Young Women With AMICS: High Risk, Inadequate Care

Women age 55 years or younger who present with acute MI complicated by cardiogenic shock (AMICS) are less likely than young male patients of the same age to receive angiography and mechanical circulatory support and they more likely to die, new data show. The study also found that within this younger population, women who are Black and those with lower socioeconomic status are disproportionately more affected by AMICS.

Lead author Saraschandra Vallabhajosyula, MD, MSc (Emory University School of Medicine, Atlanta, GA), said the findings dispute long-held beliefs that young women of reproductive age are “protected” from more serious CV events because of their hormonal status. Of the 90,648 AMICS admissions in National Inpatient Sample (NIS) from 2000 to 2017 for patients age 55 years or younger, fully 26% were women.

“The rates of cardiogenic shock in these younger women are obviously lower than what is seen in older populations, but regardless, we found it shocking,” Vallabhajosyula said. “These are technically some of the most productive members of our society, and despite that, they frequently receive low rates of angiography and PCI, both of which are proven to be of great mortality benefit and essential in the treatment of cardiogenic shock.”

Indeed, women in the study had higher in-hospital mortality if they did not receive PCI or mechanical circulatory support (MCS) , with odds ratios of around 1.2, and female sex itself was an independent predictor of higher in-hospital mortality (OR 1.11;95% CI 1.07-1.16). Compared with men, however, women with AMICS were less likely to present with STEMI, acute noncardiac organ failure, or cardiac arrest.

In a related editorial, Amanda R. Vest, MBBS, MPH (Tufts Medical Center, Boston, MA), and Leslie Cho, MD (Cleveland Clinic, Cleveland, OH), say that the “sex-specific disconnect” between disease acuity, use of interventions, and survival odds “raises important questions about both female AMICS pathophysiology and the quality of care delivered. ”

Vest and Cho further note that some patient-specific factors cannot be accounted for in administrative databases and these might explain why just 50.3% of female patients, compared to 59.5% of male patients, received intra-aortic balloon pump (IABP), percutaneous ventricular assist devices, or extracorporeal membrane oxygenation in this series. Mortality among the female patients here who did not receive these therapies “implies there were women who might have survived if appropriately recognized as mechanical support candidates.” Of note, however, randomized controlled trials have not established a clear-cut role for mechanical support in the setting of AMICS; European guidelines currently advise against routine IABP use, while US guidelines are more neutral, giving it a class IIb (B) recommendation.

These are technically some of the most productive members of our society, and despite that, they frequently receive low rates of angiography and PCI, both of which are proven to be of great mortality benefit and essential in the treatment of cardiogenic shock. Saraschandra Vallabhajosyula

Compared with men of the same age, women in the NIS database had lower rates across the board for coronary angiography, early coronary angiography, PCI, and mechanical circulatory support (P < 0.001 for all comparisons). Additionally, women were more likely than men to be Black, have lower socioeconomic status, have more comorbidities, and be admitted more frequently to rural and small hospitals (P < 0.001 for all comparisons). In-hospital mortality rates were 23.0% for women versus 21.7% for men (P < 0.001).

While men and women had comparable do-not-resuscitate status, referral for palliative care, and length of stay, the female AMICS patients had lower hospitalization costs (mean $156,372 vs $167,669; P < 0.001) and were less often discharged to home (57.2% vs 64.1%).

Implications for Health Literacy and Awareness

To TCTMD, Vallabhajosyula said the study suggests that outdated stereotypes about CV disease are damaging to women of all ages.

“If you look at acute MI, the literature still unfortunately describes it as a disease of a middle-aged white male with substernal crushing chest pain, associated with nausea or diaphoresis. Over and over, studies have shown that this is not an accurate description, and that women often present atypically,” he said. “As a consequence, women take symptoms less seriously, and medical professionals often take their symptoms less seriously.”

In the quest for equality in cardiac care, Vallabhajosyula further noted that more attention needs to be paid to the concept that gender, race, and income are negatively additive to each other.

“They’re all socioeconomic demographic disparities that do not exist in isolation,” he observed. Another major issue not addressed by the study directly but important to the conversation, Vallabhajosyula added, is that women who have MI at young ages often have less social support than men. Lack of social support for health can affect everything from preventive care utilization to successful long-term care after discharge.

In their editorial, Vest and Cho say the cardiac field has a responsibility to ensure that women are not “left behind” with regard to access to major advances in AMICS care, including the evolution of the cardiogenic shock teams and innovations in mechanical circulatory support devices. They add that the current study “strengthens the call for detailed registries to further investigate the phenomenon of cardiogenic shock in young women and highlights the importance of conscious efforts to ensure that MCS devices meet the needs of female patients.”