Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction

doi:10.1016/j.ahj.2010.09.016

American Heart Journal

Volume 161, Issue 1, January 2011, Pages 91-97

https://doi.org/10.1016/j.ahj.2010.09.016 Get rights and content

Background

Over the last decade, there have been major changes in the treatment of ST-elevation myocardial infarction (STEMI). Whether these have resulted in changes in sex differences in time to treatment is unknown. We examined temporal trends in time to reperfusion therapy among men and women with STEMI.

Methods

The study includes 2 cohorts of STEMI patients presenting to a large metropolitan region during the periods August 24, 2000, to August 20, 2002 (Cohort1, n = 753), and August 25, 2006, to December 31, 2008 (Cohort2, n = 885).

Results

In both cohorts, compared with men, women were significantly older and had more comorbidities. Rate of emergency medical services use among women increased from 55% in Cohort1 to 66% in Cohort2 (P = .02). Median time from symptom onset to first medical contact was 84 minutes among men and 121 minutes among women (P < .01) in Cohort1 and 59 minutes among men and 81 minutes among women (P < .01) in Cohort2. Median door-to-balloon time was significantly longer among women compared with men in Cohort2. After multivariable adjustment, female sex was associated with a 34% (or 27-minute) increase in time from symptom onset to first medical contact and with a 23% (or 13-minute) increase in time from hospital arrival to reperfusion therapy.

Conclusions

In the last decade, there have been significant reductions in patient and system delay, especially among women. However, women continue to have longer presentation and treatment times, suggesting that there continue to be opportunities for improvement.

Section snippets

Patient population

The patient population consisted of 2 cohorts of STEMI patients presenting to hospitals within the Edmonton region during the periods August 24, 2000, to August 20, 2002 (Cohort1), and August 25, 2006, to December 31, 2008 (Cohort2). The Edmonton region consists of 2 tertiary care hospitals with cardiac catheterization facilities and 3 additional community hospitals. Cohort1 was a prospective observational cohort of consecutive STEMI patients developed to assess the impact of initiating a

Results

Baseline characteristics of 753 patients in Cohort1 and 885 patients in Cohort2 are presented in Table I. Compared with men, women were significantly older and had higher rates of hypertension in both cohorts. The percentage of women arriving by ambulance increased from 55% in Cohort1 to 66% in Cohort2.

Discussion

The availability of 2 cohorts of consecutive patients presenting with STEMI in a large metropolitan area, separated by 4 years (and spanning almost a decade), provided a unique opportunity to examine changes in time to treatment among men and women and to determine whether sex differences persist.

Our study reveals several noteworthy changes in patients' response between Cohort1 (2000-2002) and Cohort2 (2006-2008), especially among women. First, the percentage of women using EMS increased

Conclusions

In this analysis of consecutive STEMI patients over 2 separate periods spanning almost a decade, there have been significant reductions in patient delay, especially among women. System delay has also improved with reductions in door-to-balloon and door-to-needle times. However, despite these improvements, women continue to have significantly longer times to 911 call and first medical contact, and door-to-needle times compared with men, suggesting opportunities for further improvement.

Disclosures

The authors have no disclosures to report.

Acknowledgements

We thank the Epidemiology Coordinating and Research Centre at the University of Alberta for data abstraction and entry.

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Impact of STEMI Diagnosis and Catheterization Laboratory Activation Systems on Sex- and Age-Based Differences in Treatment Delay
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Women and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems.
This observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated “physician-blind” prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts.
Five hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P = 0.04). When examining prehospital activation cohorts only, female sex (P = 0.03), off-hours presentation (P < 0.01), and physician oversight (P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 (P < 0.01), Killip class (P < 0.01), and female sex (P = 0.04) were independently associated with in-hospital mortality.
Automated “physician-blind” STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care.
Les femmes et les personnes présentant ont un infarctus du myocarde avec élévation du segment ST (STEMI) subissent de plus longs retards de traitement en dépit du diagnostic préhospitalier de STEMI et des systèmes d’activation de laboratoires de cathétérisme. On ignore le rôle que pourraient jouer les systèmes d’aiguillage des personnes atteintes de STEMI pour combler cette lacune en matière de soins. Nous avons donc examiné les différences selon le sexe et l’âge dans le retard de traitement du STEMI des différents systèmes d’activation de laboratoire en présence de STEMI.
La présente étude comparative sur l’efficacité regroupait trois cohortes rétrospectives de STEMI : une cohorte traditionnelle d’activation à l’hôpital (cohorte 1), une cohorte d’activation du laboratoire lors de diagnostic préhospitalier automatisé « à l’insu du médecin » (cohorte 2) et une cohorte d’activation du laboratoire de diagnostic préhospitalier dont la surveillance est assurée par un médecin en temps réel (cohorte 3). Les critères d’intérêt étaient les différences selon le sexe et le groupe d’âge (< ou ≥ 75 ans) dans le taux d'intervalle sous-optimal entre la première prise de contact avec les services médicaux et la pose d’un dispositif (> 90 minutes) au sein de chaque cohorte, ainsi que les prédicteurs indépendants de l’intervalle sous-optimal entre la première prise de contact avec les services médicaux et la pose d’un dispositif et la mortalité à l’hôpital de toutes les cohortes.
Cinq cents soixante (560) activations de diagnostic de STEMI ont fait l’objet d’une analyse. Dans la cohorte 1 (n = 179), les femmes et les personnes ≥ 75 ans étaient plus susceptibles de subir des intervalles sous-optimaux entre la première prise de contact avec les services médicaux et la pose d’un dispositif (78,7 % vs 36,4 %, P = 0,02 et 85,0 % vs 58,3 %, < 0,01, respectivement). Nous avons observé des résultats similaires dans la cohorte 3 (n = 109) (53,5 % vs 32,9 %, 56,5 % vs 33,3 %, respectivement ; P = 0,05, pour les deux). Toutefois, dans la cohorte 2 (n = 272), il n’y avait aucune différence significative selon l’âge (30,4 % vs 21,7 %, P = 0,18) et l’écart était numériquement plus faible, mais encore significatif chez les femmes (32,1 % vs 20,1 %, P = 0,04). Lorsque nous examinions seulement les cohortes d’activation du laboratoire lors de diagnostic préhospitalier, le sexe féminin (P = 0,03), la survenue dans les heures creuses (P < 0,01) et la surveillance du médecin (P < 0,01) étaient des prédicteurs indépendants d’intervalles plus longs entre la première prise de contact avec les services médicaux et la pose d’un dispositif. L’âge ≥ 75 ans (P < 0,01), la classification de Killip (P < 0,01) et le sexe féminin (P < 0,04) étaient indépendamment associés à la mortalité à l’hôpital.
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Clinical InvestigationAcute Ischemic Heart DiseaseTemporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction

Background

Methods

Results

Conclusions

Section snippets

Patient population

Results

Discussion

Conclusions

Disclosures

Acknowledgements

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Ann Emerg Med

Am Heart J

Prev Med

Soc Sci Med

Patient Educ Coun

Am Heart J

Am Heart J

Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIB) trial

Circulation

Time to treatment influences the impact of ST-segment resolution on one-year prognosis: insights from the Assessment of the Safety and Efficacy of New Thrombolytic (ASSENT-2) Trial

Circulation

Time is myocardium and time is outcomes

Circulation

Clinical Investigation
Acute Ischemic Heart Disease
Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction