Influence of Gender on Ischemic Times and Outcomes After ST-Elevation Myocardial Infarction

Study Questions:

Does gender influence ischemic duration and outcomes after ST-segment elevation myocardial infarction (STEMI)?

Methods:

Data for this study were collected as part of a Dutch multicenter registry, which includes consecutive patients treated with primary percutaneous coronary intervention (PCI) for STEMI at three tertiary centers in the Netherlands. STEMI was defined as symptoms of angina lasting >30 minutes, along with typical electrocardiographic changes (ST-segment elevation ≥0.2 mV in ≥2 contiguous leads, V1-V3, or ≥0.1 mV in other leads or presumed new left bundle branch block). Primary outcomes of interest were duration of ischemia and mortality. Adjusted mortality rates were calculated using Cox proportional-hazards analyses.

Results:

A total of 3,483 patients were included, of whom 868 were women (25%). Women were older, had a higher risk factor burden, and more frequently had histories of malignancy. Men more often had cardiac histories and peripheral vascular disease. Ischemic duration was longer in women (median 192 minutes [interquartile range 141-286] vs. 175 minutes [interquartile range 128-279] in men, p = 0.002). However, multivariate linear regression showed that this was due to age and comorbidity. All-cause mortality was higher at 7 days (6.0% in women vs. 3.0% in men, p < 0.001) and at 1 year (9.9% in women vs. 6.6% in men, p = 0.001). In multivariate models, female gender predicted 7-day all-cause mortality (hazard ratio, 1.61; 95% confidence interval, 1.06-2.46) and cardiac mortality (hazard ratio, 1.58; 95% confidence interval, 1.03-2.42), but not 1-year mortality. Gender was also an independent effect modifier for cardiogenic shock, leading to substantially worse outcomes in women.

Conclusions:

The investigators concluded that among women presenting with STEMI, duration of ischemia is longer than observed in men, but appears to be predominately explained by differences in age and number of comorbidities. Female gender was independently predictive of early all-cause mortality and cardiac mortality after PCI, and an interaction between gender and cardiogenic shock was noted.

Perspective:

Registry data such as these allow for an examination of factors such as age and comorbidities, which then allows for a more detailed understanding of factors related to poor outcomes. Improvements in quality of care hinge on such factors. This is also true for cardiogenic shock, where understanding factors related to gender differences in outcomes will likely improve overall STEMI care.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, EP Basic Science, Acute Heart Failure, Interventions and Vascular Medicine

Keywords: Shock, Cardiogenic, Myocardial Infarction, Cardiology, Cardiovascular Diseases, Bundle-Branch Block, Netherlands, Risk Factors, Confidence Intervals, Cost of Illness, Peripheral Vascular Diseases, Percutaneous Coronary Intervention


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