Women were slower to seek medical care for heart attacks and then received slightly less urgent, lower quality prehospital care for it, two studies showed.
In a Swiss cohort study, women had a longer ischemic time for ST-segment elevation myocardial infarction (STEMI) than men in large part because of delayed presentation. Women had a 12% higher overall ischemic time than men, with a median 215 vs 192 minutes for men to receive reperfusion following symptom onset in 2012 to 2016, reported Matthias Meyer, MD, PhD, of Triemli Hospital in Zurich, Switzerland, and colleagues in the European Heart Journal.
And a U.S. national registry showed modest disparities in EMS care for MI and other causes of chest pain as well as out-of-hospital cardiac arrest (OHCA).
Delays between MI onset and medical contact
Meyer and colleagues found that female gender was independently linked with an increased delay between symptom onset to first medical contact (P=0.02). The median patient delay in time to first medical contact was 139 minutes in women versus 114 minutes in men.
Median system delay thereafter to first medical contact to percutaneous coronary intervention (PCI)-facilitated reperfusion was 80 minutes for women versus 73 minutes in men.
“Thus further efforts to reduce ischaemic time in women are needed, such as continuing education of the public as well as health professionals,” the study authors concluded
There have been attempts to decrease patient delays and system delays over the last 10 years by improving STEMI treatment networks. A number of techniques were employed like training clinicians to better diagnose STEMI, instant catheterization laboratory activation, appropriate triage of STEMI patients to medical facilities equipped for PCI, and public education, among others, the researchers noted.
“Whether male and female STEMI patients benefit equally from current strategies to reduce ischaemic time is unclear,” the researchers wrote.
When comparing 2000-2005 with 2012-2016, the median system delay declined by 18 minutes in women and 25 minutes in men (P<0.0001 for trend, P=n.s. for gender difference).
These findings indicate that clinicians need to better understand what’s causing the delay, but it does not explain why there is a delay, noted Nieca Goldberg, MD, of New York University Langone Health in New York, who was not involved in the study.
“Despite all the advances in cardiovascular care, programs to raise awareness in women, we still see delays in care in women coming to the hospital with acute heart attack symptoms,” Goldberg told MedPage Today.
Delays in men were predicted by stent thrombosis, a Killip class of 3 or more, complete blockage in the culprit artery, and presentation during off-hours. These factors did not predict delays in women.
The researchers evaluated consecutive acute STEMI patients treated within 24 hours of onset with primary or rescue PCI at one of the largest PCI centers in Switzerland. The 967 women had a mean age of 69.1; while the 3,393 men had a mean age of 60.7.
Substandard care in the U.S.
In the U.S. registry study, women were less likely than men to receive recommended treatments for chest pain, including 2.8% fewer treated with aspirin and 2.7% fewer receiving nitroglycerin, reported Melissa McCarthy, ScD, of the George Washington University Milken Institute School of Public Health in Washington, DC, and colleagues in Women’s Health Issues.
The biggest difference was 4.6% fewer women than men presenting with chest pain were transported using sirens and lights.
While the vast majority of OHCA 911 activations received resuscitation, women again had a slight disadvantage (-1.3%; 95% CI -2.4% to -0.2%). The difference was bigger for cardiac defibrillation (-8.6%, 95% CI -11.8% to -6.2%).
“Recognizing the early warning symptoms of a heart attack is an important public health priority, not only for the people experiencing the condition, but also for the health care providers treating them,” the study authors wrote.
Many prior reports have shown gender disparities in hospital or post-hospital care, noted Rachel Bond, MD, of Northwell Health in New York, who was not involved in the study.
With this study, “we are now targeting a new subset of healthcare workers even before the patient presents to the hospital,” Bond said to MedPage Today. “This can be ground breaking as we know when it comes to acute coronary syndrome ‘time is muscle’ and the sooner appropriate, guideline-directed medical therapy is provided, the better the clinical outcomes.”
“Gender disparities in cardiovascular care exist at every level of the health care chain and undoubtedly contribute to differences in outcomes,” agreed Karol Watson, MD, PhD, of the University of California Los Angeles.
Using the National Emergency Medical Services Information System (NEMSIS), the investigators analyzed 911 activations for patients ages 40 years and older presenting with chest pain or out-of-hospital cardiac arrest (OHCA). They evaluated 2.4 million cases of chest pain cared for by 63,305 EMS agencies and 284,000 OHCA cases treated by 38,074 EMS agencies.
Commenting on the limitations of the study, Watson noted that the findings were based on “data from the largest EMS registry in the United States, but it is only one. Documentation for this registry is entirely voluntary and subject to reporting error. In addition, this paper looked at chest pain but not other anginal symptoms that are prominent in women like shortness of breath.”
“Given the limitations of NEMSIS, we recommend that these results be viewed with caution and further research and evaluation be conducted,” the researchers concluded.
The CP and OHCA study was supported by the Office on Women’s Health, the Department of Health and Human Services, the Office of Emergency Services, and the National Highway Traffic Safety Administration.
Meyer and colleagues declared they had no relevant financial relationships.
McCarthy and colleagues reported no relevant conflicts of interest.