STEMI protocol reduces sex disparities in care, outcomes
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A comprehensive STEMI protocol led to reductions in sex disparities in guideline-directed medical therapy, door-to-balloon time, in-hospital mortality and ischemic in-hospital events, according to new data.
The findings were published in European Heart Journal Open.
In an interview with Healio, Umesh N. Khot, MD, vice chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine and staff cardiologist in the section of clinical cardiology in the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, said the study began with the well-known understanding that women have worse survival and more complications with STEMI than men.
STEMI care delivery system
“It has been assumed that this is due to older age, higher comorbidity burden and more complex presentation in women compared to men,” Khot said. “However, we hypothesized that the organization of the STEMI care delivery system may have an impact on outcomes in women. We wanted to know if a system-based approach to STEMI care focused on reducing care variability would impact outcomes overall and particularly in women.”
The observational cohort study included 1,833 consecutive patients with STEMI who received PCI before (control group; n = 723) and after (protocol group; n = 1,110) implementation of a comprehensive STEMI protocol. Patients in the control group were treated from 2011 to July 14, 2014, whereas those in the protocol group received treatment from July 15, 2014, to July 15, 2019.
The protocol involved four steps aimed at standardizing STEMI care:
authorization of ED physicians to activate the cardiac cath lab without delay for cardiac consultation;
usage of a checklist to streamline critical tasks and provide real-time clinical decision support before PCI;
implementation of a policy for immediate transfer to an available cath lab; and
standardization of a protocol for transradial access as the preferred initial arterial access, although the attending interventional cardiologist had the final decision on access site.
Results revealed that women in the control group compared with men had less guideline-directed medical therapy (68.1% vs. 77.1%; P = .03), a low rate of transradial PCI (17.6% vs. 19%; P = .73) and longer door-to-balloon time (112 minutes vs. 104 minutes; P = .02); this corresponded to increased rates of in-hospital mortality (10.3% vs. 4.5%; OR = 2.44; P = .004), MACCE (16.3% vs. 9.8%; OR = 1.79; P = .01) and net adverse clinical events (NACE; 28.3% vs. 16.1%; OR = 2.06; P < .001).
Researchers observed no significant sex differences in the protocol group regarding guideline directed medical therapy (P = .81) or door-to-balloon time (P = .06), although transradial PCI was less frequent in women (71.2% vs. 77.6%; P = .03). Furthermore, there were similar rates of in-hospital mortality (P = .09) and MACCE (P = .26) between sexes; however, the higher rate of NACE in women approached statistical significance (19.4% vs. 14.8%; OR = 1.38; P = .05). A higher risk for bleeding in women (11.1% vs. 7.2%; OR = 1.6; P = .03) caused this latter discrepancy.
Ensuring standard care
“We believe that all STEMI patients, but particularly women, benefit from a system-based approach, as it ensures standard care for every patient, every time,” Khot said. “As women are traditionally higher risk than men, they see marked improvements in outcomes with this standardized approach. Each part of the four-step protocol is synergistic when applied together to benefit outcomes in women.”
In STEMI care, the focus for many years has been speed, which Khot said is important, but that eliminating care variability is even more critical. “All patients benefit from reduced STEMI care variability and patients who are at the highest risk for mortality do even better,” he said.
For more information:
Umesh N. Khot, MD, can be reached at khotu@ccf.org; Twitter: @umeshkhotmd.
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