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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">ST-segment elevation acute myocardial infarction &#40;STEMI&#41; is one of the greatest public health problems in society today&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;2</span></a> Traditionally&#44; women with STEMI have been considered to have a poorer prognosis than men with the same disorder&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> probably because they receive less optimum management &#40;fewer hospital admissions&#44; a lesser percentage of medical treatments recommended by the clinical practice guides&#44; and a lesser percentage of primary angioplasty &#91;PA&#93;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> with a greater delay in applying reperfusion therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> However&#44; recent studies&#44; after adjusting for confounding factors&#44; have identified no gender-related differences in terms of the treatment and prognosis of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The benefits derived from reperfusion therapy in STEMI are conditioned to time&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> Primary angioplasty&#44; performed within the recommended time window&#44; can reduce the mortality and reinfarction risk compared with fibrinolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> Likewise&#44; moving STEMI patients from hospitals where PA is not available 24<span class="elsevierStyleHsp" style=""></span>h a day&#44; 7 days a week &#40;24&#47;7&#41;&#44; to centers with PA 24&#47;7 has been shown to be a feasible and safe strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> For this reason&#44; PA is regarded as the treatment of choice in STEMI&#44; provided it is performed by an experienced operator within 120<span class="elsevierStyleHsp" style=""></span>min after first medical contact &#40;FMC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The implantation of STEMI management networks has contributed to expand reperfusion therapy&#44; fundamentally involving PA&#44; and thus has helped to generalize optimum treatment for each patient according to the time window recommended by the clinical practice guides&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> However&#44; only limited information is available on the impact of patient gender in STEMI cases attended by networks specifically designed to the effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;12</span></a> The present study was designed to analyze the impact of gender in terms of the medical care received and upon patient mortality &#40;in-hospital&#44; after 30 days and at one year&#41; in a population attended by a regional STEMI management network&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study population&#44; STEMI management network and the <span class="elsevierStyleItalic">Codi Infart</span> registry</span><p id="par0020" class="elsevierStylePara elsevierViewall">The present multicentric observational study is fundamented upon a prospective database of consecutive STEMI patients attended by the Catalan STEMI management network &#40;the <span class="elsevierStyleItalic">Codi Infart</span> registry&#41; from January 2010 to December 2011&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The Autonomous Community of Catalonia is located in North-Eastern Spain and has a population of approximately 7&#46;5 million inhabitants&#46; A STEMI management network was implanted in Catalonia in June 2009&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">13&#44;14</span></a> The network divided Catalonia into reference areas for the 10 pre-existing hospitals with the capacity to perform PA&#44; with the aim of affording the reperfusion therapy best suited to each individual patient&#46; The <span class="elsevierStyleItalic">Codi Infart</span> comprised 5 basic elements&#58; &#40;1&#41; The ambulances of the Medical Emergencies Service &#40;<span class="elsevierStyleItalic">Servei d&#8217;Emergencies M&#232;diques</span> &#91;SEM&#93;&#41;&#44; staffed by physician&#47;s or nurse&#47;s capable of diagnosing the symptoms&#44; interpreting the electrocardiogram &#40;ECG&#41; tracings and of administering fibrinolytic therapy&#59; &#40;2&#41; The SEM coordination center which decided the reperfusion strategy and coordinated the logistics among ambulances&#44; district hospitals and hospitals with the capacity to perform PA&#59; &#40;3&#41; The 10 hospitals with the capacity to perform PA &#40;5 of which had 24&#47;7 availability&#41;&#59; &#40;4&#41; The Intensive Care Units &#40;ICUs&#41; or Coronary Units of all the hospitals participating in the project&#44; and which received the patients after undergoing reperfusion treatment&#59; and &#40;5&#41; The inclusion of all the patients attended by the network in a mandatory prospective registry &#40;the Codi Infart registry&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Briefly&#44; the protocol specified that when a medical professional diagnosed STEMI on the basis of clinical criteria and the ECG tracing in the context of FMC&#44; the network was to be activated and the strategy would be chosen according to the clinical practice guides&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> All patients with STEMI directly admitted to a center with the capacity to perform PA underwent PA&#44; while those patients initially attended in hospitals without PA&#44; in primary care centers or directly by the SEM were moved to centers where PA was available&#44; according to the risk profile involved and if the time to PA was expected to be less than 120<span class="elsevierStyleHsp" style=""></span>min&#46; If the time to PA was expected to be longer than 120<span class="elsevierStyleHsp" style=""></span>min&#44; fibrinolytic therapy was provided if compatible with the clinical condition of the patient&#44; and only in the case of failed fibrinolysis was the patient transferred for rescue angioplasty&#46; Secondary prevention in turn was prescribed according to common medical practice in each center&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;2&#44;14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Codi Infart</span> registry is implemented according to the principles of the Declaration of Helsinki&#44; and complies with all the legal requirements&#46; All the centers were encouraged to keep the registry&#44; and all the patients attended by the network were required to be included in it&#46; Demographic and clinical data were collected&#44; together with information on the procedure&#44; the time intervals&#44; and the in-hospital complications&#44; with telephone follow-up after 30 days&#46; Mortality due to all causes after one year was documented by crossing the data of each patient with the database of the Spanish National Statistics Institute &#40;<span class="elsevierStyleItalic">Instituto Nacional de Estad&#237;stica</span> &#91;INE&#93;&#41; &#40;death certificates&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study variables</span><p id="par0040" class="elsevierStylePara elsevierViewall">In line with the purpose of the study&#44; all the variables were analyzed according to gender&#46; The primary endpoint was mortality due to all causes as determined after one year&#46; The secondary clinical endpoints included&#58; mortality due to all causes in-hospital and after 30 days&#44; and in-hospital complications&#44; defined as the combination of ventricular fibrillation&#44; ventricular tachycardia&#44; asystolia&#44; complete atrioventricular block&#44; atrial fibrillation&#44; cardiogenic shock or the need for mechanical ventilation&#44; and each of the individual components considered separately&#46; Cardiogenic shock was defined as the need for intravenous inotropic drugs and&#47;or intra-aortic balloon counterpulsation in order to keep the systolic blood pressure &#40;SBP&#41; &#62;90<span class="elsevierStyleHsp" style=""></span>mmHg&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Other secondary endpoints related to medical treatment were also evaluated&#44; such as the type of reperfusion therapy provided&#44; and the following management intervals&#58; symptoms onset-FMC&#44; FMC-diagnostic ECG&#44; diagnostic ECG-balloon&#44; FMC-balloon&#44; and symptoms onset-balloon &#40;total ischemia time&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> First medical contact in turn was defined as the first contact with the healthcare system&#44; where the patient was attended by a physician or nurse on an in-hospital or pre-hospital basis&#44; and with the capacity to activate the STEMI management network&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">All the events were assigned by the Catalan Health Department &#40;<span class="elsevierStyleItalic">Servei Catal&#224; de la Salut&#58; CatSalut&#59; Departament de Salut&#44; Generalitat de Catalunya</span>&#41;&#46; As commented above&#44; all study variables were analyzed according to gender&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">The normal distribution of continuous variables was assessed based on the Kolmogorov&#8211;Smirnov test&#46; Those variables found to present a normal distribution were expressed as the mean &#40;standard deviation &#91;SD&#93;&#41;&#44; while those lacking a normal distribution were expressed as the mean &#40;interquartile range &#91;IQR&#93;&#41;&#8211;comparisons being made using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test or Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test as applicable&#46; Categorical variables in turn were expressed as number &#40;percentage&#41; and were compared using the chi-squared test&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Cox proportional hazards regression models were developed to evaluate the association between gender &#40;exposure variable&#41; and overall mortality after 30 days and one year&#46; We performed an exploratory univariate analysis&#44; and the covariables with clinical justification or <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10 were entered in the Cox regression models&#46; The following variables were included in the models&#58; gender&#44; age&#44; diabetes mellitus&#44; previous myocardial infarction&#44; previous angioplasty&#44; previous coronary bypass surgery&#44; diagnostic ECG&#44; location of myocardial infarction&#44; Killip class upon admission&#44; place of FMC&#44; time intervals&#44; and treatment received&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The results were reported as hazard ratios &#40;HR&#41; with the corresponding 95&#37; confidence interval &#40;95&#37;CI&#41;&#46; All <span class="elsevierStyleItalic">p</span>-values were two-tailed&#44; and statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The SPSS<span class="elsevierStyleSup">&#174;</span> version 20&#46;0 statistical package &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41; was used throughout&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 5831 patients with suspected STEMI were activated within the <span class="elsevierStyleItalic">Codi Infart</span> network between January 2010 and December 2011&#46; The final analysis involved 4380 patients &#40;75&#46;1&#37;&#41;&#46; The flow chart is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Clinical characteristics and reperfusion strategies</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 4380 patients analyzed&#44; 961 &#40;21&#46;9&#37;&#41; were females and 3419 &#40;78&#46;1&#37;&#41; were males&#46; The baseline characteristics of both groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The women were comparatively older &#40;69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4 vs&#46; 60&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;8 years&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with a greater prevalence of diabetes mellitus &#40;27&#46;1 vs&#46; 18&#46;1&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and a greater prevalence of Killip class &#62;I upon admission &#40;24&#46;9 vs&#46; 17&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Furthermore&#44; the female group showed a lesser prevalence of previous myocardial infarction &#40;6&#46;9 vs&#46; 9&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#44; previous angioplasty &#40;3&#46;9 vs&#46; 6&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and previous coronary bypass procedures &#40;0&#46;3 vs&#46; 1&#46;1&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;022&#41; compared with the male group&#46; The place of FMC also differed significantly between the two groups&#46; In turn&#44; it should be mentioned that the female group comprised a greater percentage of non-reperfused patients compared with the male group &#40;8&#46;8 vs&#46; 5&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Time intervals</span><p id="par0075" class="elsevierStylePara elsevierViewall">In comparison with the male population&#44; the women that underwent PA showed greater delays in the following management time intervals&#58; symptoms onset-FMC &#40;90 vs&#46; 74<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; FMC-diagnostic ECG &#40;26 vs&#46; 22<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; diagnostic ECG-balloon &#40;83 vs&#46; 80<span class="elsevierStyleHsp" style=""></span>min&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;020&#41;&#44; FMC-balloon &#40;132 vs&#46; 122<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and symptoms onset-balloon &#40;total ischemia time&#41; &#40;236 vs&#46; 210<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The comparative data referred to the mentioned time intervals are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Clinical events</span><p id="par0085" class="elsevierStylePara elsevierViewall">The data comparing the clinical events between the groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Overall&#44; women presented a greater percentage of in-hospital complications &#40;22&#46;2 vs&#46; 19&#46;0&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;031&#41;&#46; In particular&#44; the female group showed a greater presence of atrioventricular block &#40;6&#46;1 vs&#46; 3&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; atrial fibrillation &#40;3&#46;4 vs&#46; 2&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032&#41; and cardiogenic shock &#40;9&#46;7 vs&#46; 7&#46;9&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; than the male group&#46; Furthermore&#44; women had a greater overall in-hospital mortality rate &#40;4&#46;8 vs&#46; 2&#46;6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; overall 30-day mortality rate &#40;9&#46;1 vs&#46; 4&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and overall one-year mortality rate &#40;14&#46;0 vs&#46; 8&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">However&#44; following multivariate adjustment of the data&#44; no gender differences were observed in the overall 30-day mortality rate &#40;hazard ratio &#91;HR&#93; adjusted to 30 days &#91;95&#37;CI&#93;&#58; 1&#46;25 &#91;0&#46;94&#8211;1&#46;65&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;123&#59; HR adjusted to one year &#91;95&#37;CI&#93;&#58; 0&#46;88 &#91;0&#46;69&#8211;1&#46;07&#93;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;128&#41;&#46; The Cox regression curve for mortality due to all causes after one year is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">The main conclusions of our study were&#58; &#40;1&#41; women with STEMI had a comparatively worse risk profile and a greater proportion of in-hospital complications and overall mortality&#59; &#40;2&#41; women received less reperfusion treatment and suffered longer delays in medical assistance compared with men&#59; and &#40;3&#41; after adjusting for confounding factors&#44; women and men showed similar rates referred to mortality due to all causes after both 30 days and one year of follow-up&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">STEMI management network and gender gap in medical care</span><p id="par0100" class="elsevierStylePara elsevierViewall">The implementation of strategies designed to facilitate STEMI patient access to the medical care system has been shown to reduce delays in percutaneous coronary intervention&#44;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">16&#44;17</span></a> lessen the mortality rate&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a> and lower the global hospital costs&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite the improvements in medical care resulting from introduction of the STEMI management networks&#44; the gender gap in patient management is seen to persist&#46; Indeed&#44; in our study women suffered greater delays and underwent a lesser proportion of revascularization procedures than men&#46; Previous studies have shown that women suffer greater delays in medical assistance&#44; as evidenced by longer door-balloon times and longer total ischemia times&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">20&#8211;23</span></a> By allowing ECG recordings in the home&#44; out-hospital activation of hemodynamic systems and direct patient transfer to the Hemodynamics Unit via the SEM&#44; the STEMI management networks have been associated to lesser delays in medical care and lower mortality rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Following implantation of the <span class="elsevierStyleItalic">Codi Infart</span> network&#44; the female population still shows longer management intervals and lesser reperfusion rates than the male population&#46; This gender gap in time intervals and reperfusion therapy could be explained by gender differences in the clinical presentation and physiopathology of STEMI&#46; Such differences should be considered when evaluating and treating women with suspected of confirmed STEMI&#44; since this is a population characterized by great diagnostic and therapeutic complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The comparatively older age and greater prevalence of diabetes mellitus among the women in our study is associated to a greater presence of atypical symptoms that can lead to patient delays in contacting the medical care system &#40;patient delay&#41;&#44; as well as to errors in the clinical assessment of STEMI which in turn result in delays once the patients have already entered the system &#40;system delay&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;20&#8211;23</span></a> These differences were evidenced by the fact that women showed greater delays in all the evaluated time intervals compared with the male group&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">It also should be commented that although PA is currently the preferred reperfusion strategy in STEMI&#44; particularly in women&#44; because PA is able to reduce bleeding complications in females to a greater extent than in males&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#44;27&#8211;29</span></a> the gender difference in reperfusion therapy persists in our network &#8211; as reflected by the greater percentage of women that did not receive therapy versus their male counterparts &#40;8&#46;8 vs&#46; 5&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The data obtained in our study are unable to offer an in-depth explanation for this difference&#44; though it could be mediated in part by gender-related physiopathological variations in STEMI such as the greater incidence of spontaneous coronary dissection and coronary spasm in the female population&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;26&#44;27</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">STEMI management network and outcome in women</span><p id="par0125" class="elsevierStylePara elsevierViewall">The studies carried out in the thrombolysis era&#44; such as the GUSTO IIB trial&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> have shown women to experience a greater proportion of in-hospital complications and mortality after 30 days compared with men&#46; The mentioned study also demonstrated an interaction between mortality and the female gender following the multivariate adjustment analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> These data were subsequently confirmed by other registries during the 1990s and opening years of the XXI century in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The studies published following the generalized adoption of PA in routine clinical practice<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">6&#44;7&#44;27&#44;31</span></a> also showed women to suffer greater in-hospital mortality than men&#46; This could be explained by the differences in reperfusion rate and the worse risk profile of the women with STEMI in those studies&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Following their multivariate analysis&#44; Lawesson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> found the one-year mortality rate to be 8&#37; lower in women than in men&#46; This was the first study in the context of STEMI to show women to suffer greater in-hospital mortality but lesser long-term mortality than men&#46; Our study did not identify differences in the overall mortality rate after 30 days and one year between the two genders after adjusting for the confounding factors&#46; The results obtained indicate that the implantation of STEMI management networks has contributed to equalize the middle- and long-term prognosis in males and females&#44; and suggest that if both genders could receive reperfusion therapy and medical management intervals in the same way&#44; the long-term prognosis could be even better in women than in men&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Study limitations</span><p id="par0140" class="elsevierStylePara elsevierViewall">A first limitation of this study is the fact that it is a retrospective analysis of subgroups from a prospective database of the <span class="elsevierStyleItalic">Servei Catal&#224; de la Salut</span> &#40;<span class="elsevierStyleItalic">CatSalut</span>&#41;&#46; Nevertheless&#44; it is the largest Spanish study to date on the role of patient gender in patients attended by a specific STEMI management network&#46; A second limitation is that the outcome after one year was only assessed on the basis of mortality due to all causes and other prognostic assessment parameters such as cardiac mortality&#44; myocardial infarction or the need for further revascularization&#46; A third limitation is the fact that a non-negligible percentage of patients did not receive reperfusion therapy and&#44; as commented above&#44; we do not have concrete data capable of explaining this observation &#8211; since the collection of such information was not contemplated when the registry was designed&#46; A fourth limitations is the fact that the data are referred to the Catalan population&#44; representing a Mediterranean area&#44; and therefore cannot be fully extrapolated to other geographical settings&#46; Lastly&#44; we do not have information on the extent of coronary disease &#40;e&#46;g&#46;&#44; the number of diseased vessels&#41; or on the drug treatment or interventional cardiological management provided in the course of patient follow-up&#44; and which could also influence the extrapolation of our results&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">The female population attended by our regional STEMI management network had a worse risk profile&#44; received less reperfusion therapy and showed greater delays in medical management than the male population&#46; However&#44; following the multivariate adjustment analysis&#44; the clinical outcomes after 30 days and one year in the female population were seen to be similar to those of their male counterparts&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Financial support</span><p id="par0150" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the impact of gender upon the prognosis and medical care in a regional acute ST-elevation myocardial infarction management network&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An observational study was made of consecutive patients entered in a prospective database&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Scope</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The Catalan acute ST-elevation myocardial infarction management network&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Patients treated between January 2010 and December 2011&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Interventions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Primary angioplasty&#44; thrombolysis or conservative management&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Variables of interest</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Time intervals&#44; proportion and type of reperfusion&#44; overall mortality&#44; and in-hospital complication and overall mortality at 30 days and one year were compared in relation to gender&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Of the 5831 patients attended by the myocardial infarction network&#44; 4380 had a diagnosis of acute ST-elevation myocardial infarction&#44; and 961 &#40;21&#46;9&#37;&#41; were women&#46; Women were older &#40;69&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;4 vs&#46; 60&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;8 years&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; had a higher prevalence of diabetes &#40;27&#46;1 vs&#46; 18&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; Killip class<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>I &#40;24&#46;9 vs&#46; 17&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and no reperfusion &#40;8&#46;8 vs&#46; 5&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; versus men&#46; In addition&#44; women had greater delays in medical care &#40;first medical contact-to-balloon&#58; 132 vs&#46; 122<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; and symptoms onset-to-balloon&#58; 236 vs&#46; 210<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Women presented higher percentages of overall in-hospital complications &#40;20&#46;6 vs&#46; 17&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;031&#41;&#44; in-hospital mortality &#40;4&#46;8 vs&#46; 2&#46;6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; 30-day mortality &#40;9&#46;1 vs&#46; 4&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and one-year mortality &#40;14&#46;0 vs&#46; 8&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; versus men&#46; Nevertheless&#44; after multivariate adjustment&#44; no gender differences in 30-day and one-year mortality were observed&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Despite a higher risk profile and poorer medical management&#44; women present similar 30-day and one-year outcomes as their male counterparts in the context of the myocardial infarction management network&#46;</p></span>"
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        "resumen" => "<span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evaluar el impacto del g&#233;nero sobre el pron&#243;stico y el manejo en una red regional de atenci&#243;n al infarto agudo de miocardio con elevaci&#243;n del segmento ST&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional sobre una base de pacientes consecutivos recogida prospectivamente&#46;</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Red catalana de atenci&#243;n al infarto agudo de miocardio con elevaci&#243;n del segmento ST&#46;</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Pacientes atendidos entre enero de 2010 y diciembre de 2011&#46;</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intervenciones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Angioplastia primaria&#44; fibrin&#243;lisis o manejo conservador&#46;</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables de inter&#233;s</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se compararon&#44; seg&#250;n el g&#233;nero&#44; intervalos de tiempo&#44; proporci&#243;n y tipo de reperfusi&#243;n&#44; mortalidad global y complicaciones intrahospitalarias y mortalidad global a 30 d&#237;as y un a&#241;o&#46;</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De 5&#46;831 pacientes atendidos&#44; 4&#46;380 ten&#237;an diagn&#243;stico de infarto agudo de miocardio con elevaci&#243;n del segmento ST&#44; siendo 961 &#40;21&#44;9&#37;&#41; de ellos mujeres&#46; Estas ten&#237;an mayor edad &#40;69&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;4 frente a 60&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;8 a&#241;os&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; mayor prevalencia de diabetes &#40;27&#44;1 frente a 18&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; Killip<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>I &#40;24&#44;9 frente a 17&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y ausencia de reperfusi&#243;n &#40;8&#44;8 frente a 5&#44;2&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; que los hombres&#46; Adem&#225;s&#44; las mujeres presentaban mayores retrasos en la atenci&#243;n &#40;primer contacto m&#233;dico-bal&#243;n&#58; 132 frente a 122<span class="elsevierStyleHsp" style=""></span>min&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; inicio de s&#237;ntomas-bal&#243;n&#58; 236 frente a 210<span class="elsevierStyleHsp" style=""></span>min&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; m&#225;s complicaciones intrahospitalarias &#40;20&#44;6 frente a 17&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;031&#41; y mortalidad intrahospitalaria&#44; a 30 d&#237;as y un a&#241;o &#40;4&#44;8 frente a 2&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; 9&#44;1 frente a 4&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; 14&#44;0 frente a 8&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Sin embargo&#44; tras el an&#225;lisis multivariado no hubo diferencias en mortalidad a 30 d&#237;as y un a&#241;o&#46;</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">A pesar del peor perfil de riesgo y el peor tratamiento recibido&#44; las mujeres presentaron similares resultados a 30 d&#237;as y un a&#241;o que sus hom&#243;logos masculinos atendidos por una red de atenci&#243;n al infarto&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez-Rodr&#237;guez D&#44; Regueiro A&#44; Cevallos J&#44; Bosch X&#44; Freixa X&#44; Trilla M&#44; et al&#46; Brecha de g&#233;nero en los cuidados m&#233;dicos en las redes de atenci&#243;n al infarto agudo de miocardio con elevaci&#243;n del segmento ST&#58; hallazgos de la red catalana Codi Infart&#46; Med Intensiva&#46; 2017&#59;41&#58;70&#8211;77&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Women &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>961&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Men &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3419&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Population&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">961 &#40;21&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3419 &#40;78&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;8 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;6 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes mellitus&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">260 &#40;27&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">620 &#40;18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous MI&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">331 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;007</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous angioplasty&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">236 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous CB&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;022</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diagnostic ECG&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;578&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ST-segment elevation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">883 &#40;99&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3179 &#40;99&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left bundle block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Location&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">435 &#40;45&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1487 &#40;43&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;339&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inferior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">460 &#40;47&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1738 &#40;50&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">105 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">360 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;809&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Killip class upon admission&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">722 &#40;75&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2826 &#40;82&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;10&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">261 &#40;7&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">269 &#40;7&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Killip &#62;I upon admission&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">239 &#40;24&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">593 &#40;17&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Place of FMC&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;042</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hospital without PA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">383 &#40;39&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1266 &#40;37&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hospital with PA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;16&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">483 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary care center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">160 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">666 &#40;19&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SEM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">262 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1004 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Treatment&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fibrinolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">285 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;227&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">808 &#40;84&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2956 &#40;86&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;066&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No reperfusion therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#60;0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Women &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>808&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">808 &#40;21&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2956 &#40;78&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#91;35&#8211;162&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#91;12&#8211;45&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80 &#91;60&#8211;110&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">122 &#91;92&#8211;170&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">594 &#40;17&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;412&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asystolia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete atrioventricular block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59 &#40;6&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">154 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">285 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;G&#46; Steg"
                            1 => "S&#46;K&#46; James"
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                            3 => "L&#46;P&#46; Badano"
                            4 => "C&#46; Bl&#246;mstrom-Lundqvist"
                            5 => "M&#46;A&#46; Borger"
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                      "doi" => "10.1093/eurheartj/ehs215"
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                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2012"
                        "volumen" => "33"
                        "paginaInicial" => "2569"
                        "paginaFinal" => "2619"
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                    0 => array:2 [
                      "titulo" => "Reduction in acute myocardial infarction mortality over a five-year period"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Heras"
                            1 => "J&#46; Marrugat"
                            2 => "F&#46; Ar&#243;s"
                            3 => "X&#46; Bosch"
                            4 => "J&#46; Enero"
                            5 => "M&#46;A&#46; Su&#225;rez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2006"
                        "volumen" => "59"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16712743"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Sex differences in mortality after myocardial infarction&#46; Is there evidence for an increased risk for women&#63;"
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                          "autores" => array:4 [
                            0 => "V&#46; Vaccarino"
                            1 => "H&#46;M&#46; Krumholz"
                            2 => "L&#46;F&#46; Berkman"
                            3 => "R&#46;I&#46; Horwitz"
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                  ]
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                        "tituloSerie" => "Circulation"
                        "fecha" => "1995"
                        "volumen" => "91"
                        "paginaInicial" => "1861"
                        "paginaFinal" => "1871"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7882498"
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                      "titulo" => "Analysis of sex differences in preadmission management of ST-segment elevation &#40;STEMI&#41; myocardial infarction"
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