STEMI Protocol Reduces Disparities in STEMI Care and Outcomes in Women

Implementation of a systems-based STEMI care protocol reduced gender disparities and improved STEMI care and outcomes in women, according to results of a clinical trial presented by Chetan P. Huded, MD, MSc, on Saturday, March 10, in a Young Investigator Award poster presentation at ACC.18 in Orlando, FL. The study was simultaneously published in the Journal of the American College of Cardiology.

This prospective observational registry-based study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol in the Cleveland Clinic health system comprising 10 hospitals and three free-standing emergency departments (EDs). The four-step protocol consisted of: 1) Improved ED catheterization lab activation; 2) STEMI Safe Handoff Checklist to standardize early triage and management; 3) Immediate transfer to an immediately available catheterization lab; and 4) radial-first approach for vascular access in PCI among suitable patients.

Guideline-directed medical therapy (GDMT) prior to PCI, median door-to-balloon time (D2BT), in-hospital adverse events and 30-day mortality were assessed in all patients with STEMI treated from January 1, 2011 to July 14, 2014 (control group) versus those treated from July 15, 2014 (when the protocol was implemented) to December 31, 2016 (protocol group).

A total of 1,272 consecutive patients (32 percent women) presenting with STEMI were included. The rate of radial access for PCI was similarly low between women and men in the control group (17.2 vs. 19.2 percent) and similarly high among women and men in the protocol group (62.6 percent vs. 68.8 percent). In the control group, women received significantly less GDMT (69 vs. 77 percent) and had longer D2BT (112 vs. 104 minutes) than men. After protocol implementation, no significant difference was observed in GDMT between women and men (80 vs. 84 percent) or D2BT (91 vs. 89 minutes).

Women had higher rates of post-PCI stroke, vascular complication, bleeding, transfusion, and in-hospital death than men in the control group but those differences resolved after protocol implementation. All-cause 30-day mortality was significantly higher in women (6.1 percent difference) in the control group but was only 3.2 percent higher (nonsignificant) after protocol implementation.

The investigators concluded that adopting a systems-based protocol for limiting differences in STEMI care resulted in marked improvements in care processes and clinical outcomes in women with STEMI. This strategy offers the promise of resolving the long-standing gender gap in STEMI outcomes. While the results warrant validation, the authors also stated the study population of consecutive patients should reflect the STEMI population of any large urban STEMI referral center in the U.S.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Statins

Keywords: ACC18, ACC Annual Scientific Session, Triage, Research Personnel, Control Groups, Hospital Mortality, Prospective Studies, Patient Handoff, Antineoplastic Combined Chemotherapy Protocols, Cytarabine, Etoposide, Registries, Methotrexate, Emergency Service, Hospital, Stroke, Percutaneous Coronary Intervention, Referral and Consultation, Catheterization

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