Age and Gender Differences in Quality of Care and Outcomes for Patients With ST-Segment Elevation Myocardial Infarction

Study Questions:

Do quality of care and in-hospital outcomes differ for patients <45 years who present with ST-segment elevation myocardial infarction (STEMI), as compared to patients over 45 years of age?

Methods:

Patients presenting with STEMI and enrolled in the American Heart Association’s Get With the Guidelines Coronary Artery Disease registry were analyzed. The cohort was divided into those ages 45 years or less and those ages more than 45 years. Adherence with evidence-based medical therapies was evaluated, including the acute use (within 24 hours) of aspirin and beta-blockers; the use of evidence-based therapies at discharge (aspirin, beta-blockers, clopidogrel, angiotensin-converting enzyme [ACE] inhibitors or angiotensin-receptor blocker [ARB] agents, and statins or lipid-lowering drugs); and smoking cessation counseling. An “all or none” composite performance measure encompassed six key quality of care measures: 1) patients discharged while taking aspirin, 2) patients discharged while taking beta-blockers, 3) patients receiving aspirin within 24 hours of presentation, 4) patients with documented left ventricular dysfunction discharged on ACE inhibitor or ARB, 5) smoking cessation counseling, and 6) patients with a low-density lipoprotein level >100 mg/dl receiving lipid-lowering drugs. The primary outcome measure was in-hospital all-cause mortality. Secondary outcome measures included median door-to-balloon times, median door-to-thrombolytic times, the proportion of patients meeting the American College of Cardiology/American Heart Association guideline-recommended within 90-minute door-to-balloon time, and length of hospital stay.

Results:

A total of 31,544 patients admitted with STEMI were included in this analysis. Younger patients comprised 10.3% of the cohort. When compared with the older cohort, the younger cohort was more likely to be men, black, or Hispanic, and to have a higher body mass index, baseline heart rate and systolic blood pressure, and to smoke. Younger patients were less likely to have other traditional risk factors and were less likely to be taking medications prior to admission. Younger patients had similar or better quality/performance measures with lower in-hospital mortality (unadjusted rate 1.6 vs. 6.5%, p < 0.0001; adjusted odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29-0.46) compared to older patients. Over the time period examined (2002 to 2008), quality measures improved for both younger and older patients. However, among women (as compared to men) and those <35 years of age (compared to those 36-45 years), the quality of STEMI care was lower, and adverse outcome higher. Significant interaction was seen between age and gender for in-hospital death, such that the gender difference was greater in the younger cohort. Similar interaction was seen for door-to-thrombolytic time such that the gender delay was greater in the younger cohort (women:men ratio of means = 1.73; 95% CI, 1.21-2.45 [younger] vs. 1.08; 95% CI, 1.00-1.18 [older]; p interaction = 0.0031).

Conclusions:

The investigators concluded that patients 45 years or younger presenting with STEMI have similar quality of care and in-hospital outcomes compared to older patients. However, among younger women, the quality of care was lower and the mortality was high compared to younger men.

Perspective:

These data suggest that for the most part, younger patients have similar quality of care to older patients. However, an area of concern remains the care of younger female patients. Understanding factors associated with quality of care will assist in system changes that are likely required to improve outcomes in younger women.

Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Lipid Metabolism, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Hospital Mortality, Coronary Disease, Ticlopidine, Blood Pressure, Fibrinolytic Agents, Heart Rate, Hispanic Americans, Angioplasty, Balloon, Coronary, Length of Stay, Lipoproteins, LDL, Body Mass Index, Quality of Health Care, India, Cardiovascular Diseases, Ventricular Dysfunction, Left, Smoking Cessation


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