WOMEN WITH STEMI HAVE WORSE SURVIVAL THAN MEN

Women With STEMI Fare Worse Than Men

December 10, 2008 — A contemporary look at whether there are still differences between men and women in terms of medical care and outcomes after acute myocardial infarction (AMI) has revealed that the situation appears to be improving for women but that there is still some way to go to achieve equality [1].

In their report published online December 8, 2008 in Circulation, Dr Hani Jneid (Baylor College of Medicine and Michael E De Bakey VA Medical Center, Houston, TX) and colleagues analyzed data from the American Heart Association (AHA) Get With the Guidelines program and found no differences between the sexes in terms of in-hospital mortality from AMI. However, women with ST-elevation MI (STEMI) were still more likely than men to die in the hospital.

Our work is still cut out for us

"It's disturbing that there is still a persistent gap in mortality in the highest-risk STEMI group," Jneid told heartwire. "We were able to close the gap between the sexes after adjusting for age and risk factors, but we found a disparity across the board in all treatments between women and men and a disturbing delay in treatment in women compared with men. We have room to improve on the healthcare and outcome of women when they present with this severe type of heart attack."

Dr Nieca Goldberg (Women's Heart Center, New York University, NY), an AHA spokesperson who was not involved in the research but has a special interest in women's health, told heartwire: "I'm disappointed by this research, as there have been a lot of campaigns to increase awareness about cardiovascular disease in women. It seems like we've improved our care in women with non-STEMI, but it's kind of confusing to me why women with a STEMI come in and are more likely to die." She adds that she is reassured that doctors seem to have gotten better at treating the subtler forms of heart attack, "but our work is still cut out for us."

Women less likely to receive adequate therapies

In their study, Jneid et al examined sex differences in care processes and in-hospital deaths among 78,254 patients with AMI in 420 US hospitals from 2001 to 2006. Women, in general, were older, had more comorbidities, less often presented with STEMI, and had higher unadjusted in-hospital death (8.2% vs 5.7% for men; p <>

But after multivariate adjustment, sex differences in in-hospital mortality were no longer apparent in the overall AMI cohort (adjusted odds ratio 1.04), although they persisted among STEMI patients (mortality rate 10.2% among women compared with 5.5% in men; p <>

This excess death seen in women with STEMI was primarily accounted for by an excess of very early deaths among women in the initial 24 hours of hospitalization, the researchers note. Women were less likely to receive early medical treatments, acute reperfusion therapies, timely pharmacological and mechanical reperfusion, and invasive procedures.

"This tells us that there are true disparities," Jneid says.

Adjusted ORs for clinical performance measures, invasive procedures and in-hospital death*

Measure/treatment/outcome	n	Adjusted ORa (women vs men)	p
Early medical therapy
Aspirin within 24 h	70,360	0.86	<0.0001
Beta blocker within 24 h	64,681	0.90	<0.0001
Invasive procedures
Cardiac cath	74,769	0.91	<0.0001
PCI	67,477	0.78	<0.0001
CABG	67,477	0.60	<0.0001
Revascularization	67,477	0.68	<0.0001
Acute reperfusion and timeliness of reperfusionb
DTN ≤ 30 min	2807	0.78	0.004
DTB ≤ 90 min	7673	0.87	0.004
Reperfusion therapy	24,742	0.75	<0.0001
Primary PCI	24,742	0.83	<0.0001
Fibrinolytic therapy	24,742	0.87	<0.0001
In-hospital death
Overall AMI cohort	70,105	1.04	0.1
STEMI subpopulation	23,015	1.12	0.015

* PCI indicates percutaneous coronary intervention; CABG, coronary artery bypass grafting; DTN, door-to-needle; DTB, door-to-balloon; STEMI, ST-segment elevation myocardial infarction
^a. Adjusted for age, race, body-mass index, insurance type, systolic blood pressure (BP), cardiac diagnosis, initial electrocardiogram (ECG) with diagnostic ST-segment elevation or left bundle-branch block, diabetes, hypertension, hyperlipidemia, heart failure, previous MI, peripheral vascular disease, renal insufficiency, stroke, chronic obstructive pulmonary disease, and adult history of smoking
^b. STEMI subpopulation

Reasons for higher STEMI deaths in women multifactorial

Jneid told heartwire: "Our contemporary analysis is very relevant to current clinical practice. In the present study, the mortality-rate gap was no longer observed after a comprehensive multivariable adjustment, which lends support to the notion that sex, by itself, in the current era, does not independently predict early death after AMI among hospitalized patients."

But the excess in very early death among STEMI women was likely related, at least in part, to the treatment differences, he says, "although the reasons are probably multifactorial."

"Women presenting with STEMI appear to be at high risk of dying in the initial 24 hours and to represent a subgroup of patients in whom prompt and aggressive therapies are warranted," he adds.

Focus on the gap in the chain and how to correct it

Goldberg told heartwire: "We have to see where in the chain this has gotten messed up. Is it that women are getting to the hospital later, so there is more heart-muscle damage?" she wonders. "Did they get the ECGs they needed in a timely manner, and were they correctly evaluated? Is it being explained to them that they might benefit from urgent cardiac catheterization? And is the patient being referred for intervention?"

Jneid says these will be the topics of future research. "We need to address prehospital delays and look at all aspects of patient education, the emergency medical services, the emergency room, and consultant care," he notes. "We need to focus on where the gap in the chain is and how to correct it.

"We as doctors have to use this paper as an example of why you need to go to the hospital quickly and why it's important to treat cardiovascular risk factors before anyone has any symptoms at all," Goldberg stresses. "We need to communicate to our patients that they shouldn't become a statistic."