Delays at Every Stage of STEMI Add Up to Worse Care for Women

An examination of the individual time intervals that occur from initial STEMI symptoms to PCI shows a pattern of greater delays in women than men, both before and after hospital arrival. Total ischemic time also was longer, with women being less likely than men to have a first-medical-contact (FMC)-to-device time under 90 minutes.

“Although patient delays are important, we found that the largest component of time delay in women with STEMI was actually healthcare system delays (prehospital system and hospital delays),” write Julia Stehli, MD (Monash University, Melbourne, Australia), and colleagues in the paper, which was published online June 22, 2021, in the Journal of the American Heart Association. Delays in time from arrival at a PCI-capable hospital to reperfusion occurred despite similar numbers of men and women being transported to a PCI-capable, “from which we can infer that a STEMI or at least an acute coronary syndrome was suspected in all of these patients,” they add.

The delays correlated with worse outcomes for women in the form of higher 30-day all-cause mortality (OR 1.38; 95% CI 1.06-1.79) and more major bleeding (OR 1.54; 95% CI 1.08-2.20) compared with men.

Suzanne Steinbaum, MD (Mount Sinai Hospital, New York, NY), who commented on the study for TCTMD, said that seeing the delays broken down into time intervals is “staggering.”

“Across the board, there's biases everywhere, from a woman acknowledging her symptoms to the ambulance evaluating her,” she observed. “There's not one place where someone's going to pick up the slack. It's just not happening.”

Steinbaum added that regardless of how good the care being given is, delays of even just a few minutes matter and need to be eliminated. “We know that once women have a heart attack, they do significantly worse, and this is really one of those issues where you can say it's really because of delay in care.”

Delays Everywhere

Stehli et al analyzed data on 6,330 STEMI patients (mean age 63 years; 21% women) who were included in a clinical-quality registry designed to monitor PCI performance and outcomes at 30 hospitals in Victoria, Australia. In general, women were older and had more comorbidities than men. Times were broken down into patient delays and healthcare system delays (prehospital and in-hospital), and then further broken down to include symptom onset, emergency medical services (EMS) call, first medical contact, ECG acquisition, departure to hospital, arrival at hospital, and reperfusion.

There's not one place where someone's going to pick up the slack. It's just not happening. Suzanne Steinbaum

After adjustment, women experienced more delays than did men at every interval, including EMS call-to-door time, the primary endpoint. The total healthcare delay, calculated as the time from the EMS call-to-device time, was 10 minutes longer for women than men, while the total ischemic time was 17 minutes longer.

Delays According to Sex: Adjusted Geometric Mean

The percentage of women who achieved a FMC-to-device time of 90 minutes or less was 20.2% versus 27.6% for men (P < 0.001). Ascertainment of an ECG within 10 minutes of FMC was the only variable with no differences between women and men (P = 0.62).

According to Stehli and colleagues the data illustrate a complex series of differences in presentation and in patient and professional bias.

Some things specific to female STEMI presentation such as nausea, radiation of pain, and shortness of breath may “lead to an initial misdiagnosis at the time of EMS phone call and the delay in EMS call-to-FMC seen in women,” the researchers note. “However, longer healthcare delays have been described even in women with typical symptoms, suggesting a healthcare worker bias may still exist with women perceived as lower risk for STEMI.”

Checklists and Calls to Action

One potential way to combat gender disparity and bias, in addition to healthcare worker education, is systems-based approaches to STEMI care that include machine learning and checklists, Stehli and colleagues say.

Steinbaum agreed, adding that checklists not only aid in consistency of care, but also reduce the potential for human error in all its forms. “I think it comes down to [the need for] this algorithmic process,” she said. “The checklist is a constant way of taking out someone's impression of a given patient.”

According to Steinbaum, delays in female STEMI care coupled with the unknown health repercussions from the COVID-19 pandemic constitute an urgent call to action to fix the gender inequality in cardiovascular healthcare delivery. In a recent article in Medicina, she writes that the disproportionate stress on women—from losing or giving up jobs, to helping children with homeschooling, to having less time for self-care—raises serious concerns that those burdens will take a physical toll in the coming years in the form of an uptick in heart disease in women.

“We are going to see this having an effect,” she told TCTMD. “If we don't figure this piece out—the fact that women will not be taken care of equally as well as men—then in 5 to 10 years from now, we're in trouble.”