Gender Disparities in Cardiovascular Care, with Gregory Weiss, MD

Gregory Weiss, MD

While cardiovascular disease remains the leading cause of death for both men and women worldwide, females with ST-elevation heart attacks receive less guideline-directed medical therapy, and longer door to balloon times when compared to men.¹ This is not a new problem. It has been well documented that women experience higher adverse event rates, heart failure, and mortality from ST-elevation myocardial infarction (STEMI).² The American Heart Association and the European Society of Cardiology consider reducing sex disparities in STEMI an international priority.

While Chetan et al. have previously shown that the use of a STEMI protocol can reduce sex disparities in the short term, it was unknown if long-term outcomes were comparable. The authors of this study sought to examine sex disparities in STEMI care as well as outcomes five years after protocol implementation. The authors designed and conducted an observational cohort study of consecutive patients with STEMI treated with percutaneous coronary intervention (PCI). The STEMI protocol consisted of 4 steps intended to standardize care for all patients, men and women:

1. Emergency physicians were permitted to activate the catheterization lab without delay.
2. A checklist was used to streamline critical tasks and provide real-time clinical decision support prior to PCI.
3. A policy of immediate transfer to an immediately available catheterization lab was implemented.
4. A trans-radial artery access was established as the standard however the attending cardiologist had the last word.

The primary outcomes examined were:

1. The use of guideline-directed medical therapy (GDMT) prior to arterial sheath insertion.
2. The use of trans-radial access.
3. Door to balloon time.

Results

The authors found that, in the control group, guideline-directed medical therapy was administered significantly less in females while in the protocol group administration was similar to men.¹ Trans-radial artery access was used rarely in the control group with a significant increase in both men and women in the protocol group.¹ Finally, door to balloon time was significantly longer in women from the control group.¹ In the protocol group door to balloon times were not significantly different between men and women.¹

With regards to clinical outcomes, women in the control group had higher rates of in-hospital mortality and major adverse cardiac and cerebrovascular events (MACCE) than those in the protocol group.¹ While bleeding events were reduced in protocol women, sex disparity persisted in the protocol group with significantly more bleeding in women compared to men^.1 Finally, women in the protocol group had higher rates of reinfarction than men.¹

There are 4 take-home messages from these results:¹

1. The use of guideline-directed medical therapy and door to balloon times were similar between sexes for 5 years after implementation of the STEMI protocol.
2. There were major improvements in the use of trans-radial PCI in both males and females.
3. Sex disparities in mortality and major adverse cardiac or cerebrovascular (MACCE) events were no longer observed for 5 years after protocol implementation.
4. A significantly higher rate of bleeding in females persisted despite implementation of a STEMI protocol including promotion of trans-radial PCI.

Just like preflight checklists, medical checklists are a form of standardization that have been shown to reduce errors and improve outcomes. Here we see that standardization led to women receiving the same treatment and realizing, for the most part, the same outcomes. While most outcomes were improved in women, higher bleeding rates persisted. More research will be needed to determine why.

The fact that ethnic, racial, socioeconomic, and sex disparities persist in medicine continues to vex clinicians. With so much wealth and knowledge in the world we have little excuse. Leveling the playing field through standardization is a good place to start. We have the evidence and know how to care for patients presenting with STEMI. Universal adoption of a standardized evidence-based protocol for treating STEMI patients should be the standard of care. This is important research that can be extrapolated to nearly every other field of medicine. Our patients deserve the best we can do.

References:

1. Chetan P. Huded M.D., Anirudh Kumar M.D., Nicholas Kassis M.D., et al. Five years of a comprehensive ST elevation myocardial infarct protocol and its association with sex disparities. European Heart Journal Open, oeab011, https://doi.org/10.1093/ehjopen/oeab011
2. Cenko E, van der Schaar M, Yoon J, Manfrini O, Vasiljevic Z, Vavlukis M, Kedev S, Milicic D, Badimon L, Bugiardini R. Sex-Related Differences in Heart Failure After ST-Segment Elevation Myocardial Infarction. Journal of the American College of Cardiology 2019;74(19):2379-2389.