Study Highlights Discrepancies in STEMI Recognition, Care Between Young Men, Women

Young women with STEMI are less likely to receive reperfusion therapy and more likely to experience treatment delays compared with men of similar age, according to an analysis of VIRGO study published in the April 14, 2015, issue of Circulation.

“Our findings underscore the importance of focusing efforts on identifying the sex-specific causes of delay because shorter times to reperfusion improve mortality,” write Gail D’Onofrio, MD, MS, of Yale-New Haven Hospital (New Haven, CT), and colleagues.

The researchers looked at the 1,465 STEMI patients (57% men) aged 18 to 55 years who were enrolled in the prospective VIRGO study at 103 US hospitals between August 2008 and January 2012. All patients presented either directly to the enrolling PCI site or were transferred within 24 hours.

Notably, women were more likely than men to have atypical chest pain or no symptoms (16% vs 10%; P = .008) and to present longer than 6 hours after symptom onset (35% vs 23%; P = .002).

Women Half as Likely Receive Reperfusion

Among the 1,238 patients (761 women, 477 men) eligible for reperfusion, 93% received it, with 90% undergoing PCI. Among the 10% of patients given fibrinolytic therapy, 94% received it prior to transfer.

Women were more likely than men to go untreated (9% vs 4%; P = .002). After adjustment for age, transfer status, atypical symptoms, and race, women were more than twice as likely as men to not receive reperfusion (OR 2.31; 95% CI 1.32-4.06).

Roughly equal proportions (approximately 26%) of both women and men had an ECG beyond 10 minutes after arrival, but the median door-to-balloon (D2B) time was longer for women than men (88 vs 80 minutes; P = .002). Women were also more likely than men to exceed recommended D2B timeframe guidelines, with the difference driven by transfer patients.

In a model only considering sex, women were 1.7 times more likely than men to exceed reperfusion time goals, and adjustment for sociodemographic factors, prior heart disease, and risk factors only slightly attenuated the association (OR 1.61; 95% CI 1.24-2.08). Even with further adjustment for clinical factors and transfer status, sex remained a significant factor in meeting reperfusion goals.

Mortality was higher in patients exceeding recommended guidelines than in those who did not at both 1 month (P = .013) and 12 months (P = .036).

Recognizing Atypical Symptoms

The study provides 2 novel insights, the authors write. Namely, delays in reperfusion therapy for STEMI occur not just in older women but in young women as well. And the disparity in STEMI treatment occurs more often in young women who receive fibrinolytic therapy and/or require transfer to PCI centers.

By design, VIRGO sought to “overcome the known limitation of female underrepresentation in all clinical trials” by enrolling 1 man for every 2 women, Alexandra J. Lansky, MD, of Yale-New Haven Shoreline Medical Center  (Guilford, CT), told TCTMD in a telephone interview. Thus, “for the first time, we have direct evidence of what we have suspected… to explain the previously reported worsening outcomes in our female patients with acute MI.”

Delays could occur at multiple points in the care path, Dr. D’Onofrio and colleagues say, including:

 

• ECG interpretation by ER physicians
• Barriers in the activation process
• Obtaining consent
• Referral hospital acceptance
• During reevaluation at the receiving facility

 

But in a telephone interview with TCTMD, Samir B. Pancholy, MD, of Mercy Hospital and Community Medical Center (Scranton, PA), said discrepancies can arise even earlier in the process.

“Women [often have] the mindset that when they feel something [is] not right, they typically don’t think of a heart attack. They are expecting an elephant to sit on their chest in order for them to… call 911,” he said, adding that studies have also found 911 operators to be less likely to identify an emergency in female compared with male callers. “That’s where the opportunities for education begin.”

Additionally, younger patients are typically less likely to accurately describe their symptoms than older patients, Dr. Pancholy said. “[Younger] patients don’t take their symptoms very seriously, and they can be in the mode of denying or minimizing [them to get] out of the healthcare facility,” he said. In addition, younger patients are more likely to have problems like substance abuse, which can hamper their ability to communicate.

Education Needed Across the Board

“Education of Emergency Department professionals is pivotal,” writes Nanette K. Wenger, MD, of Grady Memorial Hospital (Atlanta, GA), in an accompanying editorial. “The ECG changes of STEMI are not subtle, but there remains major dependence on Emergency Department professionals to have a high index of suspicion of myocardial infarction even for young women with atypical symptoms, to immediately obtain the ECG, and then to promptly address transfer to the cardiac catheterization laboratory or transfer to a PCI-capable facility, because myocardial ischemia kills.”

Community programs are also vital for increasing public awareness of atypical symptoms in women, Dr. Wenger says, citing the Go Red for Women and Heart Truth campaigns as good examples.

Using data from the current study, the influence of demographic differences among young women can be further explored, Dr. Wegner suggests. “There should be the opportunity to compare the baseline variables, interventions, and outcomes for the young black and young white women…. Given the underrepresentation of Hispanic and Asian women, their information cannot be derived from the VIRGO study.”

Dr. Pancholy stressed that physician awareness is also key. “We need to continually analyze the process and see where we can improve…. At every level of assessment, we have to start keeping in the backs of our minds that we’re dealing with a patient who is not going to fit the mold of a male problem. We need to put a different set of glasses on for women and minorities.”

Specifically, Dr. Lansky suggested, physicians and those working in emergency medical services “must have a heightened index of suspicion in their differential diagnosis when faced with a young woman… and immediately think ECG and cardiac enzymes to rule out this potentially fatal or disabling disease.”

 

 

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Sources:1. D’Onofrio G, Safdar B, Lichtman JH, et al. Sex differences in reperfusion in young patients with ST-segment elevation myocardial infarction: results from the VIRGO study. Circulation. 2015;131:1324-1332.
2. Wegner NK. Disparities in STEMI management for the young goose and young gander: clinical, organizational, and educational challenges [editorial]. Circulation. 2015;131:1310-1312.