Access to Reperfusion Therapy and Mortality in Women with ST-Segment–Elevation Myocardial Infarction: VICTIM Register

Jussiely Cunha Oliveira Mayse Pereira Souza Barros Ikaro Daniel de Carvalho Barreto Rubens Cruz Silva Filho Volfanio Araújo Andrade André de Melo Oliveira Ticiane Clair Remacre Munareto Lima Jeferson Cunha Oliveira Larissa Andreline Maia Arcelino Laís Costa Souza Oliveira Eduesley Santana-Santos Marcos Antônio Almeida-Santos Antônio Carlos Sousa José Augusto Soares Barreto FilhoAbout the authors

Resumo

Fundamento:

A reperfusão miocárdica é parte fundamental do tratamento para infarto agudo do miocárdio com supradesnivelamento de ST (IAMCSST) e é responsável por reduzir morbimortalidade no paciente acometido. No entanto, as taxas de reperfusão são geralmente mais baixas e as taxas de mortalidade mais altas em mulheres que em homens.

Objetivos:

Avaliar a prevalência do uso de terapias de reperfusão em mulheres e homens com IAMCSST nos hospitais com capacidade para realizar intervenção coronariana percutânea (ICP) no estado de Sergipe.

Métodos:

Trata-se de estudo transversal que utilizou dados do Registro VICTIM. Foram avaliados pacientes com diagnóstico de IAMCSST admitidos nos quatro hospitais com capacidade para realizar ICP no estado de Sergipe, sendo um público e três privados, no período de dezembro de 2014 a junho de 2018. Foi aplicada análise multivariada com modelo ajustado utilizando mortalidade como variável dependente. Em todas as análises, o nível de significância adotado foi de 5% (p<0,05).

Resultados:

Foram incluídos 878 voluntários com diagnóstico confirmado de IAMCSST, dos quais 33,4% eram mulheres. Apenas 53,3% dos pacientes foram submetidos à reperfusão miocárdica (134 mulheres versus 334 homens). A fibrinólise foi realizada somente em 2,3% de todos os pacientes (1,7% das mulheres versus 2,6% dos homens; p=0,422). Nas mulheres, a taxa de ICP primária foi menor (44% versus 54,5%; p=0,003) e a mortalidade hospitalar foi maior (16,1% versus 6,7%; p<0,001) que nos homens.

Conclusão:

As mulheres apresentam taxas significativamente menores de ICP primária e significativamente maiores de mortalidade hospitalar que os homens. A taxa de reperfusão em ambos os gêneros foi baixa e houve nítida subutilização de agentes trombolíticos.

Palavras-chave:
Infarto do Miocárdio; Mulheres; Reperfusão Miocárdica; Intervenção Coronária Percutânea; Morbimortalidade; Gênero e Saúde; Disparidades em Assistência à Saúde

Abstract

Background:

Myocardial reperfusion is a fundamental part of the treatment for ST elevation myocardial infarction (STEMI) and is responsible for reducing morbidity and mortality in affected patients. However, reperfusion rates are usually lower and mortality rates higher in women compared to men.

Objectives:

To evaluate the prevalence of the use of reperfusion therapies among women and men with STEMI in hospitals where percutaneous coronary intervention (PCI) is available in the state of Sergipe.

Methods:

This is a cross-sectional study that used data from the VICTIM Register. Patients diagnosed with STEMI admitted to the four hospitals (one public and three private) where PCI is available in the state of Sergipe were evaluated, from December 2014 to June 2018. A multivariate analysis with adjusted model using mortality as a dependent variable was made. In all analyses, the level of significance adopted was 5% (p < 0.05).

Results:

A total of 878 volunteers with a confirmed diagnosis of STEMI, of which 33.4% were women, were included in the study. Only 53.3% of the patients underwent myocardial reperfusion (134 women versus 334 men). Fibrinolysis was performed only in 2.3% of all patients (1.7% of women versus 2.6% of men; p = 0.422). The rate of primary PCI was lower (44% versus 54.5%; p = 0.003) and hospital mortality was higher (16.1% versus 6.7%; p < 0.001) in women than in men.

Conclusion:

Women have significantly lower rates of primary PCI and higher hospital mortality. Reperfusion rates were low in both sexes and there was a clear underutilization of thrombolytic agents.

Keywords:
Myocardial Infarction; Women; Myocardial Reperfusion; Percutaneous Coronary Intervention; Morbimortality; Gender and Health; Healthcare Disparities

Introduction

Early myocardial reperfusion is the mainstay of the treatment of acute myocardial infarction with ST elevation (STEMI) and its use is associated with better prognosis.11. Piegas LS, Timerman A, Feitosa GS, Nicolau JC,Mattos LAP, Andrade MD, et al.,Sociedade Brasileira de Cardiologia. V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2015; 105(2):1-105. However, in different parts of the world, women have presented lower reperfusion rates than men.22. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369–75.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157

Percutaneous coronary intervention (PCI) is currently considered the gold standard treatment for STEMI because it has better success rates, a higher frequency of complete reperfusion (TIMI grade 3) and a lower incidence of recurrent ischemia, reinfarction and death when compared to fibrinolysis. The procedure is indicated for patients with STEMI who may have access to therapy within 90 minutes of diagnosis, in addition to those who have contraindications to the use of fibrinolytic drugs or in cardiogenic shock. Its use is beneficial if performed within 12 hours of the onset of pain, or up to 24 hours after diagnosis, if ischemia persists. The use of fibrinolytic drugs is of fundamental importance for patients who will not have timely access to PCI and patients in the prehospital environment.11. Piegas LS, Timerman A, Feitosa GS, Nicolau JC,Mattos LAP, Andrade MD, et al.,Sociedade Brasileira de Cardiologia. V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2015; 105(2):1-105.,77. O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, Chung MK, Lemos JA, et al. 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;127(4):362-425.,88. Ibanez B, James S, Agewall S, Antunes MJ, Ducci CB, Bueno H, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017;00:1–66.

Despite the proven relevance of early coronary reperfusion therapy, several studies have shown disparities between sexes when it comes to the approach for patients with STEMI.22. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369–75.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157 Women have lower rates of PCI and fibrinolysis than men22. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369–75.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157 as well as more complications associated with reperfusion therapy.99. Akhter N, Milford-Beland S, Roe MT, Piana RN, Kao J, Shroff A. Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology–National Cardiovascular Data Registry (ACC NCDR). Am Heart J. 2009;157(1): 141–148.1111. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016; 133(9): 916-47. In women, the prognosis after ischemia is worse than in men, possibly reflecting a less aggressive therapeutic approach.44. Gasperi R, Cantarelli MJ, Castello Jr HJ, Gonçalves R, Gioppato S, Guimarães JB, et al. Impacto do Sexo Feminino nos Resultados da Intervenção Coronária Percutânea Contemporânea. Rev Bras Cardiol Invasiva. 2011; 19(2): 178-183.,66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157,1212. Leurent G, Garlantezec R, Auffret V, Hacot JP, Coudert I, Filippi, et al. Gender differences in presentation, management and inhospital outcome in patients with STsegment elevation myocardial infarction: data from 5000 patients included in the ORBI prospective French regional registry. Arch Cardiovasc Dis. 2014; 107(5)291–298.,1313. Freisinger E, Sehner S, Malyar NM, Suling A, Reinecke H, Wegscheider K. Nationwide Routine-Data Analysis of Sex Differences in Outcome of Acute Myocardial Infarction. Clin Cardiol. 2018 Aug;41(8):1013-21.

This study aimed to assess the prevalence of the use of reperfusion therapies among women and men with STEMI in hospitals where PCI is available in the state of Sergipe.

Materials and methods

This is a cross-sectional study that used data from the VICTIM Register1414. Oliveira JC, Oliveira LC, Oliveira JC, Barreto ID, Santos MA, Lima TC, et al. Disparities in Acute Myocardial Infarction Treatment Between Users of the Public and Private Healthcare System in Sergipe. Int J Cardiovasc Sci. 2018;31(4)339-358. - Via Crucis for Treatment of Myocardial Infarction, collected from December 2014 to June 2018, in the four hospitals in Sergipe where PCI is available. All institutions are located in the capital; only one of them serves public service users and is renowned for its performance in the treatment of STEMI. The other institutions are private and offer assistance on demand.

The collection was carried out by the researchers using their own research questionnaire which was composed of the following variables: age, ethnicity, social class, education, health coverage, risk factors, symptoms at presentation, Killip and Kimball classification, GRACE risk score; data regarding the time elapsed between the onset of symptoms and the decision to call for help, the decision to call for help to arrival at the first hospital without angioplasty, time from the first hospital to the hospital with angioplasty, and the total time elapsed since the onset of symptoms until arrival at the hospital with angioplasty; use of fibrinolytic treatments, PCI or coronary artery bypass grafting, in addition to clinical course of patients during hospitalization after AMI regarding mortality, chronic heart failure, re-infarction, or shock. The information was collected through interviews with the patient or caregiver and from patients’ medical records.

The study included all patients over 18 years of age admitted to the above-mentioned hospitals after confirmation of STEMI by an electrocardiogram, and according to the V Brazilian Society of Cardiology guidelines,11. Piegas LS, Timerman A, Feitosa GS, Nicolau JC,Mattos LAP, Andrade MD, et al.,Sociedade Brasileira de Cardiologia. V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2015; 105(2):1-105. which suggests the presence of at least one of the following five criteria for confirmation of the diagnosis of infarction: symptoms of myocardial ischemia such as chest pain; changes in the ST segment/T wave or complete left bundle branch block; development of pathological Q waves on the ECG; imaging evidence of loss of viable myocardium or wall motion abnormalities; or the identification of an intracoronary thrombus by angiography or autopsy. In addition, patients signed an informed consent form before inclusion in the study.

Patients who died before the interview, patients who were not eligible for inclusion in the Via Crucis, that is, who were hospitalized for other causes when STEMI was detected and hence did not go through the timeline from the onset of out-of-hospital symptoms until arrival at the hospital with PCI; patients who did not sign the informed consent form; who suffered reinfarction within 28 days after the incident myocardial infarction; patients who had a change in diagnosis, that is, those who were admitted for STEMI, but were identified with another problem after the exams; and patients assisted by a health plan seen in a philanthropic hospital (Figure 1) were excluded from the study. Data collection was carried out consecutively in the selected institutions.

Figure 1
Flowchart of excluded patients; STEMI: ST elevation myocardial infarction.

This research was approved by research ethics committee of the Federal University of Sergipe (UFS) (approval number 483,749).

Statistical analysis

Categorical variables were described using absolute and relative frequency, and continuous variables were described using mean and standard deviation or median and interquartile range, according to the normality of the data. To assess differences in measures of central tendency, the Shapiro-Wilk test was first applied to assess the adherence of continuous variables to the normal distribution, and when the validity of this assumption was confirmed, the Student’s t test was used for independent samples; otherwise, the Mann-Whitney test was used. Categorical variables were assessed using Pearson’s X2 test. In the multivariate analysis, a simple logistic regression was used; mortality was the outcome and sex was the independent variable. The model was adjusted for health coverage, age, reperfusion and GRACE Risk Score. The statistical analysis was performed using the SPSS software for Windows version 17; results were considered statistically significant if p-values were less than 0.05, with 95% confidence interval.

Results

A total of 878 patients (33.4% women) diagnosed with STEMI were studied. Compared to men, women were older, most belonged to lower social class, did not finish college, and 30% never went to school. The predominant ethnic group was non-white in both groups and the most used service was the public service, as can be seen in Table 1.

Table 1
Demographic and clinical characteristics of patients with ST elevation myocardial infarction (STEMI)

Regarding the time from symptom onset to arrival at the hospital where PCI was available, no significant difference between sexes was observed in the time spent from the onset of symptoms to the decision to call for medical help, or in the time between the decision to call medical help and arrival at the first hospital without capacity to perform PCI. However, the time spent from presentation at the first hospital to arrival at the hospital where PCI was available was significantly longer for women than men, with a median of 460 h (IQ 233.75-1283.25) and 390 h (IQ 215- 775), respectively. The same was observed when only users of the Unified Health System (SUS) were analyzed, with a median of 535h (IQ 330-1565) and 450h (IQ 300-1035) for women and men, respectively. As for the total time spent between the onset of symptoms and arrival at the hospital where PCI was available, there was a significant delay to treatment in both men [545h (IQ332-1122)] and women 705h [(IQ 71-1612.5)]. This was clearly associated with the type of health system, as the time was longer for users of the public system compared with users of the private one [792.5h (456.75-1800) and 598h (390-1331.75), respectively]. In addition, in the public service, the number of women who were not reperfused was significantly greater than in the private service. No differences were found in the use of fibrinolytic agents, success of PCI, and coronary artery bypass grafting between men and women (Table 2).

Table 2
Access to the angioplasty service, treatment and hospital outcomes of patients with ST elevation myocardial infarction (STEMI)

However, the logistic regression between mortality and sex revealed a higher likelihood of death in the female sex [CR = 2.54 (95% CI: 1.58-4.06); p < 0.001], as well as when adjusted for health coverage [CR = 2.47 (95% CI: 1.54-3.96); p < 0.001], health coverage and age [CR = 2.27 (95% CI: 1.40-3.59); p = 0.001], health coverage, age and reperfusion [CR = 2.20 (95% CI: 1.35-3.59); p = 0.002], health coverage, age, reperfusion and GRACE risk score [CR = 2.36 (95% CI: 1.44-3.88); p = 0.001].

Discussion

In the present study, lower reperfusion rates and higher mortality rates were observed in women than in men. Moreover, the rate of use of reperfusion therapy was low in both sexes, and significantly lower in women. Several national and international studies have called attention to the low rates of reperfusion as a growing problem, and thus more effective strategies for the implementation of care protocols for the treatment of STEMI are urgently required.1515. Oliveira JC, Santos MA, Oliveira J, Oliveira LC, Barreto ID, Lima TC, et al.Disparities in Access and Mortality of Patients With ST - Segment–Elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register. J Am Heart Assoc. 2019;8(20).,1616. Nicolau JC, Franken M, Lotufo PA, Carvalho AC, Neto JAM, Lima FG, et al. Utilização de Terapêuticas Comprovadamente Úteis no Tratamento da Coronariopatia Aguda: Comparação entre Diferentes Regiões Brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE – Brazilian Registry on Acute Coronary Syndromes). Arq Bras Cardiol. 2012;98(4):282-289.

The present findings are similar to those of previous studies carried out in the north and northeast of Brazil reporting a reperfusion rate in patients with STEMI of 52.5%.1616. Nicolau JC, Franken M, Lotufo PA, Carvalho AC, Neto JAM, Lima FG, et al. Utilização de Terapêuticas Comprovadamente Úteis no Tratamento da Coronariopatia Aguda: Comparação entre Diferentes Regiões Brasileiras. Análise do Registro Brasileiro de Síndromes Coronarianas Agudas (BRACE – Brazilian Registry on Acute Coronary Syndromes). Arq Bras Cardiol. 2012;98(4):282-289. This confirms that we are far from meeting the recommendations on reperfusion rates, such as observed in developed countries. For example, the STRategical Reperfusion Early After Myocardial infarction (STREAM) study observed rates as high as 98.2% of patients treated and receiving some reperfusion strategy (thrombolysis with or without rescue or primary PCI) in a developed country.1717. Welsh RC, Van de Werf F, Westerhout CM, Goldstein P, Gershlick AH, Wilcox RG, et al. Outcomes of a Pharmacoinvasive Strategy for Successful Versus Failed Fibrinolysis and Primary Percutaneous Intervention in Acute Myocardial Infarction (from the Strategic Reperfusion Early After Myocardial Infarction [STREAM] Study). Am J Cardiol. 2014;114(6):811-819.

The present study also revealed an inequality between sexes, with lower rates of reperfusion in women when compared to men, especially when analyzing data from SUS users. Such inequality was also verified in several national and international studies,22. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369–75.,33. Chieffo A, Hoye A, Mauri F, Mikhail G, Ammerer M, Grines C, et al. Gender-based issues in interventional cardiology: a consensus statement from the Women in Innovations (WIN) Initiative. Rev Esp Cardiol. 2010;63(2):200-8.,44. Gasperi R, Cantarelli MJ, Castello Jr HJ, Gonçalves R, Gioppato S, Guimarães JB, et al. Impacto do Sexo Feminino nos Resultados da Intervenção Coronária Percutânea Contemporânea. Rev Bras Cardiol Invasiva. 2011; 19(2): 178-183.,66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157,1818. D’onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, et al. Sex Differences in Reperfusion in Young Patients With ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(15):1324-1332. such as the study conducted in China – Insights From the China Patient-Centered Evaluated Assessment the Cardiac Events (PEACE) – in which Chinese women had lower reperfusion rates even when they were promptly referred for treatment.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157 The study entitled Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) found that, in the United States, women were 2.31 times more likely to not receive reperfusion than men.1818. D’onofrio G, Safdar B, Lichtman JH, Strait KM, Dreyer RP, Geda M, et al. Sex Differences in Reperfusion in Young Patients With ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(15):1324-1332.

Some studies have pointed out that the greater number of comorbidities and the fact of having a more severe condition at the time of the diagnosis of STEMI could expose women to the risk-treatment paradox, in which it is observed that patients with a more severe condition receive less therapeutic interventions.1919. Parker AB, Naylor CD, Chong A, Alter DA. Socio-Economic Status and Acute Myocardial Infarction Study Group Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction. Can J Cardiol.2006;22(2):131-9.,2020. Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Global Registry of Acute Coronary Events investigators. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009; 95(1):20-6. In these cases, the physician may not offer adequate treatment because he believes that the intervention will be useless in view of the patient’s severe state, or because he fears that the adverse effects will outweigh the benefits generated by the intervention in the patient with multiple comorbidities.1919. Parker AB, Naylor CD, Chong A, Alter DA. Socio-Economic Status and Acute Myocardial Infarction Study Group Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction. Can J Cardiol.2006;22(2):131-9. In the PEACE study, women had a higher frequency of risk factors than men, including those assessed in the present study, except smoking, which was more prevalent among men.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157 From this perspective, the Global Registry of Acute Coronary Events study found that women were older and had more comorbidities when treated with PCI.2020. Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Global Registry of Acute Coronary Events investigators. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009; 95(1):20-6. Accordingly, in the present study, women were older, and had a higher number of associated risk factors and a more severe Killip and Kimball classification than men.

As for the average time spent between arrival at the first hospital and access to the hospital with PCI service, a much longer time than that suggested by the Brazilian guideline11. Piegas LS, Timerman A, Feitosa GS, Nicolau JC,Mattos LAP, Andrade MD, et al.,Sociedade Brasileira de Cardiologia. V Diretriz da Sociedade Brasileira de Cardiologia sobre Tratamento do Infarto Agudo do Miocárdio com Supradesnível do Segmento ST. Arq Bras Cardiol. 2015; 105(2):1-105. was observed when analyzing the total population. Analysis of the average time from symptom onset to arrival at the hospital with hemodynamics, stratified by sex, treatment delay was even greater among women, which was maintained in the analysis of SUS users only. Thus, the delay to arrive at the hospital with angioplasty reflected in low rates of use of primary PCI in the general population, with lower rates in women when compared with men in the general population (Figure 2) and among SUS users. In the evaluation of users of private health services, more expressive values were observed for the performance of primary PCI in females. In Brazil, factors associated with health service, such as difficult access and little structure, besides the inadequate choice of transportation made by patients, can contribute to inadequate access to therapy, leading to long delays.1515. Oliveira JC, Santos MA, Oliveira J, Oliveira LC, Barreto ID, Lima TC, et al.Disparities in Access and Mortality of Patients With ST - Segment–Elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register. J Am Heart Assoc. 2019;8(20).,2121. Damasceno CA, Mussi FC. Fatores de retardo pré-hospitalar no infarto do miocárdio: uma revisão de literatura. Cienc Cuid Saude. 2010; 9(4):821. Contrary to other reports,1212. Leurent G, Garlantezec R, Auffret V, Hacot JP, Coudert I, Filippi, et al. Gender differences in presentation, management and inhospital outcome in patients with STsegment elevation myocardial infarction: data from 5000 patients included in the ORBI prospective French regional registry. Arch Cardiovasc Dis. 2014; 107(5)291–298.,2222. Calé R, de Sousa L, Pereira H, CostaM, Almeida MS. Angioplastia primária na mulher: realidade nacional. Rev Port Cardiol. 2014;33(6):353-61.,2323. Nguyen HL, Saczynski JS, Gore JM, Goldberg RJ. Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction a systematic review. Circ Cardiovasc Qual Outcomes. 2010;3(1):82–92. in the present study, women did not experience significant delays, compared to men, when making a decision to call for help.

Figure 2
Timeline of access to treatment of patients with ST elevation myocardial infarction.

Values found for the use of fibrinolytic agents were lower than those observed in the PEACE study, which found that in 2011, 26.8% of women and 33.5% of men with STEMI were submitted to fibrinolysis.66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157 Furthermore, the study entitled Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) reported a higher rate of mortality and complications among women after fibrinolysis when compared with the volunteers submitted to PCI,1111. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016; 133(9): 916-47.,2424. Weaver WD, White HD, Wilcox RG, Aylward PE, Morris D, Guerci A, et al. Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy: GUSTO-I investigators. JAMA. 1996;275(10):777–82. since the early thrombolytic therapy, with due indication, reduces mortality in both sexes.77. O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, Chung MK, Lemos JA, et al. 2013 ACCF/AHA Guideline for the Management of ST Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;127(4):362-425. However, there are several barriers to the use of this therapy, since women have more contraindications to this method and greater risks of complications.1111. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016; 133(9): 916-47.

In an American study conducted in 2018, mortality within 30 days after STEMI was 10.7% in women and 4.6% in men (p = 0.002).2525. Huded CP, Johnson M, Kravitz K, Menon V, Abdallah M, Gullet TC, et al. 4-Step Protocol for Disparities in STEMI Care and Outcomes in Women. J Am Coll Cardiol. 2018; 71(19):2122-32. In the present study, women had significantly higher rates of hospital mortality and post-ischemic heart failure than men. The GUSTO I2424. Weaver WD, White HD, Wilcox RG, Aylward PE, Morris D, Guerci A, et al. Comparisons of characteristics and outcomes among women and men with acute myocardial infarction treated with thrombolytic therapy: GUSTO-I investigators. JAMA. 1996;275(10):777–82. and ACC-NCDR99. Akhter N, Milford-Beland S, Roe MT, Piana RN, Kao J, Shroff A. Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology–National Cardiovascular Data Registry (ACC NCDR). Am Heart J. 2009;157(1): 141–148.(National Cardiovascular Data Registry- American College of Cardiology) records corroborate the information and show that women are more likely to develop heart failure following AMI. However, the association of risk factors, greater delay in reach the hospital with PCI service, and age of appearance of the condition may also have impacted the higher mortality rate,1111. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016; 133(9): 916-47.,1313. Freisinger E, Sehner S, Malyar NM, Suling A, Reinecke H, Wegscheider K. Nationwide Routine-Data Analysis of Sex Differences in Outcome of Acute Myocardial Infarction. Clin Cardiol. 2018 Aug;41(8):1013-21. in addition to the longer time spent receiving treatment99. Akhter N, Milford-Beland S, Roe MT, Piana RN, Kao J, Shroff A. Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology–National Cardiovascular Data Registry (ACC NCDR). Am Heart J. 2009;157(1): 141–148.,1414. Oliveira JC, Oliveira LC, Oliveira JC, Barreto ID, Santos MA, Lima TC, et al. Disparities in Acute Myocardial Infarction Treatment Between Users of the Public and Private Healthcare System in Sergipe. Int J Cardiovasc Sci. 2018;31(4)339-358.,1515. Oliveira JC, Santos MA, Oliveira J, Oliveira LC, Barreto ID, Lima TC, et al.Disparities in Access and Mortality of Patients With ST - Segment–Elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register. J Am Heart Assoc. 2019;8(20).,2626. Barbosa RR, Silva VR, Renato RG, Cesara FB, Mauroa VF, Bayerla DMR, et al. Diferenças de gênero nos resultados da intervenção coronariana percutânea primaria em pacientes com infarto do miocárdio com elevação de ST. Rev Bras Cardiol Invasiva. 2015;23(2):96-101. and less access to adequate treatment.44. Gasperi R, Cantarelli MJ, Castello Jr HJ, Gonçalves R, Gioppato S, Guimarães JB, et al. Impacto do Sexo Feminino nos Resultados da Intervenção Coronária Percutânea Contemporânea. Rev Bras Cardiol Invasiva. 2011; 19(2): 178-183.,66. Du X, Spatz ES, Dreyer RP, Hu S, Wu C, Li S, et al. Sex differences in Clinical Profiles and Quality of Care Among Patients With ST-Segment Elevation Myocardial Infarction From 2001 to 2011: Insights From the China Patient-Centered Evalueted Assessment os Cardiac Events (PEACE): Retrospective Study. J Am Heart Assoc. 2016; 5(2):e002157,1212. Leurent G, Garlantezec R, Auffret V, Hacot JP, Coudert I, Filippi, et al. Gender differences in presentation, management and inhospital outcome in patients with STsegment elevation myocardial infarction: data from 5000 patients included in the ORBI prospective French regional registry. Arch Cardiovasc Dis. 2014; 107(5)291–298.,1313. Freisinger E, Sehner S, Malyar NM, Suling A, Reinecke H, Wegscheider K. Nationwide Routine-Data Analysis of Sex Differences in Outcome of Acute Myocardial Infarction. Clin Cardiol. 2018 Aug;41(8):1013-21.,1515. Oliveira JC, Santos MA, Oliveira J, Oliveira LC, Barreto ID, Lima TC, et al.Disparities in Access and Mortality of Patients With ST - Segment–Elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register. J Am Heart Assoc. 2019;8(20).

The present study brought an assessment between public and private services, which revealed worse results for users of the public service, especially among women. In addition, our findings point to an absence of public policies regarding adequate access of patients with STEMI to adequate treatment.

Limitations

The present study has some limitations that include the low social and educational level of participants, especially among SUS users, which may have compromised the self-reporting of their medical history. The collection of data on door-to-balloon time was compromised by the lack of information of times in the medical records, especially in the public service. In addition, only mortality and hospital outcomes were studied and there was no follow-up after discharge to assess whether there were disparities between sexes regarding prognosis after hospitalization.

Conclusion

Disparities between sexes were observed in the present study with lower rates of primary PCI and higher rates of hospital mortality among women. The low use of primary PCI was probably one of the variables responsible for the higher mortality in women. The low rates of reperfusion in women, both considering the general population and in SUS users only, were directly associated with delayed arrival at the hospital with hemodynamic service, since early reperfusion is the key point of treatment. Such findings point to the need for strategies to improve access of women with STEMI to effective therapeutic strategies.

  • Sources of Funding
    This study was funded by CNPq, number 14/2013.
  • Study Association
    This article is part of the thesis of Doctoral submitted by Jussiely Cunha Oliveira, from Universidade Federal de Sergipe.
  • Ethics approval and consent to participate
    This study was approved by the Ethics Committee of the Universidade Federal de Sergipe under the protocol number 483.749. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

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Publication Dates

  • Publication in this collection
    16 Apr 2021
  • Date of issue
    Apr 2021

History

  • Received
    15 July 2019
  • Reviewed
    23 Jan 2020
  • Accepted
    16 Mar 2020
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