Female Gender Is An Independent Female Gender Is An Independent Predictor Of In-Hospital Mortality Predictor Of In-Hospital Mortality

After STEMI In The Era of After STEMI In The Era of Primary PCI. Insights From The Primary PCI. Insights From The Greater Paris Area PCI RegistryGreater Paris Area PCI Registry

Hakim Benamer, Muriel Tafflet, Sophie Bataille, Sylvie Escolano, Xavier Mouranche, Jean-Pierre Tresca, Bernard Livarek, Vincent Fourchard, Christophe Caussin, Emmanuel Teiger, Philippe Garot, Yves Lambert, Xavier Jouven, and Christian Spaulding

CARDIO-ARHIF Scientific Committee and INSERM U 970, Paris Descartes University, Paris, France

Presenter Disclosure Information

• Christian Spaulding

• Female gender is an independent predictor of in-hospital mortality after STEMI in the era of primary PCI: Insights from the Greater Paris Area Registry

FINANCIAL DISCLOSURE: The Greater Paris Area registry is funded by a French government hospital agency (ARH)

UNLABELED/UNAPPROVED USES DISCLOSURE: none

IntroductionIntroduction

• In patients presenting with STEMI, PCI has been shown to significantly improve survival and rescue and adjunctive PCI are effective therapies after thrombolytic therapy

• Studies of sex differences in mortality after STEMI have consistently indicated that women have higher death rates, especially for short-term follow-ups

• Although different baseline and procedural characteristics may account for increased mortality, they are not sufficient to explain the discrepancy in outcome. Furthermore, most of these studies were performed before the widespread use of PCI for STEMI

IntroductionIntroduction

• Greater Paris Area Registry: mandatory registry which gathers the clinical and angiographic data on all coronary angiograms and PCIs performed in this region

• Aim of the study: to determine if female gender is still an independent predictor of mortality in patients with STEMI treated by PCI

MethodsMethods

• Population : The Greater Paris area comprises 11 million inhabitants and accounts for 18% of the French population. 42 centers perform PCI. In 2001, the government hospital agency of the Greater Paris area set up a mandatory registry of all PTCAs performed in this region

• Variables entered: Patients demographics, procedural information, per and post-procedural complications and clinical status at hospital discharge

• Quality check: Internal and external audits are performed twice a year. Deaths are crossed-checked in another hospital-based data-base (PMSI)

French guidelines for AMIFrench guidelines for AMI

• The majority of STEMI patients are transported to hospital by a pre-hospital emergency system ambulance with a physician on board

• French guidelines recommend primary PCI as reperfusion therapy if the transportation time to a catheterization laboratory is less than 45 minutes

• If the expected transportation time is more than 45 minutes, pre-hospital thrombolytic therapy is administered if no contra-indications are noted

• In all cases, patients are transported to a PCI capable hospital

Outcomes of interestOutcomes of interest• Aim of this study: to examine the relationship

between gender and in-hospital outcome in STEMI treated by PCI within 24 hours of onset of chest pain

• Data entered between 2003 and 2007 in 16 726 procedures was screened for:

– STEMI of less than 12 h of duration or STEMI of more than 12 but less than 24 h of duration if the operator considered emergency PCI necessary because of continuous ischemia or complications

– cardiogenic shock and/or successfully resuscitated OHCA due to acute coronary artery occlusion

• In-hospital all-cause mortality rate was chosen as the primary endpoint and independent predictors were assessed

Baseline characteristicsBaseline characteristics

N Men

N=13096

Women

N=3664

p

Clinical factors

Age, years (SD) 16726 59.3 (13.0) 69.7 (14.3) <0.0001

Diabetes Mellitus, n (%) 16538 2016 (15.6) 687 (19.0) <0.0001

Cardiogenic shock, n (%) 16760 522 (4.0) 246 (6.7) <0.0001

Reperfusion strategy

Primary PCI, n (%)

Successful thrombolysis, n (%)

Failed thrombolysis, n (%)

16280 10496 (82.6)

1254 (9.8)

956 (7.5)

3177 (88.9)

228 (6.4)

169 (4.7)

<0.0001

Angiographic characteristicsAngiographic characteristics

N Men

N=13096

Women

N=3664

p

Coronary artery disease

extension

Coronary lesions <50%

One vessel disease (%)

Two vessel disease (%)

Three vessel disease (%)

Left main stenosis (%)

16749

331 (2.5)

5627 (43.0)

4081 (31.2)

3049 (23.3)

421 (3.2)

96 (2.6)

1599 (43.7)

1111 (30.3)

855 (23.3)

136 (3.7)

0.8

0.1

Percutaneous coronary intervention data

N Men

N=13096

Women

N=3664

p

No Treated lesions mean +/- SD 16328 1.28 (0.60) 1.30 (0.61) 0.4

Primary success % 16326 95.9 94.7 0.002

No of BMS/patient mean +/- SD 16375 1.15 (0.84) 1.14 (0.85) 0.9

No of DES/patient mean +/- SD 15948 0.15 (0.47) 0.14 (0.46) 0.06

PCI of SVG, n (%) 16584 132 (1.0) 28 (0.8) 0.2

In-hospital all cause mortality and complications

N Men

N=13096

Women

N=3664

p

In hospital mortality 16358 4.3 (551) 9.8 (350) <0.000

1

Vascular

complications

1653

6

5.4 (708) 7.9 (289) <0.00

1

Transfusion 16514 0.4 (45) 1.2 (42) <0.000

1

Vascular surgery 16514 0.2 (16) 0.2 (7) 0.3

Independent predictors of mortality by multivariate Independent predictors of mortality by multivariate analysis analysis

OR [IC] p 

Female gender Female vs Male 1.29 [1.06 – 1.56] 0.01

Age Per year 1.06 [1.05 – 1.07] <0.0001

Diabetes Mellitus Yes vs no 1.54 [1.25 – 1.90] <0.0001

Cardiogenic Shock Yes vs no 19.10 [15.48 – 23.58] <0.0001

PCI failure per % 0.26 [0.18 – 0.35] <0.0001

BMS  no BMS vs at least one BMS 0.76 [0.58 – 1.00] 0.05

DES No DES vs at least one DES 0.40 [0.26 – 0.61] <0.0001

Left main Yes vs no 2.04 [1.50 – 2.79] <0.0001

Lesion extension2 and 3 vessel vs one or

none0.58 [0.33 – 1.03] 0.06

Thrombolysis Failed thrombolysis vs successful 1.80 [1.05 – 3.08] 0.03

In-hospital mortality according to age and In-hospital mortality according to age and gendergender

Figure1: In hospital Mortality

1,7

3

6,2

12

2,4

4,5

7

16,1

0 5 10 15 20

< 55

[55-65[

[65-75[

>= 75

Women (n=3573)

Men (n=12751)

Years old

p = .2

p = .06

p = .4

p = .0005

LimitationsLimitations

• To obtain a high rate of patients with complete data, the number of clinical and angiographic variables entered in the database was limited

• Out of hospital mortality is unknown

• Analysis of subgroups in registries is limited by the observational nature of the analysis. However, the large number of patients included in our registry limits this potential bias

• The analysis was limited to patients who were catheterized within 24 hours of an acute myocardial infarction and no data is available on patients who were not reperfused  

ConclusionConclusion

• Previous studies have demonstrated that female gender was an independent predictor of in-hospital mortality after STEMI

• However, PCI was not widely used in these registries

• In our large registry based analysis, in patients treated with PCI for STEMI, female gender was still an independent predictor of in-hospital mortality after STEMI

• There is a clear need for further studies to explain this difference so that gender inequities in clinical care can be eliminated