Department of Cardiology, Austin Health, Melbourne, Australia.
Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
Am J Cardiol. 2019 Sep 15;124(6):833-841. doi: 10.1016/j.amjcard.2019.06.008. Epub 2019 Jun 24.
Guidelines mandate emergent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of gender. We sought to compare the door-to-balloon times and the impact of timely reperfusion on clinical outcomes in women compared with men presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI). We analyzed data from 6,179 consecutive patients presenting with STEMI undergoing PPCI from the Melbourne Interventional Group registry (2005 to 2017). The primary outcome was long-term mortality. Of the 6,179 patients included 1,258 (20.3%) were female. Female patients were older (69 ± 13 vs 62 ± 12 years; p < 0.001), had more co-morbidities and had longer median symptom-to-balloon times (204 [interquartile range {IQR} 154 to 294] vs 181 [IQR 139 to 258] minutes; p < 0.001) and longer median door-to-balloon times (81 [IQR 55 to 102] vs 75 [IQR 51 to 102)] minutes; p < 0.001), while receiving less drug-eluting stents (39% vs 43%; p = 0.01) and having less radial access for PPCI (15% vs 21%; p < 0.001). Furthermore, female patients received less guideline-directed medical therapy than men with less prescription of aspirin (93.4% vs 95.4%; p = 0.02), statins (96.5% vs 97.6%; p < 0.05), and beta blockers (84.3% vs 89.4%; p < 0.001). Unadjusted in-hospital and 30-day mortality rates were higher in women (8.8% vs 6.2%, 9.8% vs 6.9%; p < 0.001). However, on Cox-proportional hazards modeling, gender was not an independent predictor of long-term mortality (hazards ratio 0.99, 95% confidence interval 0.83 to 1.18; p = 0.92) at a mean follow-up of 4.8 ± 3.5 years. In conclusion, in this large multicenter registry of patients with STEMI, women had longer ischemic times, higher risk profiles, and differing interventional approaches compared with men. Addressing these gender inequalities with early identification of symptoms, adherence to guideline-directed medical therapy, as well as higher rates of radial access and use of drug-eluting stents has the potential to further improve outcomes in women with STEMI.
指南规定，无论性别如何，ST 段抬高型心肌梗死（STEMI）患者均需紧急血运重建。我们旨在比较女性和男性 STEMI 患者行经皮冠状动脉介入治疗（PPCI）的门球时间和及时再灌注对临床结局的影响。我们分析了来自墨尔本介入治疗组登记处（2005 年至 2017 年）的 6179 例连续 STEMI 患者的 PPCI 数据。主要结局是长期死亡率。在纳入的 6179 例患者中，有 1258 例（20.3%）为女性。女性患者年龄更大（69±13 岁 vs. 62±12 岁；p<0.001），合并症更多，中位症状至球囊时间更长（204[四分位距 {IQR}154 至 294] 分钟 vs. 181[IQR 139 至 258] 分钟；p<0.001）和中位门球时间更长（81[IQR 55 至 102] 分钟 vs. 75[IQR 51 至 102] 分钟；p<0.001），同时接受更少的药物洗脱支架（39% vs. 43%；p=0.01），接受 PPCI 时桡动脉入路更少（15% vs. 21%；p<0.001）。此外，与男性相比，女性患者接受的指南指导的药物治疗更少，阿司匹林的处方率较低（93.4% vs. 95.4%；p=0.02），他汀类药物的处方率较低（96.5% vs. 97.6%；p<0.05），β受体阻滞剂的处方率较低（84.3% vs. 89.4%；p<0.001）。女性患者的院内和 30 天死亡率较高（8.8% vs. 6.2%，9.8% vs. 6.9%；p<0.001）。然而，在 Cox 比例风险模型中，性别不是长期死亡率的独立预测因素（风险比 0.99，95%置信区间 0.83 至 1.18；p=0.92），平均随访时间为 4.8±3.5 年。总之，在这项针对 STEMI 患者的大型多中心注册研究中，女性与男性相比，缺血时间更长，风险状况更高，介入治疗方法也有所不同。通过早期识别症状、坚持指南指导的药物治疗，以及提高桡动脉入路和使用药物洗脱支架的比例，有可能进一步改善 STEMI 女性患者的结局。
