Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study

Abstract

Background: Sex disparities in reperfusion therapy for patients with acute ST-segment-elevation myocardial infarction have been documented. However, little is known about whether these patterns exist in the comparison of young women with men.

Methods and results: We examined sex differences in rates, types of reperfusion therapy, and proportion of patients exceeding American Heart Association reperfusion time guidelines for ST-segment-elevation myocardial infarction in a prospective observational cohort study (2008-2012) of 1465 patients 18 to 55 years of age, as part of the US Variations in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study at 103 hospitals enrolling in a 2:1 ratio of women to men. Of the 1238 patients eligible for reperfusion, women were more likely to be untreated than men (9% versus 4%, P=0.002). There was no difference in reperfusion strategy for the 695 women and 458 men treated. Women were more likely to exceed in-hospital and transfer time guidelines for percutaneous coronary intervention than men (41% versus 29%; odds ratio, 1.65; 95% confidence interval, 1.27-2.16), more so when transferred (67% versus 44%; odds ratio, 2.63; 95% confidence interval, 1.17-4.07); and more likely to exceed door-to-needle times (67% versus 37%; odds ratio, 2.62; 95% confidence interval, 1.23-2.18). After adjustment for sociodemographic, clinical, and organizational factors, sex remained an important factor in exceeding reperfusion guidelines (odds ratio, 1.72; 95% confidence interval, 1.28-2.33).

Conclusions: Young women with ST-segment-elevation myocardial infarction are less likely to receive reperfusion therapy and more likely to have reperfusion delays than similarly aged men. Sex disparities are more pronounced among patients transferred to percutaneous coronary intervention institutions or who received fibrinolytic therapy.

Keywords: myocardial infarction; myocardial reperfusion.

Figure 1

VIRGO enrollment sites.

Figure 2

Consort. NSTEMI indicates non–ST-segment–elevation myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-segment–elevation myocardial infarction.

Figure 3

Sequential logistic regression for the effect of sex on exceeding recommended guidelines for PCI and fibrinolysis reperfusion. The following covariates are sequentially included in the adjusted models. Adjusted model 1=sex only; adjusted model 2=model 1, sociodemographics (age, race), previous heart disease (MI, CABG, PCI), and the presence of cardiovascular risk factors (diabetes mellitus, obesity, hypertension, hypercholesterolemia, and smoking); adjusted model 3=model 2, transfer status, ECG before arrival, presence of LBBB, presence of atypical symptoms, presenting within 6 hours of symptom onset and hemodynamic instability on arrival; and adjusted model 4=model 3 and receipt of fibrinolytic therapy. The forest plot shows the odds ratios for women vs men. CABG indicates coronary artery bypass graft; LBBB, left bundle-branch block; MI, myocardial infarction; and PCI, percutaneous coronary intervention.