Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada?

Abstract

Aims:

This study examined clinical factors associated with sex differences in the use of acute reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention) in ST-elevation myocardial infarction (STEMI) patients, and the interaction between sex and these factors in Sweden and Canada.

Methods:

Patients with STEMI in Sweden (n=32,676 from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) were compared with similar patients in Canada (n=3375 from the Canadian Global Registry of Acute Coronary Events) for the period 2004–2008.

Results:

Unadjusted vs. age-adjusted odds ratios (OR) for no reperfusion (women vs. men) were for Sweden 1.57 (95% CI 1.49–1.64) vs. 1.14 (95% CI 1.08–1.20), and for Canada 1.61 (95% CI 1.39–1.87) vs. OR 1.18 (95% CI 1.01–1.39). Sex differences persisted after multivariable adjustments (including prehospital delay, atypical symptoms, diabetes), factors for which no interaction with sex was found. Among women <60 years, adjusting for atypical symptoms in Canada and angiographic data in Sweden made the greatest contribution to explaining observed sex differences.

Conclusions:

In both countries, acute reperfusion therapy in STEMI was used less often in women than in men. Factors associated with these sex differences appear to differ between older and younger women. Targeted interventions are needed to optimize care for women with STEMI, as well as sex- and age-stratified reporting of quality indicators to assess their effectiveness.

Keywords

Myocardial infarction reperfusion therapy sex differences

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References

Canadian Cardiovascular Society; American Academy of Family Physicians; American College of Cardiology; American Heart Association, Antman

Hand

Armstrong

. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 51: 210–247.

Van de Werf

Bax

Betriu

.; ESC Committee for Practice Guidelines (CPG). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29: 2909–2945.

Cohen

Gensini

Maritz

. The role of gender and other factors as predictors of not receiving reperfusion therapy and of outcome in ST-segment elevation myocardial infarction. J Thromb Thrombolysis 2005; 19: 155–161.

Kang

Suh

Yoon

.; KAMIR/KorMI Registry. Sex differences in management and mortality of patients with ST-elevation myocardial infarction (from the Korean Acute Myocardial Infarction National Registry). Am J Cardiol 2012; 109: 787–793.

Nguyen

Goldberg

Gore

. Age and sex differences, and changing trends, in the use of evidence-based therapies in acute coronary syndromes: perspectives from a multinational registry. Coron Artery Dis 2010; 21: 336–344.

Lawesson

Alfredsson

Fredrikson

. Time trends in STEMI – improved treatment and outcome but still a gender gap: a prospective observational cohort study from the SWEDEHEART register. BMJ Open 2012; 2: e000726.

Cohen

Boiangiu

Abidi

. Therapy for ST-segment elevation myocardial infarction patients who present late or are ineligible for reperfusion therapy. J Am Coll Cardiol 2010; 55: 1895–1906.

Stenestrand

Wallentin

. Early statin treatment following acute myocardial infarction and 1-year survival. JAMA 2001; 285: 430–436.

GRACE Investigators. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 2001; 141: 190–199.

10.

Goodman

Huang

Yan

.; Expanded Global Registry of Acute Coronary Events (GRACE2) Investigators. The expanded Global Registry of Acute Coronary Events: baseline characteristics, management practices, and hospital outcomes of patients with acute coronary syndromes. Am Heart J 2009; 158: 193–201.

11.

Levey

Coresh

Balk

.; National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139: 137–147.

12.

Jani

Montoye

Mehta

.; American College of Cardiology Foundation Guidelines Applied in Practice Steering Committee. American College of Cardiology Foundation Guidelines Applied in Practice Steering Committee. Sex differences in the application of evidence-based therapies for the treatment of acute myocardial infarction: the American College of Cardiology’s Guidelines Applied in Practice Projects in Michigan. Arch Intern Med 2006; 166: 1164–1170.

13.

Brieger

Eagle

Goodman

.; GRACE Investigators. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest 2004; 126: 461–469.

14.

Möllmann

Liebetrau

Nef

. The Swedish paradox: or is there really no gender difference in acute coronary syndromes? Eur Heart J 2011; 32: 3070–3072.

15.

Norhammar

Schenck-Gustafsson

. Type 2 diabetes and cardiovascular disease in women. Diabetologia 2013; 56: 1–9.

16.

Reynolds

Srichai

Iqbal

. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation 2011; 124: 1414–1425.

17.

Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg

James

Atar

. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569–2619.

18.

Wenger

. Gender disparity in cardiovascular disease: bias or biology? Expert Rev Cardiovasc Ther 2012; 10: 1401–1411.

19.

Mehilli

Kastrati

Dirschinger

. Sex-based analysis of outcome in patients with acute myocardial infarction treated predominantly with percutaneous coronary intervention. JAMA 2002; 287: 210–215.