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Pre-hospital treatment delays result in poorer STEMI outcomes for women
SAN DIEGO — Women with STEMI are more likely than men to have delays between symptom onset and treatment, resulting in higher in-hospital mortality, according to results presented at the American College of Cardiology Scientific Sessions.
Researchers reported data from a study of 7,457 patients with STEMI (2,282 women) who were enrolled in the ISACS-TC registry from 2010 to 2014.
The average delay between symptoms and calling emergency medical services was 60 minutes among women compared with 45 minutes among men. Women were also more likely to have a home-to-hospital delay of 60 minutes or longer (70.3% vs. 29.7%).
Receipt of care within 12 hours of symptom onset was reported in 76% of women compared with 80.4% of men (P < .001).
Reperfusion therapy occurred less common among women (69.5% vs. 73.5%; P = .003). Factors associated with lower rates of reperfusion therapy included a delay of 12 hours or longer from symptom onset to treatment (adjusted OR = 5.37; 95% CI, 4.58-6.31), prior HF (OR = 2.77; 95% CI, 1.99-3.87) and Killip class 2 (OR = 1.53; 95% CI, 1.27-1.86).
Overall, the in-hospital mortality rate was 11.8% for women vs. 6.3% for men. After adjustment for confounders, in-hospital mortality was significantly more common among women (OR = 1.34; 95% CI, 1.01-1.77). However, researchers noted that multivariable analyses adjusting for home-to-hospital delay of 60 minutes or less eliminated the difference in in-hospital mortality rates between sexes (OR = 0.9; 95% CI, 0.31-2.56 for women vs. men).
Raffaele Bugiardini
In other results, door-to-needle and door-to-balloon times were similar between women and men. During a press briefing held prior to the ACC Scientific Sessions, Raffaele Bugiardini, MD, FACC, FAHA, FESC, professor of clinical cardiology at the University of Bologna, Italy, said these results suggest that the differences between women and men do not persist once patients have entered the hospital.
"Our analyses indicate that sex differences in outcomes persist [among STEMI patients] because the women have worse in-hospital mortality," Bugiardini said. "Fewer women receive timely reperfusion therapy, which appears to be driven by longer pre-hospital delays. Heart disease is also a women's disease, and it is important to approach this issue through education initiatives aimed at patients ... but also at the physician level, to promote early access to the health system." - by Adam Taliercio and Erik Swain
Reference:
Bugiardini R, et al. Abstract 1125M-17. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.
Disclosure: One researcher reports serving on a speaker's bureau for KRKA, a pharmaceutical company in Macedonia.
Perspective
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We have known from previous data that women often delay taking action at the time of symptoms, but this study carefully has dissected out delays in treatment by identifying the onset of symptoms. It has demonstrated that it is not a delay once the patient arrives at the hospital. That is a really important piece, because we had not found definitively where the delay was. This means that either women are not recognizing their symptoms, or if they do recognize symptoms as being possibly cardiac in etiology, they don’t recognize that they need to get to the hospital.
Because of that delay, more women than men were not eligible for thrombolysis, and their in-hospital mortality was higher. The authors carefully analyzed contributors, and it appears that in fact the major contributor was delay in presentation to the hospital.
There has been a lot of effort placed on awareness campaigns, and it’s very clear from looking at surveys of women that over the course of the last decade or so, women when queried clearly identified what symptoms they should be watching for. But in spite of this, they don’t take action. So we have to go further with the messaging on how to take action. Dialing 911 or getting to the hospital when you have those symptoms needs to be stressed. The focus has been on what symptoms could be heart-related, but the message also needs to be “take action and go to the hospital.”