The most common risk factor is smoking. In terms of in-hospital outcome, left ventricular ejection fraction was significantly lower in women. There was no significant difference in one-year outcomes between both genders.

Impact of Sex and Contact-to-Device Time on Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction-Findings From the National Cardiovascular Data Registry

Background

Emergent myocardial reperfusion via primary percutaneous coronary intervention is optimal care for patients presenting with ST‐segment elevation myocardial infarction (STEMI). Delays in such interventions are associated with increases in mortality. With the shift in focus to contact‐to‐device (C2D) time as a new perfusion metric, this study was designed to examine how sex affects C2D time and mortality in STEMI patients.

Methods and Results

Clinical data on male and female STEMI patients were extracted and analyzed from the National Cardiovascular Data Registry from July 1, 2008 to December 31, 2014. A total of 102 515 patients were included in the final analytic cohort. The median C2D time in female patients with STEMI was delayed when compared to male patients (80 [65–97] versus 75 [61–90] minutes; P<0.001). The unadjusted mortality was higher in female patients when compared to male patients with STEMI (4.1% versus 2.0%; P<0.001). For every 5‐minute increase in C2D time, the adjusted odds ratio for mortality was 1.04 (95% CI, 1.03–1.06) for female patients with STEMI and 1.07 (95% CI, 1.06–1.09) for male patients (P for sex by C2D interaction=0.003).

Conclusions

To date, this is the largest analysis of STEMI patients that measures the impact of the new recommended C2D reperfusion metric on in‐hospital mortality. Female STEMI patients have longer C2D times and increased mortality. The disparity can be improved and survival can increase in this high‐risk patient cohort by decreasing systems issues that cause increased reperfusion times in female STEMI patients.

Differences in Terminal Hospitalization Care Between U.S. Men and Women

CONTEXT

In many settings, men and women receive different care.

OBJECTIVES

We sought to determine whether men and women receive different care during terminal hospitalizations.

METHODS

We analyzed data of 98,314 adult patients who died while hospitalized in 458 acute care hospitals in the U.S. during 2011. We examined sex-based differences in lengths of stay (LOS), resuscitation status, and intensive interventions and processes of care, adjusting for patient- and hospital-level characteristics.

RESULTS

Women represented half of the sample (48,509; 49.34%), were older than men (73.8 vs. 70.6 years, P < 0.0001), and less likely to be married (27.7% vs. 48.3%, P < 0.001). Among all patients, median LOS was four days (interquartile range 2-10); 19.1% of subjects received cardiopulmonary resuscitation; 37.6% had a do-not-resuscitate order during the admission; and 51.6% received mechanical ventilation. Compared with men, women had slightly shorter hospitalizations (adjusted LOS: -0.16 days; 95% CI -0.19, -0.12) and were more likely to have a do-not-resuscitate order (odds ratio [OR] 1.08; 95% CI 1.05, 1.11). Women remained less likely to receive care in an intensive care unit (OR 0.95; 95% CI 0.93, 0.98), cardiopulmonary resuscitation (OR 0.83; 95% CI 0.80, 0.86), mechanical ventilation (OR 0.94; 95% CI 0.91, 0.97), hemodialysis (adjusted OR 0.81; 95% CI 0.78, 0.86), or surgical procedures (OR 0.88; 95% CI 0.84, 0.93).

CONCLUSION

Men who die in hospitals receive more aggressive care than women. Further research should examine potential causes of this overall pattern.

Gender differences in risk factors and clinical outcomes in young patients with acute myocardial infarction

BACKGROUND

There are limited data on the influence of gender on risk factors and clinical outcomes in young patients with acute myocardial infarction (AMI).

METHODS

This prospective study stratified outcomes according to gender in patients of age ≤50 years with a diagnosis of AMI, and who were enrolled in the nationwide registry of the Korea Working Group of Myocardial Infarction. The end point was the incidence of major adverse cardiovascular events (MACEs) defined as the composite of cardiac death, recurrent myocardial infarction (MI), and repeat revascularisation at 30 days and 1 year after admission.

RESULTS

The registry enrolled 30 001 patients with AMI, of whom 5200 met the study inclusion criteria; 4805 patients were male and 395 were female. Current smoking was significantly higher in men, while hypertension and diabetes mellitus were significantly more common in women. Women underwent less coronary revascularisation, and were less likely to be on optimal medical therapy compared with men despite having a higher Killip class at presentation and higher risk angiographic findings. Although women had higher rates of MACEs (3.8% vs 1.8%, p=0.018 at 30 days and 7.8% vs 4.7%, p=0.004 at 1-year follow-up) compared with men, female gender was not an independent predictor of MACEs after adjusting for propensity score.

CONCLUSIONS

There were significant gender differences in the risk factors for coronary artery disease and the short-term and long-term clinical outcomes of young patients with AMI. Continued preventive strategies should be focused on gender-different risk factor reduction in these young patients.

Gender-related mortality and in-hospital complications following ST-segment elevation myocardial infarction: data from a primary percutaneous coronary intervention cohort

BACKGROUND

The increased mortality related to female gender in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) has been reported from various patient cohorts and treatment strategies with controversial results. In the present work, we evaluated the impact of female gender on mortality and in-hospital complications among a specific subset of consecutive STEMI patients managed solely by PPCI.

HYPOTHESIS

Female gender is not an independent predicor for mortality among STEMI patients.

METHODS

We performed a retrospective, single-center observational study that included 1346 consecutive STEMI patients undergoing PPCI, of which 1075 (80%) were male. Patient's records were evaluated for 30-day mortality, in-hospital complications, and long-term mortality over a mean period of 2.7 ± 1.6 years.

RESULTS

Compared with males, females were older (69 ± 13 vs 60 ± 13 years, P < 0.001), had a significantly higher rate of baseline risk factors, and had prolonged symptom duration (460 ± 815 minutes vs 367 ± 596 minutes, P = 0.03). Females suffered from more in-hospital complications and had higher 30-day mortality (5% vs 2%, P = 0.008) as well as higher overall mortality (12.5% vs 6%, P < 0.001). In spite of the significant mortality risk in unadjusted models, a multivariate adjusted Cox regression model did not demonstrate that female gender was an independent predictor for mortality among STEMI patients.

CONCLUSIONS

Among patients with STEMI treated by PPCI, female gender is associated with a higher 30-day mortality and complications rates compared to males. Following multivariate analysis, female gender was not a significant predictor of long-term death following STEMI.

From door-to-balloon time to contact-to-device time: predictors of achieving target times in patients with ST-elevation myocardial infarction

BACKGROUND

The 2013 American College of Cardiology Foundation/American Heart Association ST-segment elevation myocardial infarction (STEMI) guidelines have shifted focus from door-to-balloon (D2B) time to the time from first medical contact to device activation (contact-to-device time [C2D] ).

HYPOTHESIS

This study investigates the impact of prehospital wireless electrocardiogram transmission (PHT) on reperfusion times to assess the impact of the new guidelines.

METHODS

From January 2009 to December 2012, data were collected on STEMI patients who received percutaneous coronary interventions; 245 patients were included for analysis. The primary outcome was median C2D time in the PHT group and the secondary outcome was D2B time.

RESULTS

Prehospital wireless electrocardiogram transmission was associated with reduced C2D times vs no PHT: 80 minutes (interquartile range [IQR], 64-94) vs 96 minutes (IQR, 79-118), respectively, P < 0.0001. The median D2B time was lower in the PHT group vs the no-PHT group: 45 minutes (IQR, 34-56) vs 63 minutes (IQR, 49-81), respectively, P < 0.0001. Multivariate analysis showed PHT to be the strongest predictor of a C2D time of <90 minutes (odds ratio: 3.73, 95% confidence interval: 1.65-8.39, P = 0.002). Female sex was negatively predictive of achieving a C2D time <90 minutes (odds ratio: 0.23, 95% confidence interval: 0.07-0.73, P = 0.01).

CONCLUSIONS

In STEMI patients, PHT was associated with significantly reduced C2D and D2B times and was an independent predictor of achieving a target C2D time. As centers adapt to the new guidelines emphasizing C2D time, targeting a shorter D2B time (<50 minutes) is ideal to achieve a C2D time of <90 minutes.