Systems-based approach to STEMI care shown to benefit women

In women, a systems-based approach to ST-segment elevation myocardial infarction (STEMI) care may lessen the repercussions of suboptimal care and worsened outcomes, according to a recent article published in the Journal of the American College of Cardiology.

Experts widely recognize that STEMI care offered to women is inferior to that offered to men, and marked by lower rates of guideline-directed medical therapy (GDMT) and lengthier door-to-balloon times (D2BT). Women with STEMI also deal with worse clinical outcomes, increased adverse events in the hospital, and higher mortality rates.

The American Heart Association has made it a priority to close knowledge gaps concerning the treatment of STEMI in women. Furthermore, authors of the 2017 European Society of Cardiology STEMI guidelines have admitted that women with STEMIs usually receive evidence-based care less commonly than men do.

Researchers conducting a recent meta-analysis of 68,536 women with STEMI found that the female gender was independently associated with a 48% increased relative risk of death in the hospital.

“It is unknown whether a systems-based approach to STEMI care that minimizes care variability can achieve similar care and outcomes for men and women,” wrote these authors, led by Chetan P. Huded, MD, MSc, of the Heart and Vascular Institute Center for Healthcare Delivery Innovation, and the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. “The purpose of this study was to describe the care processes and clinical outcomes of men versus women with STEMI before and after implementation of a comprehensive 4-step STEMI protocol at our institution.”

The team conducted a prospective, observational registry-based study of all consecutive patients diagnosed with STEMI and treated with primary percutaneous coronary intervention (PCI) at the Cleveland Clinic main campus between January 1, 2011, and December 31, 2016. They prospectively collected baseline characteristics, procedural data, and in-hospital outcomes.

The authors started STEMI protocol on July 15, 2014, comprised of the following:

1. Catheterization lab activation in the emergency department without the need for a cardiology consult
2. Utilization of a STEMI Safe Handoff Checklist to standardize the early triage of patients, the management of patients, and guideline-directed medical therapy
3. Urgent transfer to an open catheterization lab
4. Utilization of a radial-first PCI approach

Of note, the control period for this study was between January 1, 2011, and July 14, 2014.

Dr. Huded and colleagues gathered data about guideline-directed medical therapy (GDMT) before PCI, door-to-balloon time (D2BT), adverse events occurring in the hospital, and 30-day mortality.

The final analysis included 1,272 participants (32% women) and, overall, the women served were older and had more comorbidities than did their male counterparts.

Women in the control group experienced longer D2BT (median: 104 vs 112 minutes; P=0.023) and less GDMT (77% vs 69%; P=0.019). Furthermore, these women had more in-hospital stroke, vascular complications, bleeding, transfusion, and morbidity.

With the implementation of the 4-step STEMI protocol, sex disparities resolved with respect to GDMT, D2BT, and in-hospital adverse events. Importantly, the researchers also observed that the absolute sex-difference in 30-day mortality fell by 2.9% between the control group (+6.1% in women; P=0.002) and those receiving the 4-step protocol (+3.2% in women; P=0.090).

“Adoption of systems-based solutions for minimizing STEMI care variability led to marked improvements in care processes and clinical outcomes in women with STEMI,” the researchers concluded. “This strategy offers the promise to provide equal care of men and women, resolving the longstanding sex gap in STEMI outcomes.”