Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis☆,☆☆
Introduction
It is well accepted that there are differences in the presentation and outcome of women and men with acute myocardial infarction (AMI). Women with AMI are sicker than men on presentation and have higher short and long-term mortality [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Although much of the difference in sex-specific outcomes has been attributable to differences in baseline variables and therapies provided, most of the earlier reports examining the cohort of women and men with ST-segment elevation myocardial infarction (STEMI) demonstrated a higher event rate in women even after adjustment for differences in cardiovascular risk profiles and management [1], [2], [10], [11], [12], [13], [14], [15].
Current guidelines recommend percutaneous coronary intervention (PCI) as first line therapy for STEMI [16]. Primary PCI (P-PCI) is widely used throughout the country and there have been numerous practice and quality improvement initiatives aimed at reducing door-to-balloon time in an effort to improve outcomes. Since women with STEMI have higher risk profiles compared to men, the similar relative risk reduction observed with P-PCI would translate into an even larger absolute benefit for women [3], [4]. To this effect, many subsequent studies have investigated the impact of gender differences in short and long-term mortality in STEMI patients undergoing P-PCI. Among these studies, there is a great variability in reported results with some but not all reporting similar mortality in women and men. The majority of these studies however are small in size (including fewer than 300 women) and therefore may have been under-powered to examine mortality as a clinical endpoint [3], [4], [5], [6], [7], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39]. Hence, we performed a meta-analysis of all published studies that reported sex-specific data on short and long-term mortality among STEMI patients undergoing P-PCI, aimed at comprehensively and quantitatively reviewing evidence from all available studies.
Section snippets
Search strategy
We searched MEDLINE, EMBASE and SCOPUS databases for manuscripts published from inception to November 2014. We used the following key words and medical subject headings: (“ST-elevation myocardial infarction”, “STEMI”, “myocardial infarction”, “percutaneous coronary intervention”, “PCI”, “primary PCI”, “angioplasty”, “primary angioplasty”) and (“gender”, “sex”, “female”, “male”). A manual search of reference lists of the original retrieved studies and appropriate review articles was also
Results
The search strategy retrieved 2874 citations after removing duplicates. Among these citations, 63 articles were selected for full text review. Based on our selection criteria, a total of 48 studies [3], [4], [5], [6], [7], [8], [9], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [42], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62] were included in the
Discussion
Primary PCI is the recommended treated for acute STEMI [21] and is now the most common method of reperfusion in the US. Our meta-analysis examined a population of women and men with STEMI who were exclusively referred for P-PCI and demonstrated higher in-hospital, 30-day and long-term mortality in women compared to men. After adjustment for baseline co-morbidities, clinical profile and treatment, the association was attenuated but still significant for in-hospital and 30-day mortality whereas
Limitations
Several limitations of this meta-analysis should be considered. One major limitation in conducting a meta-analysis of observational studies is the inevitability of combining data from studies that are not equally designed. Study samples were heterogeneous in terms of clinical profile, baseline characteristics and geographic location. Such differences may have contributed to the moderate heterogeneity observed in our study. Second, we used multivariable adjusted effect estimate; however not all
Conclusions
Sex-based differences exist in short and long-term mortality among patients with STEMI undergoing P-PCI. However these differences are markedly attenuated following adjustment for age, clinical differences and/or angiographic parameters and therapies provided, such that long-term mortality appears similar in women and men. This reinforces the importance of providing prompt evidence based reperfusion therapy to eligible women and men with acute STEMI.
Conflict of interest/disclosures
None of the authors have any financial or other relations that could lead to a conflict of interest.
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Presented in a part at the American Heart Association Scientific Sessions, Chicago, November 2014.
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All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.