Is there still a gender gap in STEMI care? Insights from a German multicenter, metropolitan STEMI network

Sascha Macherey-Meyer (Köln)1, M. Meertens (Mainz)2, S. Heyne (Köln)3, S. Braumann (Köln)3, I. Ahrens (Köln)4, F. M. Baer (Köln)5, F. Eberhardt (Köln)6, M. Horlitz (Köln)7, J.-M. Sinning (Köln)8, A. Meissner (Köln)9, S. Baldus (Köln)1, C. Adler (Köln)10, S. Lee (Köln)10

1Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 2Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 3Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 4Krankenhaus der Augustinerinnen, Akademisches Lehrkrankenhaus Klinik für Kardiologie und internistische Intensivmedizin Köln, Deutschland; 5St. Antonius Krankenhaus Medizinische Klinik & Kardio-Diabetes-Zentrum Köln Köln, Deutschland; 6Ev. Krankenhaus Köln-Kalk Kardiologie & Internistische Intensivmedizin Köln, Deutschland; 7Krankenhaus Porz am Rhein gGmbH Klinik für Kardiologie, Elektrophysiologie u. Rhythmologie Köln, Deutschland; 8St. Vinzenz-Hospital Innere Medizin III - Kardiologie Köln, Deutschland; 9Kliniken der Stadt Köln gGmbH, Krankenhaus Merheim Medizinische Klinik II Köln, Deutschland; 10Universitätsklinikum Köln Klinik III für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland


Background:  Worldwide studies highlighted a gender gap in general medical and cardiovascular care with inferior outcome in women in the past. ST-segment myocardial infarction (STEMI) is a life-threatening diseaserequiring precise diagnostic algorithms and optimized treatment. STEMI guideline recommendations are independent of gender. But globally reported observational data are signaling gender disparities even in STEMI care.


Objective: This study examined the clinical outcome in an all-comer STEMI cohort in a metropolitan area of a high-income country with specific awareness for gender disparities.

Methods: The STEMI network is a cooperation of 16 hospitals andlocal emergency medical services. The registry includes patients treated between January 2005 and December 2020. Primary outcome was in-hospital all-cause mortality. Data were analyzed using Student’s t test and Chi square test.


Results: 4663 patients including 1230 women (26.4%) and 3433 men (73.6%) were eligible. Women were older than men (69.8 vs. 61.0 years, mean, p<0.001). Symptom-to- first medical contact (FMC) time was increased in women (370.1 vs. 315.4, p=0.027). But FMC-to-balloon (112.8 vs. 106.0, p=0.247) or door-to-balloon time (66.3 vs 63.0, p=0.267) did not significantly differ between the groups. During the preclinical course, women less frequently required resuscitation (11.8 vs. 15.6%, p=0.008), but had comparable intubation (10.9 vs 12.4%, p=0.180) or mortality rates (0% and 0.3%, p=0.201).  Women were less likely referred for angiography (98.2 vs. 99.2%, p=0.005), and had a lower stent implantation rate (79.1 vs. 83.2%, p=0.002). Left artery descending (35.6 vs. 39.1%, p=0.033) and left circumflex artery were less commonly affected in women (10.8 vs. 13%, p=0.048). Procedure-related complications (11.5 vs. 8.5%, p=0.003) and access-site bleeding (1.6 vs.0.7%, p=0.008) were increased in women. Incidence of cardiogenic shock, re-infarction, stroke and episodes of ventricular fibrillation were comparable between the groups (see figure). Creatinkinase levels were lower in women (1537.5 vs. 2053.9 U/L, p<0.001), but the distribution of post-infarction left ventricular ejection fraction was comparable between the groups [normal 52.6 vs. 50.8%, mildly reduced 30.2 vs. 32.4%, and reduced 17.2 vs. 16.8%, p=0.600]. Women had a significantly increased in-hospital all-cause mortality (12.3 vs. 8.4%, p<0.001). Prescription rates of ACE inhibitor, Angiotensin receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist were comparable between the groups. In secondary prevention following STEMI, there was a significantly lower aspirin prescription rate (91.9 vs. 93.8%, p= 0.045), and a trend towards lower use of statins in women (89.5 vs. 91.3, p=0.082). 


Conclusion: The present registry analysis indicates a persistent gender gap in STEMI care in a German metropole. We observed an alarmingly higher in-hospital mortality in women, even though men more frequently required resuscitation or suffered cardiogenic shock. System-related delay was not different, but an increased patient-related delay in women was acknowledged. The signals of less guideline adherence in secondary prevention following STEMI disease in women are a novel finding and require further investigations.

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