Reducing care variability also shrinks gender gap in STEMI outcomes

A four-step protocol designed to improve care for all patients who experience ST-segment elevation myocardial infarction (STEMI) also reduced gender-specific disparities in suboptimal care and clinical outcomes, Cleveland Clinic researchers reported in the Journal of the American College of Cardiology.

Although women continued to have higher 30-day mortality following STEMI presentation, the difference was reduced from 6.1 percent to 3.2 percent after the protocol was implemented. Importantly, female patients throughout the study period were four years older on average than their male counterparts and carried a greater burden of cardiovascular comorbidities.

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

The authors studied 1,272 consecutive participants who received percutaneous coronary intervention (PCI) after STEMI from 2011 through 2016. Because the STEMI protocol was implemented on July 15, 2014, they were able to analyze the quality of treatment and clinical outcomes both before and after the changes went into effect.

The four-step protocol consisted of the following measures taken across the Cleveland Clinic’s STEMI network, which consists of 10 hospitals and three free-standing emergency departments (EDs):

  1. The ED physician was allowed to activate the cardiac catheterization lab without consulting a cardiologist.
  2. A STEMI Safe Handoff Checklist was implemented to standardize early triage and management of patients. The checklist outlined roles of ED and cardiology nurses and physicians to allow for faster assessment of the patient, provided guidance on choice and administration method of medical therapy and included information on factors which increase the risk of PCI-related complications.
  3. Immediate transfer to an available cath lab.
  4. A radial access approach as the first option for all suitable patients undergoing primary PCI.

After the implementation of this process, the use of guideline directed medical therapy (GDMT) improved from 77 percent to 84 percent in men and from 69 percent to 80 percent in women. Door-to-balloon time (D2BT) decreased by at least 15 minutes for both groups, with a larger reduction for women (from median 112 minutes to median 91 minutes). Sex-specific differences in in-hospital adverse events disappeared and the 30-day mortality gap shrunk despite women representing the higher-risk group of patients.

“The resolution of sex disparities in use of GDMT and D2BT performance translated into improved clinical outcomes, with men and women having similarly low rates of in-hospital adverse events and similar reductions in 30-day mortality,” the researchers noted.

Huded and colleagues pointed out their mortality reductions, while “promising,” were underpowered to reach statistical significance. They were encouraged to find rates of transradial PCI jumped from below 20 percent for both sexes before the protocol was implemented to 68.8 percent and 62.6 percent in men and women, respectively, after determining that should be the default approach.

“Adoption of transradial PCI for STEMI in women in particular may be limited because female sex is an independent predictor of transradial PCI failure,” Huded and coauthors wrote. “Despite this concern, we illustrate that radial access for primary PCI can be successfully adopted in women and men alike with concomitant major reductions in D2BT in both sexes.”