Clinical research study
Age and Gender Differences in Quality of Care and Outcomes for Patients with ST-segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjmed.2011.11.016Get rights and content

Abstract

Background

Young patients (aged  45 years) presenting with ST-segment elevation myocardial infarction present unique challenges. The quality of care and in-hospital outcomes may differ from their older counterparts.

Methods

A total of 31,544 patients presenting with ST-segment elevation myocardial infarction and enrolled in the American Heart Association's Get With the Guidelines Coronary Artery Disease registry were analyzed. The cohort was divided into those aged 45 years or less and those aged more than 45 years.

Results

Young patients accounted for 10.3% of all ST-segment elevation myocardial infarction cases. Compared with older patients, younger patients were less likely to have traditional cardiovascular risk factors and had similar or better quality/performance measures with lower in-hospital mortality (unadjusted rate 1.6 vs 6.5%, P <.0001; adjusted odds ratio [OR], 0.37; 95% confidence interval [CI], 0.29-0.46). Time trend analysis (2002-2008) suggested an increase over time in the “all or none” composite performance measure in both the younger and older patients (68%-97% and 69%-96%, respectively). However, there was significantly lower quality of care and worse outcomes in women (vs men) and in the very young (≤35 vs 36-45 years). Significant interaction was seen between age and gender for in-hospital death, such that the gender difference was greater in the younger cohort. Similar interaction was seen for door-to-thrombolytic time such that the gender delay was greater in the younger cohort (women:men ratio of means = 1.73, 95% CI, 1.21-2.45 [younger] vs 1.08, 95% CI, 1.00-1.18 [older]; Pinteraction = .0031).

Conclusion

Young patients aged 45 years or less presenting with ST-segment elevation myocardial infarction overall had similar quality of care and in-hospital outcomes as older counterparts. However, quality of care was significantly lower and mortality was higher in young women (vs young men) and the very young (≤35 vs 36-45 years).

Section snippets

Data Source and Study Population

Patients enrolled in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) registry, a prospective, multicenter, national, observational registry and quality improvement initiative established by the American Heart Association, were chosen for this analysis.13, 14 For the purposes of the present analysis, patients were included if the initial electrocardiogram showed new ST-segment elevation or a new left bundle branch block or a diagnosis of ST-segment elevation myocardial infarction.

Baseline Characteristics and In-Hospital Treatment

Among the 31,544 patients with ST-segment elevation myocardial infarction, 3257 (10.3%) were categorized as young (aged  45 years). When compared with the older cohort, the younger cohort were more likely to be men, black, or Hispanic, and to smoke, but were less likely to have traditional risk factors (Table 1) and had higher body mass index, baseline heart rate, and systolic blood pressure, but were less likely to be taking medications before admission. A high percentage of both groups

Discussion

Our analysis of data from approximately 32,000 patients with ST-segment elevation myocardial infarction, from 369 sites, showed that the young patients presenting with ST-segment elevation myocardial infarction were more likely to be men, smokers, black, or Hispanic, whose quality of care and in-hospital outcomes were similar to or better than that of their older counterparts. In addition with the implementation of the GWTG program, the “all or none” composite performance measure has steadily

Study Limitations

Our data are from a prospective registry. However, this is still the largest series on young patients with ST-segment elevation myocardial infarction. Our data included only hospitalized patients with ST-segment elevation myocardial infarction and did not account for out-of-hospital deaths. In addition, we were able to assess only in-hospital outcomes. In our subgroup analysis, we did not have data on illicit drug use in the very young cohort. In addition, given the lack of angiographic data,

Conclusions

In this largest series to date, younger patients with ST-segment elevation myocardial infarction were more likely to be men, black or Hispanic, or smokers, whose quality of care and in-hospital outcomes were similar to or better than that of their older counterparts. There was significantly lower quality of care as assessed by performance measures and significantly worse outcomes in young women (vs young men) and the very young (≤35 vs 36-45 years), suggesting the need for increasing awareness

References (26)

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Funding: The Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program was provided by the American Heart Association. The GWTG-CAD program was supported in part through the American Heart Association Pharmaceutical Roundtable and an unrestricted educational grant from Merck.

Conflicts of Interest: Sripal Bangalore: advisory board for Daichii Sankyo. Gregg C. Fonarow: consulting for Novartis Pfizer. Eric Peterson: research funding from BMS/Sanofi, Eli Lilly, Merck, and Ortho McNeil Pharmaceuticals. Anne S. Hellkamp: none. Adrian F. Hernandez: none. Warren Laskey: none. Frank Peacock: scientific advisory board for Abbott, Beckman-Coulter, Biosite, and The Medicines Co; research grants for Abbott, BAS, Biosite, Brahms, Nanosphere, EKR, and The Medicines Co; speakers bureau for Abbott, Biosite, and The Medicines Co; ownership interest in Vital Sensors. Christopher P. Cannon: research grants/support from Accumetrics, AstraZeneca, Glaxo Smith Kline, Merck, and Takeda; advisory board (but funds donated to charity) for Bristol-Myers Squibb/Sanofi, Novartis, and Alnylam; honorarium for development of independent educational symposia for Pfizer and AstraZeneca; clinical advisor for and equity in Automedics Medical Systems. Lee Schwamm: Chair, GWTG steering committee (unpaid). Deepak L. Bhatt: research grants from Astra Zeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company, and Amarin.

Authorship: All authors had access to the data and played a role in writing this manuscript.

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