Cardiovascular Rounds

Why are young women more likely to die in the hospital after a STEMI?

by Marissa Schwartz

A recent study in the Journal of the American College of Cardiology found significant sex differences in STEMI treatment for younger adults. Compared to men, women with STEMI were more likely to die in the hospital or receive interventions.

The study examined data from the Healthcare Cost and Utilization Project (HCUP)’s Nationwide Inpatient Sample from 2004 to 2011, focusing on patients between 18 to 59 years of age. Study authors found that although young women with AMI were less likely than young men with AMI to present with STEMI, among STEMI patients, women were less likely than men to receive coronary angiography or reperfusion (PCI, thrombolysis, or CABG).

Younger women were also more likely to die in the hospital and have longer length of stay compared to younger men.

These findings raise an obvious question: why are women at a seeming disadvantage when it comes to STEMI interventions? The study authors offer several suggestions.

  • Younger women are less likely to have chest pain and discomfort, and more likely to have atypical presentations, potentially leading to under-recognition or delayed presentation of STEMI, making acute reperfusion less likely
  • Younger women have a higher frequency of alternative etiologies (e.g., Takotsubo [stress] cardiomyopathy, spontaneous coronary artery dissection, coronary vasospasm), leading to lower revascularization rates
  • Women have a 2-fold increased bleeding risk compared to men, possibly preventing women with atypical symptoms from receiving guideline-specific interventions

Additionally, beyond the rates of revascularization, why is in-hospital mortality higher in women? Authors offer multiple explanations:

  • Women are less likely than men to receive adjunctive medical therapies
  • Younger women typically have less extensive history of non-occlusive coronary artery disease may result in lesser myocardial ischemic preconditioning, which could result in greater vulnerability to acute ischemia
  • Women with STEMI experience longer treatment delays upon arrival to the hospital (e.g., longer door-to-EKG, door-to-needle, and door-to-balloon times)
  • Finally, men are more likely than women to die before arriving at the hospital, potentially confounding the higher in-hospital mortality rates in women

For both women and men with STEMI, reperfusion rates are increasing, as is in-hospital mortality, while LOS is decreasing. Yet despite these sex-consistent changes in temporal trends, sex differences in absolute rates persist. These data, as the study concludes, provide an opportunity not only to improve STEMI care overall, but also “to bridge the sex-disparity in providing care to younger patients with STEMI.”

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