Four-step protocol reduces gender gap in STEMI care

ORLANDO, Fla. — Implementation of a comprehensive four-step STEMI treatment protocol improved outcomes in women and helped close the gaps in care between men and women with STEMI.

The four-step protocol focuses on:

ED cath lab activation;
a STEMI Safe Handoff Checklist;
immediate transfer of the patient to an available cath lab; and
movement toward a radial-first approach to PCI.

From 2011 to 2014 — before the new protocol was implemented at their institution — Umesh Khot, MD, vice chairman of CV medicine at the Cleveland Clinic, and colleagues observed significant disparities in care between women and men with STEMI undergoing PCI. Compared with men, women were less likely to receive guideline-directed medical therapy before PCI (77% vs. 69%; P = .019) and had longer door-to-balloon times (104 vs. 112 minutes; P = .023). They also had worse outcomes after PCI, including higher rates of in-hospital stroke, vascular complications, bleeding, transfusion and death.

Umesh Khot

However, after implementation of the new protocol, STEMI care improved in both sexes, with the differences in care between and women no longer being statistically significant. More men and women received guideline-directed medical therapy before PCI (84% vs. 80%; P = .23), door-to-balloon times decreased (89 vs. 91 minutes; P = .15) and the rates of in-hospital adverse events were comparably lower.

Furthermore, 30-day mortality before the new protocol was 6.1% higher in women. After implementation of the protocol, however, the difference decreased to 3.2% (P = .09).

“Our focus was ensuring that patients received standardized care, regardless of who they were or their presentation. We standardized how the cath lab was activated, incorporated the safety checklist, ensured rapid transfer of patients and moved toward a radial-first approach to access,” Khot told Cardiology Today’s Intervention. “When evaluating the data, we saw improvements overall, but it was striking that when stratified by gender, we saw dramatic improvements among women with STEMI.”

This finding, he said, was important because research has shown that women with STEMI receive less than ideal care and often have more complications and mortality than men.

“It’s assumed that women presenting with STEMI are higher-risk patients because they tend to have more comorbidities and more complex presentation,” Khot said. “Therefore, some physicians might attribute these disparities in care to the fact that women with STEMI are a higher-risk population than men with STEMI, but we showed that standardization of care not only benefits all patients but particularly benefits women.”

The study included 1,272 consecutive patients with STEMI undergoing PCI, of whom 32% were women. On average, women tended to be 4 years older in both the pre- and post-intervention periods.

The current study was underpowered to prove a mortality benefit, Khot said, so moving forward, he would like to see other centers adopt similar programs and evaluate whether there is a true difference. – by Melissa Foster

References:

Huded CP. Abstract 915-04. Presented at: American College of Cardiology Scientific Session; March 10-12, 2018; Orlando, Fla.

Huded CP, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.02.039.

Disclosures: Khot reports he has served as a consultant for AstraZeneca. One author reports he has served as a consultant for Abbott Vascular, Boston Scientific and Medtronic. All other authors report no relevant financial disclosures.