Delayed Care and Mortality Among Women and Men With Myocardial Infarction

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Abstract

Background

Women with ST‐segment–elevation myocardial infarction ( STEMI) have higher mortality rates than men. We investigated whether sex‐related differences in timely access to care among STEMI patients may be a factor associated with excess risk of early mortality in women.

Methods and Results

We identified 6022 STEMI patients who had information on time of symptom onset to time of hospital presentation at 41 hospitals participating in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry ( NCT01218776) from October 2010 through April 2016. Patients were stratified into time‐delay cohorts. We estimated the 30‐day risk of all‐cause mortality in each cohort. Despite similar delays in seeking care, the overall time from symptom onset to hospital presentation was longer for women than men (median: 270 minutes [range: 130–776] versus 240 minutes [range: 120–600]). After adjustment for baseline variables, female sex was independently associated with greater risk of 30‐day mortality (odds ratio: 1.58; 95% confidence interval, 1.27–1.97). Sex differences in mortality following STEMI were no longer observed for patients having delays from symptom onset to hospital presentation of ≤1 hour (odds ratio: 0.77; 95% confidence interval, 0.29–2.02).

Conclusions

Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01218776.

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Most cited references 33

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How can I deal with missing data in my study?

D A Bennett (2001)

Missing data in medical research is a common problem that has long been recognised by statisticians and medical researchers alike. In general, if the effect of missing data is not taken into account the results of the statistical analyses will be biased and the amount of variability in the data will not be correctly estimated. There are three main types of missing data pattern: Missing Completely At Random (MCAR), Missing At Random (MAR) and Not Missing At Random (NMAR). The type of missing data that a researcher has in their dataset determines the appropriate method to use in handling the missing data before a formal statistical analysis begins. The aim of this practice note is to describe these patterns of missing data and how they can occur, as well describing the methods of handling them. Simple and more complex methods are described, including the advantages and disadvantages of each method as well as their availability in routine software. It is good practice to perform a sensitivity analysis employing different missing data techniques in order to assess the robustness of the conclusions drawn from each approach.

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Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

John Canto, William J Rogers, Robert J. Goldberg … (2012)

Women are generally older than men at hospitalization for myocardial infarction (MI) and also present less frequently with chest pain/discomfort. However, few studies have taken age into account when examining sex differences in clinical presentation and mortality. To examine the relationship between sex and symptom presentation and between sex, symptom presentation, and hospital mortality, before and after accounting for age in patients hospitalized with MI. Observational study from the National Registry of Myocardial Infarction, 1994-2006, of 1,143,513 registry patients (481,581 women and 661,932 men). We examined predictors of MI presentation without chest pain and the relationship between age, sex, and hospital mortality. The proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0% [95% CI, 41.8%-42.1%] vs 30.7% [95% CI, 30.6%-30.8%]; P < .001). There was a significant interaction between age and sex with chest pain at presentation, with a larger sex difference in younger than older patients, which became attenuated with advancing age. Multivariable adjusted age-specific odds ratios (ORs) for lack of chest pain for women (referent, men) were younger than 45 years, 1.30 (95% CI, 1.23-1.36); 45 to 54 years, 1.26 (95% CI, 1.22-1.30); 55 to 64 years, 1.24 (95% CI, 1.21-1.27); 65 to 74 years, 1.13 (95% CI, 1.11-1.15); and 75 years or older, 1.03 (95% CI, 1.02-1.04). Two-way interaction (sex and age) on MI presentation without chest pain was significant (P < .001). The in-hospital mortality rate was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had greater hospital mortality than younger men without chest pain, and these sex differences decreased or even reversed with advancing age, with adjusted OR for age younger than 45 years, 1.18 (95% CI, 1.00-1.39); 45 to 54 years, 1.13 (95% CI, 1.02-1.26); 55 to 64 years, 1.02 (95% CI, 0.96-1.09); 65 to 74 years, 0.91 (95% CI, 0.88-0.95); and 75 years or older, 0.81 (95% CI, 0.79-0.83). The 3-way interaction (sex, age, and chest pain) on mortality was significant (P < .001). In this registry of patients hospitalized with MI, women were more likely than men to present without chest pain and had higher mortality than men within the same age group, but sex differences in clinical presentation without chest pain and in mortality were attenuated with increasing age.

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System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.

Jens Lassen, Lisette Jensen, Søren Paaske Johnsen … (2010)

Timely reperfusion therapy is recommended for patients with ST-segment elevation myocardial infarction (STEMI), and door-to-balloon delay has been proposed as a performance measure in triaging patients for primary percutaneous coronary intervention (PCI). However, focusing on the time from first contact with the health care system to the initiation of reperfusion therapy (system delay) may be more relevant, because it constitutes the total time to reperfusion modifiable by the health care system. No previous studies have focused on the association between system delay and outcome in patients with STEMI treated with primary PCI. To evaluate the associations between system, treatment, patient, and door-to-balloon delays and mortality in patients with STEMI. Historical follow-up study based on population-based Danish medical registries of patients with STEMI transported by the emergency medical service and treated with primary PCI from January 1, 2002, to December 31, 2008, at 3 high-volume PCI centers in Western Denmark. Patients (N = 6209) underwent primary PCI within 12 hours of symptom onset. The median follow-up time was 3.4 (interquartile range, 1.8-5.2) years. Crude and adjusted hazard ratios of mortality obtained by Cox proportional regression analysis. A system delay of 0 through 60 minutes (n = 347) corresponded to a long-term mortality rate of 15.4% (n = 43); a delay of 61 through 120 minutes (n = 2643) to a rate of 23.3% (n = 380); a delay of 121 through 180 minutes (n = 2092) to a rate of 28.1% (n = 378); and a delay of 181 through 360 minutes (n = 1127) to a rate of 30.8% (n = 275) (P < .001). In multivariable analysis adjusted for other predictors of mortality, system delay was independently associated with mortality (adjusted hazard ratio, 1.10 [95% confidence interval, 1.04-1.16] per 1-hour delay), as was its components, prehospital system delay and door-to-balloon delay. System delay was associated with mortality in patients with STEMI treated with primary PCI.

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Author and article information

Contributors

Raffaele Bugiardini: raffaele.bugiardini@unibo.it

Journal

Journal ID (nlm-ta): J Am Heart Assoc

Journal ID (iso-abbrev): J Am Heart Assoc

Journal ID (doi): 10.1002/(ISSN)2047-9980

Journal ID (publisher-id): JAH3

Journal ID (hwp): ahaoa

Title: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Electronic): 2047-9980

Publication date (Electronic): 21 August 2017

Publication date Collection: August 2017

Volume: 6

Issue: 8 ( doiID: 10.1002/jah3.2017.6.issue-8 )

Electronic Location Identifier: e005968

Affiliations

[ ¹ ] Department of Experimental Diagnostic and Specialty Medicine University of Bologna Italy

[ ² ] Clinical Center of Serbia Medical Faculty University of Belgrade Serbia

[ ³ ] University Clinical Hospital Center Bezanijska Kosa Faculty of Medicine University of Belgrade Serbia

[ ⁴ ] University Clinic of Cardiology Medical Faculty University “Ss. Cyril and Methodius” Skopje Macedonia

[ ⁵ ] Clinic for Cardiology Clinical Center Kragujevac Kragujevac Serbia

[ ⁶ ] Faculty of Medical Sciences University in Kragujevac Serbia

[ ⁷ ] Department for Cardiovascular Diseases University Hospital Center Zagreb University of Zagreb Croatia

[ ⁸ ] Clinical Center University of Sarajevo Bosnia and Herzegovina

[ ⁹ ] Institute of Natural Sciences University of Physical Education Budapest Hungary

[ ¹⁰ ] Department of Physiology New York Medical College Valhalla NY

[ ¹¹ ] Cardiovascular Research Institute (ICCC) CiberCV‐Institute Carlos III IIB‐Sant Pau Hospital de la Santa Creu i Sant Pau Autonomous University of Barcelona Spain

Author notes

[*] [* ] Correspondence to: Raffaele Bugiardini, MD, FESC, FAHA, FACC, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, Bologna, Italy. E‐mail: raffaele.bugiardini@ 123456unibo.it

Article

Publisher ID: JAH32485

DOI: 10.1161/JAHA.117.005968

PMC ID: 5586439

PubMed ID: 28862963

SO-VID: a33eda3b-f959-4e9b-9139-61640e708eb0

License:

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

History

Date received : 27 February 2017

Date accepted : 07 July 2017

Page count

Figures: 1, Tables: 4, Pages: 10, Words: 8301

Custom metadata

source-schema-version-number 2.0

component-id jah32485

cover-date August 2017

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.1.7 mode:remove_FC converted:24.08.2017

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: acute coronary syndrome,mortality,prehospital delay,women,acute coronary syndromes,coronary artery disease,mortality/survival

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: acute coronary syndrome, mortality, prehospital delay, women, acute coronary syndromes, coronary artery disease, mortality/survival

Delayed Care and Mortality Among Women and Men With Myocardial Infarction

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Abstract

Background

Methods and Results

Conclusions

Clinical Trial Registration

Related collections

Cardiovascular Innovations and Applications

Most cited references 33

How can I deal with missing data in my study?

Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality.

System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.

Author and article information

Contributors

Journal

Affiliations

Author notes

Article

History

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