Acute myocardial infarction in women: is there a sex disparity between
door-to-balloon time and clinical outcomes?
Sara D. Collins
Washington Hospital Center, Washington, DC 20010, USA
Received 3 September 2010; accepted 3 September 2010
Keywords: Coronary artery disease; Myocardial infarction; Percutaneous coronary intervention; Diabetes mellitus;
Hypertension; Congestive heart failure
Coronary artery disease (CAD) has traditionally been
thought of as a disease that predominantly affects men.
Women, however, are more likely than men to die from a
myocardial infarction (MI). Despite increased awareness of
heart disease in women and improved outcomes after
percutaneous coronary intervention (PCI), women with MI
have more mortality and delays to treatment than men.
Although all of the reasons behind these differences are not
clear, women presenting with MI are a more morbid patient
population than their male counterparts. Women consistently
demonstrate higher baseline risk, including older age, higher
rates of diabetes mellitus (DM), hypertension (HTN) and
congestive heart failure (CHF) [1–5]. This was initially
demonstrated in trials conducted in the thrombolytic era, but
has persisted in the current era of PCI [3,5].
Another source of sex disparity in ST-elevation MI
(STEMI) management is delay to treatment. It is well
established that the benefit of PCI over fibrinolytic therapy is
lost with delay in administering treatment. A meta-regression
analysis of 23 randomized controlled trials in 2003 showed
that for every 10-minute delay in PCI (defined as the
difference between door to balloon and door to needle), the
favorable reduction in mortality is reduced by 0.94%
(P=.016). When the delay in PCI is 62 min, there is no
longer a reduction in mortality with PCI over fibrinolytics
. Unfortunately, studies have shown that women make up
a higher percentage of patients in the more delayed door-to-
balloon (DTB) time, as well as total ischemic time [1,5,7].
The cause for this delay in STEMI treatment is unknown.
Difficulties in recognizing symptoms in women on the part
of the patient may be where the problem begins. Many large-
scale campaigns have addressed educating the public on
recognizing the symptoms of MI. Once women with
suspected MI present to the health-care system, however, it
is the responsibility of the health-care provider to diagnose
and treat STEMI in a timely fashion. Unfortunately, delays in
DTB and total ischemic time are evidence that the system is
flawed from a provider's standpoint as well.
Disparities in the management of women with CAD
warrant further investigation, but whether these differences
translate into disparities in outcomes between men and
women remains controversial. Studies have shown that
women with acute MI have higher rates of in-hospital death
and complications, including major bleeding, than do men
with acute MI [1,3,5,8]. In some of these analyses, baseline
risk at least partially accounted for the higher death rate in
women [5,8]. More concerning, however, is that, in many
cardiac studies, female sex is an independent predictor of
early death and adverse events.
In the In the Global Use of Strategies To open Occluded
arteries in acute coronary syndromes (GUSTO V) study,
reteplase vs. abciximab plus half dose reteplase were
compared in patients with STEMI or new left-bundle branch
block. Female sex was an independent predictor of 30-day
mortality even after adjusting for potential confounders (OR
2.00; 95% CI 1.59–2.53) . The CADILLAC trial assessed
treatment with primary PCI using PTCA vs. bare metal
Cardiovascular Revascularization Medicine 13 (2012) 125 – 127
Corresponding author. Washington Hospital Center, 110 Irving Street,
NW, Suite 4B-1, Washington, DC 20010, USA.
E-mail address: firstname.lastname@example.org.
1553-8389/10/$ – see front matter © 2012 Published by Elsevier Inc.