Automated prehospital STEMI activation reduces gender gap in treatment delays

Christine Pacheco

ANAHEIM, Calif. — A “physician-less” protocol to activate a cath lab team while a patient with STEMI was in the ambulance reduced the gender gap in treatment delays compared with protocols with physician involvement, according to data presented at American Heart Association Scientific Sessions.

Christine Pacheco, MD, cardiology resident at Centre Hospitalier de l’Université de Montréal (CHUM), and colleagues analyzed data from consecutive patients with confirmed STEMI. Patients were categorized into three cohorts: traditional hospital-based STEMI activation (n = 181; 47 women), automated physician-less prehospital STEMI activation (n = 270; 77 women) and prehospital STEMI activation with physician oversight (n = 116; 31 women).

A physician-less activation system is a protocol applied to patients presenting with dyspnea or chest pain in which an in-the-field ECG is performed by an ambulance technician. If the automated ECG diagnosis reads that the patient is having an acute MI, a cardiac catheterization laboratory team is activated immediately by the ambulance technician.

“There’s, therefore, no physician overreading or reinterpretation of the ECG prior to the patient’s arrival in the cath lab,” Pacheco said.

The outcomes of interest for all three cohorts were the proportion of men and women with suboptimal door-to-device and first-medical-contact-to-device times. Both were considered suboptimal if they were greater than 90 minutes.

“The reason we decided to look at both door-to-device time and contact-to-device time was because our traditional hospital-based activation cohort antedated the 2013 [American College of Cardiology]/AHA recommendations on STEMI care, which shifted the focus from door-to-balloon to contact-to-device as the best treatment target that we should be looking at in order to optimize outcomes in STEMI patients,” Pacheco said.

In the traditional hospital-based activation cohort, 61.7% of women had a door-to-device time greater than 90 minutes vs. 35.8% of men (P < .01). Women were also more likely to have a contact-to-device time greater than 90 minutes (80.9%) compared with men (58.8%; P < .01).

The gender gap regarding suboptimal treatment delay seemed to disappear in the automated physician-less prehospital STEMI activation cohort, according to the presentation. The differences between women and men for suboptimal door-to-device time (5.2% vs. 2.1%; P = .17) and contact-to-device time (31.2% vs. 20.3%; P = .06) were no longer statistically significant.

Women in the prehospital STEMI activation with physician oversight cohort were more likely to have suboptimal device-to-treatment times (19.4%) compared with men (2.4%; P < .01). This was also seen in contact-to-device times but the difference was not statistically significant (51.6% vs. 34.1%; P = .09).

Neither female sex, age older than 75 years or off-hours presentation were independent predictors of suboptimal treatment delays among those in the automated physician-less prehospital STEMI activation cohort.

“This system appeared to be immune to these factors,” Pacheco said.

Whereas in cohorts with physician involvement, age older than 75 years and female sex were predictors of suboptimal treatment delays, and off-hours presentation was a predictor of suboptimal contact-to-device times only.

“There does appear to be significant collinearity between age and female gender in these cohorts, and interaction between these two clinical characteristics and the impact on decision making remains to be explored,” Pacheco said. – by Darlene Dobkowski

Reference:

Pacheco C, et al. Gender Disparities and Women’s Cardiovascular Disease. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, Calif.

Disclosure: Pacheco reports no relevant financial disclosures.