Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Abstract

AimTo investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.MethodsNationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.ResultsThere were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3–84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9–77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%–13.1%) vs 2.3% (IQR 0.8%–7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.ConclusionAccording to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap.

Biology and bias: do we have the will to improve cardiovascular disease outcomes for women?

“…Goals can be updated for further improvement with measured progress over time. It is clear from this new study4 and work of others8 9 that protocols for the delivery of recommended AMI treatments for women can reduce the sex–AMI mortality gap. Accordingly, the question is: do we have the will to improve CVD outcomes for women?…”

“…The new study by Wilkinson et al 4 offers an explicit ACCA suite of QIs metrics that can be used as a checklist (figure 2) with goals to improve AMI outcomes for women (and men). Specifically, use of these metrics that are both measurable4 and achievable given prior experience with protocolised care8 9 would likely close disparities in AMI that adversely impact women (and continue to improve outcomes for men).…”

“…Specifically, use of these metrics that are both measurable4 and achievable given prior experience with protocolised care8 9 would likely close disparities in AMI that adversely impact women (and continue to improve outcomes for men). This AMI ‘Save Lives Checklist’ (figure 2) is not intended to be comprehensive; the initial goals reflect the metrics achieved in men,4 and additions and modifications to fit local practice are encouraged. Goals can be updated for further improvement with measured progress over time.…”

“…A new report4 using the recently developed and validated European Society of Cardiology Acute Cardiovascular Care Association (ACCA) Quality Indicators (QIs) for AMI offers insight into improving outcomes for women. These investigators found that women in England and Wales less frequently received guideline-indicated AMI care and had significantly higher mortality than men.…”

“…Diagnostic uncertainty drives therapeutic uncertainty, as evidenced by the failure to provide evidence-based guidelines AMI therapy despite clear evidence of an AMI and elevated 30-day risk in women documented by Wilkinson and coauthors 4. While knowledge gaps exist regarding specific treatment of MINOCA, for example, statin and dual antiplatelet treatment of AMI due to coronary vasospasm, spontaneous coronary artery dissection and Takotsubo cardiomyopathy is controversial, current AMI acute and chronic pharmacological secondary prevention guidelines are based on randomised clinical trials in patients with AMI from prior decades with less coronary angiography, which most certainly included MINOCA patients.…”