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Meta-Analysis of Gender Disparities in In-hospital Care and Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

Published:February 24, 2021DOI:https://doi.org/10.1016/j.amjcard.2021.02.015
      Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.
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      REFERENCES

        • Benjamin EJ
        • Muntner P
        • Alonso A
        • Bittencourt MS
        • Callaway CW
        • Carson AP
        • Chamberlain AM
        • Chang AR
        • Cheng S
        • Das SR
        • Delling FN
        • Djousse L
        • Elkind MSV
        • Ferguson JF
        • Fornage M
        • Jordan LC
        • Khan SS
        • Kissela BM
        • Knutson KL
        • Kwan TW
        • Lackland DT
        • Lewis TT
        • Lichtman JH
        • Longenecker CT
        • Loop MS
        • Lutsey PL
        • Martin SS
        • Matsushita K
        • Moran AE
        • Mussolino ME
        • O'Flaherty M
        • Pandey A
        • Perak AM
        • Rosamond WD
        • Roth GA
        • Sampson UKA
        • Satou GM
        • Schroeder EB
        • Shah SH
        • Spartano NL
        • Stokes A
        • Tirschwell DL
        • Tsao CW
        • Turakhia MP
        • VanWagner LB
        • Wilkins JT
        • Wong SS
        • Virani SS
        • American Heart Association Council on E, Prevention Statistics C, Stroke Statistics S
        Heart disease and stroke statistics-2019 update: a report from the American Heart Association.
        Circulation. 2019; 139: e56-e528
        • Ibanez B
        • James S
        • Agewall S
        • Antunes MJ
        • Bucciarelli-Ducci C
        • Bueno H
        • Caforio ALP
        • Crea F
        • Goudevenos JA
        • Halvorsen S
        • Hindricks G
        • Kastrati A
        • Lenzen MJ
        • Prescott E
        • Roffi M
        • Valgimigli M
        • Varenhorst C
        • Vranckx P
        • Widimsky P
        • Group ESCSD
        2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2018; 39: 119-177
        • Levine GN
        • Bates ER
        • Blankenship JC
        • Bailey SR
        • Bittl JA
        • Cercek B
        • Chambers CE
        • Ellis SG
        • Guyton RA
        • Hollenberg SM
        • Khot UN
        • Lange RA
        • Mauri L
        • Mehran R
        • Moussa ID
        • Mukherjee D
        • Ting HH
        • Stemi Writing C
        • O'Gara PT
        • Kushner FG
        • Ascheim DD
        • Brindis RG
        • Casey Jr., DE
        • Chung MK
        • de Lemos JA
        • Diercks DB
        • Fang JC
        • Franklin BA
        • Granger CB
        • Krumholz HM
        • Linderbaum JA
        • Morrow DA
        • Kristin Newby L
        • Ornato JP
        • Ou N
        • Radford MJ
        • Tamis-Holland JE
        • Tommaso CL
        • Tracy CM
        • Joseph Woo Y
        • Zhao DX
        • Acc/Aha Task Force M
        • Halperin JL
        • Levine GN
        • Anderson JL
        • Albert NM
        • Al-Khatib SM
        • Birtcher KK
        • Bozkurt B
        • Brindis RG
        • Cigarroa JE
        • Curtis LH
        • Fleisher LA
        • Gentile F
        • Gidding S
        • Hlatky MA
        • Ikonomidis J
        • Joglar J
        • Kovacs RJ
        • Magnus Ohman E
        • Pressler SJ
        • Sellke FW
        • Shen WK
        • Wijeysundera DN
        2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial Infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
        Catheter Cardiovasc Interv. 2016; 87: 1001-1019
        • Langabeer 2nd, JR
        • Dellifraine J
        • Fowler R
        • Jollis JG
        • Stuart L
        • Segrest W
        • Griffin R
        • Koenig W
        • Moyer P
        • Henry TD.
        Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times.
        J Emerg Med. 2014; 46: 355-362
        • Jacobs AK
        • Antman EM
        • Faxon DP
        • Gregory T
        • Solis P.
        Development of systems of care for ST-elevation myocardial infarction patients.
        Circulation. 2007; 116: 217-230
        • Chew DP
        • Scott IA
        • Cullen L
        • French JK
        • Briffa TG
        • Tideman PA
        • Woodruffe S
        • Kerr A
        • Branagan M
        • Aylward PE.
        National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016.
        Med J Aust. 2016; 205: 128-133
        • Huo Y
        • Zhang Y
        • Han Y
        • Yan H
        • Ge J.
        Cardiovascular diseases in China: The blue book myocardial infarction.
        Cardiol Plus. 2017; 2: 39-54
        • Ani C
        • Pan D
        • Martins D
        • Ovbiagele B.
        Age- and sex-specific in-hospital mortality after myocardial infarction in routine clinical practice.
        Cardiol Res Pract. 2010; 2010752765
        • Nguyen JT
        • Berger AK
        • Duval S
        • Luepker RV.
        Gender disparity in cardiac procedures and medication use for acute myocardial infarction.
        Am Heart J. 2008; 155: 862-868
        • Hvelplund A
        • Galatius S
        • Madsen M
        • Rasmussen JN
        • Rasmussen S
        • Madsen JK
        • Sand NP
        • Tilsted HH
        • Thayssen P
        • Sindby E
        • Hojbjerg S
        • Abildstrom SZ.
        Women with acute coronary syndrome are less invasively examined and subsequently less treated than men.
        Eur Heart J. 2010; 31: 684-690
        • Conrotto F
        • D'Ascenzo F
        • Humphries KH
        • Webb JG
        • Scacciatella P
        • Grasso C
        • D'Amico M
        • Biondi-Zoccai G
        • Gaita F
        • Marra S
        A meta-analysis of sex-related differences in outcomes after primary percutaneous intervention for ST-segment elevation myocardial infarction.
        J Interv Cardiol. 2015; 28: 132-140
        • Cenko E
        • Yoon J
        • Kedev S
        • Stankovic G
        • Vasiljevic Z
        • Krljanac G
        • Kalpak O
        • Ricci B
        • Milicic D
        • Manfrini O
        • van der Schaar M
        • Badimon L
        • Bugiardini R.
        Sex differences in outcomes after STEMI: effect modification by treatment strategy and age.
        JAMA Intern Med. 2018; 178: 632-639
        • Bugiardini R
        • Manfrini O
        • Cenko E.
        Female sex as a biological variable: a review on younger patients with acute coronary syndrome.
        Trends Cardiovasc Med. 2019; 29: 50-55
        • Sabbag A
        • Matetzky S
        • Porter A
        • Iakobishvili Z
        • Moriel M
        • Zwas D
        • Fefer P
        • Asher E
        • Beigel R
        • Gottlieb S
        • Goldenberg I
        • Segev A.
        Sex differences in the management and 5-year outcome of young patients (<55 years) with acute coronary syndromes.
        Am J Med. 2017; 130 (1324 e1315-1324 e1322)
        • D'Onofrio G
        • Safdar B
        • Lichtman JH
        • Strait KM
        • Dreyer RP
        • Geda M
        • Spertus JA
        • Krumholz HM.
        Sex differences in reperfusion in young patients with ST-Segment–Elevation myocardial infarction.
        Circulation. 2015; 131: 1324-1332
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman D.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151 (264-269)
        • Yu J
        • Mehran R
        • Grinfeld L
        • Xu K
        • Nikolsky E
        • Brodie BR
        • Witzenbichler B
        • Kornowski R
        • Dangas GD
        • Lansky AJ
        • Stone GW.
        Sex-based differences in bleeding and long term adverse events after percutaneous coronary intervention for acute myocardial infarction: three year results from the HORIZONS-AMI trial.
        Catheter Cardiovasc Interv. 2015; 85: 359-368
        • Nallamothu BK
        • Normand SL
        • Wang Y
        • Hofer TP
        • Brush Jr., JE
        • Messenger JC
        • Bradley EH
        • Rumsfeld JS
        • Krumholz HM
        Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.
        Lancet. 2015; 385: 1114-1122
        • Park J
        • Choi KH
        • Lee JM
        • Kim HK
        • Hwang D
        • Rhee TM
        • Kim J
        • Park TK
        • Yang JH
        • Song YB
        • Choi JH
        • Hahn JY
        • Choi SH
        • Koo BK
        • Chae SC
        • Cho MC
        • Kim CJ
        • Kim JH
        • Jeong MH
        • Gwon HC
        • Kim HS
        • Investigators K-N
        Prognostic implications of Door-to-Balloon time and Onset-to-Door time on mortality in patients With ST -Segment-Elevation myocardial infarction treated with primary percutaneous coronary intervention.
        J Am Heart Assoc. 2019; 8e012188
        • Ferry AV
        • Anand A
        • Strachan FE
        • Mooney L
        • Stewart SD
        • Marshall L
        • Chapman AR
        • Lee KK
        • Jones S
        • Orme K
        • Shah ASV
        • Mills NL.
        Presenting symptoms in men and women diagnosed with myocardial infarction using sex-specific criteria.
        J Am Heart Assoc. 2019; 8e012307
        • Lichtman JH
        • Leifheit EC
        • Safdar B
        • Bao H
        • Krumholz HM
        • Lorenze NP
        • Daneshvar M
        • Spertus JA
        • D'Onofrio G
        Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (variation in recovery: role of gender on outcomes of young AMI patients).
        Circulation. 2018; 137: 781-790
        • Lawesson SS
        • Isaksson RM
        • Ericsson M
        • Angerud K
        • Thylen I
        • Grp SS.
        Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study.
        BMJ Open. 2018; 8e020211
        • Bertakis KD
        • Azari R
        • Helms LJ
        • Callahan EJ
        • Robbins JA.
        Gender differences in the utilization of health care services.
        J Fam Pract. 2000; 49: 147-152
        • Thompson AE
        • Anisimowicz Y
        • Miedema B
        • Hogg W
        • Wodchis WP
        • Aubrey-Bassler K.
        The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study.
        BMC Fam Pract. 2016; 17 (38)
        • Barrett-Connor E
        • Bush TL.
        Estrogen and coronary heart disease in women.
        JAMA. 1991; 265: 1861-1867
        • Akhter N
        • Milford-Beland S
        • Roe MT
        • Piana RN
        • Kao J
        • Shroff A.
        Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).
        Am Heart J. 2009; 157: 141-148
        • D'Ascenzo F
        • Gonella A
        • Quadri G
        • Longo G
        • Biondi-Zoccai G
        • Moretti C
        • Omede P
        • Sciuto F
        • Gaita F
        • Sheiban I.
        Comparison of mortality rates in women versus men presenting with ST-segment elevation myocardial infarction.
        Am J Cardiol. 2011; 107: 651-654
        • Pendyala LK
        • Torguson R
        • Loh JP
        • Kitabata H
        • Minha S
        • Badr S
        • Dvir D
        • Barbash IM
        • Satler LF
        • Pichard AD
        • Waksman R.
        Comparison of adverse outcomes after contemporary percutaneous coronary intervention in women versus men with acute coronary syndrome.
        Am J Cardiol. 2013; 111: 1092-1098
        • Radovanovic D
        • Erne P
        • Urban P
        • Bertel O
        • Rickli H
        • Gaspoz JM
        • Investigators AP
        Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20,290 patients from the AMIS Plus Registry.
        Heart. 2007; 93: 1369-1375
        • Wei J
        • Mehta PK
        • Grey E
        • Garberich RF
        • Hauser R
        • Bairey Merz CN
        • Henry TD
        Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol.
        Am Heart J. 2017; 191: 30-36
        • Vaccarino V
        • Parsons L
        • Every NR
        • Barron HV
        • Krumholz HM.
        Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants.
        N Engl J Med. 1999; 341: 217-225
        • Rakowski T
        • Siudak Z
        • Dziewierz A
        • Dubiel JS
        • Dudek D.
        Impact of smoking status on outcome in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.
        J Thromb Thrombolysis. 2012; 34: 397-403
        • White HD.
        Deconstructing the paradox of smoking and improved short-term cardiovascular outcomes after myocardial infarction.
        J Am Coll Cardiol. 2020; 75: 1755-1757
        • Redfors B
        • Furer A
        • Selker HP
        • Thiele H
        • Patel MR
        • Chen S
        • Udelson JE
        • Ohman EM
        • Eitel I
        • Granger CB
        • Maehara A
        • Kirtane AJ
        • Genereux P
        • Jenkins PL
        • Ben-Yehuda O
        • Stone GW.
        Effect of smoking on outcomes of primary PCI in patients with STEMI.
        J Am Coll Cardiol. 2020; 75: 1743-1754
        • Kaifoszova Z
        • Kala P
        • Alexander T
        • Zhang Y
        • Huo Y
        • Snyders A
        • Delport R
        • Alcocer-Gamba MA
        • Gavidia LM.
        Stent for life initiative: leading example in building STEMI systems of care in emerging countries.
        EuroIntervention. 2014; 10: T87-T95
        • Jacobs AK
        • Antman EM
        • Ellrodt G
        • Faxon DP
        • Gregory T
        • Mensah GA
        • Moyer P
        • Ornato J
        • Peterson ED
        • Sadwin L
        • Smith SC.
        Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention - The American Heart Association's Acute Myocardial Infarction (AMI) Advisory Working Group.
        Circulation. 2006; 113: 2152-2163