Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Alexandra J. Lansky

Abstract

Background: Cardiovascular disease is the leading cause of death worldwide. Outcomes of patients with ST-segment–elevation myocardial infarction (STEMI) have improved through widespread implementation of systems-of-care, yet sex disparities continue to be reported. A comprehensive, global study of sex disparities in contemporary STEMI care and outcomes has not been undertaken.

Objective: To examine whether sex differences in STEMI management and mortality outcomes persist worldwide and by geographic region.

Methods: A systematic PubMed literature search was performed using search terms “sex” or “gender” and “STEMI” for studies in English from 2000 to present reporting sex-based STEMI mortality. Articles with primary data on sex-based STEMI mortality were included. Data collected prior to 2000, sub-categorized data, and studies with less than 50 women were excluded. Meta-analyses were conducted using random effects models and are reported overall and by geographic region. Heterogeneity was assessed via Cochran’s Q statistic. Sex differences were evaluated in baseline characteristics, door-to-balloon times, and mortality (in-hospital, 30-day, 6 months, and 1 year).

Main Outcome and Measure: The primary outcome is in-hospital to 12-month mortality. Secondary outcome is Door-to-Balloon/Door-to-Reperfusion time.

Results: 613 published manuscripts were reviewed and ultimately 75 studies included in the meta-analysis, representing 29 countries in 6 geographic regions and 731,990 patients (32% female). Women were older and had more diabetes and hypertension. Overall, unadjusted in-hospital mortality was 2-fold higher in women compared to men (2.09 OR, 95%CI 1.91-2.08; p<0.0001), with excess mortality in all regions and time-points. Adjusting for age alone did not alter the mortality discrepancy. After adjustment for hypertension and diabetes the difference in sex-based mortality was no longer significant. Additionally, reperfusion therapy was less common in women, door-to-reperfusion time was longer in all countries with a mean delay of 5.3 minutes (p<0.0001).

Conclusions: This study demonstrates concerning global sex disparities in risk factors, time to treatment, STEMI care and a doubling of unadjusted mortality in women. Adjustments for comorbidities suggest that modifiable risk factors, rather than difference in reperfusion therapy, account primarily for the difference in mortality. This highlights the need for a global call-to-action to elucidate critical factors and barriers to preventive care to reduce the observed sex gap in STEMI outcomes worldwide.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 05/29/2021

Share

COinS