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Women Undertreated, Face Worse Outcomes in STEMI
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Among patients with STEMI, women were less likely than men to be treated with appropriate invasive procedures or medication and were more likely to have poor outcomes 6 months after the event, researchers reported.
The researchers analyzed 2,898 patients with STEMI (715 women; mean age for women, 67 years; mean age for men, 61 years) from the CONCORDANCE ACS registry treated in Australia between February 2009 and May 2016.
“We focused on patients with ST-elevation myocardial infarction because the clinical presentation and diagnosis of this condition is fairly consistent, and patients should receive a standardized management plan,” Clara K. Chow, MBBS, FRACP, PhD, a cardiologist at Westmead Hospital, senior lecturer at Sydney Medical School and head of the cardiac program at The George Institute for Global Health, said in a press release.
The primary outcome was rates of revascularization, including PCI, thrombolysis and CABG. Secondary outcomes included rates of timely revascularization, major adverse CV event rates, other clinical outcomes and prescription of preventive treatments at discharge.
Compared with men, women were more likely to have hypertension, diabetes, prior stroke, chronic kidney disease, chronic HF and dementia, and they were less likely to have had prior CAD, MI, PCI or CABG, according to the researchers.
After adjustment for GRACE risk score quartile, women were less likely than men to undergo coronary angiography (adjusted OR = 0.53; 95% CI, 0.41-0.69) or revascularization (aOR = 0.42; 95% CI, 0.34-0.52), Chow and colleagues wrote. They were also less likely to receive timely revascularization (aOR = 0.72; 95% CI, 0.63-0.83) or primary PCI (aOR = 0.76; 95% CI, 0.61-0.95).
At 6 months, women had higher rates of major adverse CV events (aOR = 2.68; 95% CI, 1.76-4.09) and death (aOR = 2.17; 95% CI, 1.24-3.8), according to the researchers.
At discharge, women were less likely than men to receive beta-blockers, statins and cardiac rehabilitation referrals, Chow and colleagues wrote.
“The reasons for the undertreatment and management of women compared to men in Australian hospitals aren’t clear,” Chow said in the release. “It might be due to poor awareness that women with STEMI are generally at higher risk, or by a preference for subjectively assessing risk rather than applying more reliable, objective risk prediction tools. Whatever the cause, these differences aren’t justified. We need to do more research to discover why women suffering serious heart attacks are being under-investigated by health services and urgently identify ways to redress the disparity in treatment and health outcomes.” – by Erik Swain
Disclosures: The CONCORDANCE registry has been funded by grants to the Sydney Local
Health District from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp and Dohme/Schering Plough, the National Heart Foundation of Australia and Sanofi Aventis. The authors report no relevant financial disclosures.
Perspective
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Umesh N. Khot, MD
These findings are consistent with findings seen not only in the United States, but worldwide. It is well-known that women are higher-risk than men, but in virtually all measurements, women receive less optimal care than men when it comes to STEMI. These findings continue to add to overwhelming data showing differences in the STEMI care process for men and women. This is an important article that highlights a common problem around the world.
The first step to reduce the gender gap in STEMI care is to understand that this is an issue. There is an assumption that, since STEMI is a fairly standardized care process, there should not be any difference. But that is not the case. The second step is to focus on having strong structures in place to make sure that patients receive consistent treatment at every time. Our group recently published a paper showing what happens when we structure the care for STEMI (Huded CP, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.02.039); the care equalizes. Women in particular benefit from a highly structured care process.
This study cements the issue that there is a gap. We need to focus on solving the gap and fixing the problem. We need to create systems of care that treat women and men equally and improve care for all.
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