Treatment and outcome in acute myocardial infarction in a community in relation to gender

doi:10.1016/j.ijcard.2008.03.065

International Journal of Cardiology

Volume 135, Issue 3, 10 July 2009, Pages 315-322

https://doi.org/10.1016/j.ijcard.2008.03.065 Get rights and content

Abstract

Aim

To describe treatment and outcome in all patients in a community with acute myocardial infarction (AMI) in relation to gender.

Methods

All patients discharged from hospital between 2001 and 2002 in Göteborg, Sweden, with a diagnosis of AMI underwent a survey to find possible gender differences. All p-values are age adjusted.

Results

Among 1423 admissions, women comprised 41% and were older than men (mean 79 versus mean 72 years). Women were admitted to a coronary care unit less frequently than men (49% versus 67%; p = 0.005). Women underwent coronary angiography less frequently (21% versus 40%; p = 0.02). Percutaneous coronary intervention (PCI) was performed in 10% of the women and 18% of the men (p = 0.36). Coronary artery bypass grafting (CABG) was performed in 2% of the women and in 9% of the men (p < 0.0001).

Female gender was associated with a lower risk of reinfarction during first year after hospital discharge (12% versus 16%; p = 0.003). The cumulative three-year mortality was 49% in women and 41% in men. However, when adjusting for age, admittance to CCU, coronary angiography and coronary revascularisation, risk of death during 3 years was lower in women than men (odds ratio 0.72; 95% confidence interval 0.60–0.85; p = 0.0001).

Conclusion

In the community of Göteborg women (mean age 79 years) with AMI are prioritised differently than men (mean age 72 years), prior to admission to a CCU. This results in a less invasive strategy in women, particularly with regard to CABG. When adjusting for difference in age, admittance to CCU and coronary revascularisation female gender was associated with a low risk of death during the subsequent 3 years.

Introduction

There is an ongoing debate about the gender perspective in the treatment and outcome of patients who suffer from acute myocardial infarction (AMI). A number of studies have suggested that women are given lower priority than men in various respects [1], [2], [3], [4], [5] and that this might jeopardise the outcome for women.

The clinical benefit of an invasive strategy is also less marked in women. In fact, a more aggressive revascularisation policy has not been shown to confer any benefit in women with unstable coronary artery disease, as opposed to the situation in men [6], [7].

However, recent data indicate that, among patients below 80 years of age who reach the coronary care unit and fulfil the criteria for acute coronary syndrome, there is no marked gender difference in the allocation of therapeutic resources [8]. As the current study did not include patients older than 80 years of age or patients suffering from AMI who did not reach the CCU, the situation in these groups is unknown.

The present survey aims to bridge the gap in knowledge by evaluating the treatment strategies and outcome among all patients in the Municipality of Göteborg, Sweden, who were discharged from hospital with a diagnosis of AMI (dead or alive), in relation to gender.

Section snippets

Place of study

Göteborg is the second largest city in Sweden. In 2002, Göteborg had a population of 475,000 inhabitants. The total population in Sweden at this time was 8,940,000 million people. There are two large hospitals in the city, one with and one without facilities for revascularisation.

Patients

All the patients were screened from the diagnosis register at the two city hospitals. All the patients in the municipality are admitted to one of these two hospitals. All the patients who were given a discharge

Study population

The study population is unique as it includes all patients hospitalised within a community and discharged from hospital (dead or alive) with a diagnosis of AMI, regardless of where in hospital the patient was treated, regardless of whether there was a suspicion of AMI on admission to hospital and regardless of whether AMI was the primary diagnosis.

This is a notable difference in comparison with both randomised studies and registry data, both of which frequently select patients with a lower risk

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However, there are also multiple behavioural components that may contribute to these noted gender differences. Both with regards to the exposed individuals’ safety behaviour, propensity to call for additional information, or how the exposed person’s need for health care is perceived (Loikas et al., 2015; Herlitz et al., 2009). However, the present study does not offer the sufficient resolution to investigate causal factors of the noted gender differences.
We present a retrospective analysis of records on occupational accidents from the Swedish Poisons Information Centre. The aim was to explore these data as a means for surveillance of accidents and incidents with chemicals at the workplace. We extracted data on all telephone consultations regarding occupational incidents (n = 8240) during 2010–2014. One third of the calls were made by health care staff (31%) and two thirds were made by the public (69%). For the latter group, about half (54%) received advice on how to manage on site. One out of five workplace incidents were assessed by the operating expert (pharmacists and physicians) as a major risk for severe symptoms. The three most commonly reported chemical groups were alkali (n = 1510, excluding ammonia), hydrocarbons (n = 1129, including halogenated hydrocarbons) and acids (n = 984). Eye exposure was the most common exposure route recorded (n = 3049), followed by inhalation (n = 2635) and skin (n = 1438). Data from the Swedish Poisons Information Centre offers insights about occupational accidents and incidents with chemical products and also include a higher number of accidents in absolute numbers as compared with the official injury statistics. With a clear focus on type of poisoning agent, treatment and health effects, poisons information data may serve as a means for surveillance on chemical incidents at the workplace.
Comparison of the performances of cardiac troponins, including sensitive assays, and copeptin in the diagnostic of acute myocardial infarction and long-term prognosis between women and men
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Fourth, the prognostic accuracy offered by cTnT, hs-cTnT, and copeptin was similar in women and men, even when a different cutoff value based on the 99th percentile value in women and men was applied. These findings have important clinical implications and extend previous work on gender differences.3-10,16,23 The role of cardiac biomarkers may be even more prominent in women because they more likely than men report atypical symptoms, such as dyspnea, weakness, nausea, and backpain1; these unspecific complaints may delay accurate diagnosis or even lead to misdiagnosis of AMI or acute coronary syndrome.
Concerns have been raised about possible gender disparities in cardiac investigations and/or outcome. This study sought to examine and compare the diagnostic and prognostic performance of selected cardiac biomarkers in women versus men.
In a prospective, multicenter cohort of patients with acute chest pain cardiac troponin T (cTnT) (fourth-generation Roche assay), high-sensitivity cTnT (hs-cTnT), and copeptin were measured at presentation.
Of 1,247 patients, 420 were women and 827 were men. Although the rate of acute myocardial infarction was similar in women (14.5%) and men (16.6%, P = .351), women more frequently had cardiac but noncoronary causes of chest pain (17.4% vs 10.8%, P = .001) and less frequently had unstable angina (8.8% vs 16.6%, P = .002) than men. Diagnostic accuracy as quantified by the area under the receiver operating characteristic curve (AUC) for acute myocardial infarction in women was 0.90 (95% CI 0.84-0.95) for cTnT, which was lower than the AUC for hs-cTnT alone (0.94, 95% CI [0.91-0.98]), the combination of cTnT with copeptin (0.96, 95% CI [0.94-0.98]) or the combination of hs-cTnT with copeptin (0.96, 95% CI [0.93-0.98]) (P = .008, P = .006, and P = .002, respectively). Prognostic accuracy as quantified by the AUCs for 1-year mortality was 0.69 (0.56-0.83), 0.86 (0.79-0.93), 0.87 (0.81-0.94), and 0.87 (0.80-0.94), respectively. No relevant gender differences in AUCs were observed.
The diagnostic and prognostic performance of cTnT, hs-cTnT, and copeptin is as good in women as in men. High-sensitivity cTnT and the combination of cTnT and copeptin outperform cTnT alone, both in women and men.
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The prehospital emergency care has had a rapid progress in Sweden in terms of technology, treatments and personnel education demands. In the County of Skane there is at least one specialized nurse in every ambulance. Possible misuses of the resources by the public have been acknowledged.
To investigate the public’s use, knowledge and expectations of the prehospital emergency care in Skane, southern Sweden.
A cross sectional descriptive survey, using a stratified sampling. Inclusion criteria were: 18 year or older and currently living in Skane.
Of 735 people who were asked 54.4% (n = 400) chose to participate in the study. 44.0% of the respondents had been transported with ambulance. 34.5% of the respondents believed that the lowest educated personnel responsible for the patient was the paramedic. The results show that the respondents trust the personnel’s knowledge and work skills. Older informants expected faster treatment by a physician when arriving by ambulance to the hospital, regardless of medical condition.
The public had confidence in the ambulance personnel’s knowledge, ability to make assessment and give treatment despite not being updated on the current competence of the personnel. A positive experience of contact with the ambulance service was distinct.
Inequalities in the early treatment of women and men with acute chest pain?
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In the municipality of Göteborg and probably in many other communities, a large percentage of patients with ACS are treated outside a dedicated CCU. Among those patients, sex differences possibly constitute larger problems, with lower frequencies of coronary angiography and revascularization in the female group [21]. Several surveys have shown that women with AMI have more nonspecific symptoms including pain in the neck, back, and abdomen, and this is in accordance with our findings [14-17].
The aim of this study was to identify sex differences in the early chain of care for patients with chest pain.
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A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included.
When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13).
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Community-based gender perspectives of triage and treatment in suspected myocardial infarction
2012, International Journal of Cardiology
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Four surveys performed during the last decade within the Municipality of Göteborg are included in the analysis. Three of them have previously been published [6,12,13]. However, some of the data that are presented here were not presented in the original articles.
The gender perspectives of the triage of acute coronary syndromes (ACS) in a community are insufficiently explored.
Patients (n = 3224) with symptoms of ACS, in whom ECG was sent by the ambulance crew to a coronary care unit (CCU)/ cath lab, were investigated in the municipality of Göteborg in 2004–2007. Background, triage priority, investigations and treatment were analysed (p-values age adjusted) in relation to gender. Data were compared with three published studies (1995–2002: Surveys 1–3).
Women were directly admitted to the CCU significantly less frequently than men (23 versus 35%, p < 0.0001). Adjusted for ECG findings, age, symptoms and medical history, odds ratio and 95% confidence limits (for direct admission; men versus women) were 0.61; 0.46–0.82.
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Cardiac troponins are the most sensitive and specific biomarker for myocardial infarction (MI) diagnosis. If there is a gender bias in MI diagnosis, it could be reduced by more consistently applying objective diagnostic criteria to improve women's outcomes. This study set out to assess the accuracy and correlates of the cardiac troponin I (cTnI) assay in the diagnosis of non-ST-segment elevation MI, to determine how the assay accuracy and correlates vary by gender, and to explore the interaction between factors that may influence cTnI accuracy and affect gender differences in diagnosis. The data were obtained from the CHECKMATE study. It included 924 patients with possible myocardial ischemia excluding subjects with ST-segment elevation. The Dade-Behring Stratus CS STAT near-patient instrument (Dade Behring, Inc, Newark, Del) was used to measure cTnI. We assessed baseline troponin accuracy using a standard MI definition. There were 125 subjects with a definite MI diagnosis. Baseline troponin was 44% sensitive and 97% specific in predicting MI, with no significant gender differences. In contrast, other positive cardiac markers, namely rising or falling creatine-kinase MB fraction and positive electrocardiogram, occurred more frequently in men. Sensitivity (SE) of baseline troponin was higher in subjects where baseline troponin was obtained longer than 2 hours after the chest pain onset. The study did not observe a significant difference in the assay SE or specificity by gender. This observation, plus the fact that other positive cardiac markers occurred more frequently in men, suggest the troponin test may help to improve the diagnosis of MI in women.

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Treatment and outcome in acute myocardial infarction in a community in relation to gender

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Place of study

Patients

Study population

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Lancet

Int J Cardiol

Am Heart J

Int J Cardiol

J Am Coll Cardiol

Am Heart J

J Electrocardiol

J Electrocardiol

Am Heart J

Sex differences in management and outcome after acute myocardial infarction in the 1990s: a prospective observational community-based study. Israeli thrombolytic survey group

Circulation