CLINICAL RESEARCH
CORONARY INTERVENTIONS
EuroIntervention 2016;12:e 542- e 549 published online
Longer pre-hospital delays and higher mortality in women
with STEMI: the e-MUST Registry
Hakim Benamer1,2,3*, MD; Sophie Bataille4, MD; Muriel Tafflet5,6,7, MPH; Patricia Jabre5,8, MD;
François Dupas9, MD; François X. Laborne10, MD; Frédéric Lapostolle11,12, MD, PhD;
Hugues Lefort13, MD; Jean-Michel Juliard14, MD; Jean-Yves Letarnec15, MD;
Lionel Lamhaut5,8, MD; Gaelle Lebail16, MD; Thevy Boche17, MD; Aurélie Loyeau4;
Christophe Caussin18, MD; Mireille Mapouata4; Nicole Karam5,6,7,19, MD, MPH;
Xavier Jouven5,6,7,19, MD, PhD; Christian Spaulding5,6,7,19, MD, PhD; Yves Lambert20, MD;
for the e-MUST Registry Investigators**
e-edition August 2016
1. Cardiology Department, European Hospital of Paris - La Roseraie, ICV-GVM, Aubervilliers, France; 2. Interventional
Cardiology Department, Institut Jacques Cartier, ICPS, Massy, France; 3. Cardiology Department, Foch Hospital, Suresnes,
France; 4. Registry Department of the Regional Health Agency of the Greater Paris Area, Paris, France; 5. INSERM Unit 970,
Paris Cardiovascular Research Center - PARCC, Paris, France; 6. Paris Descartes University, Paris, France; 7. Sudden Death
Expertise Center, Paris, France; 8. SAMU 75, Necker Hospital, Assistance Publique - Hopitaux de Paris, Paris, France;
9. SAMU 95, Pontoise Hospital, Pontoise, France; 10. SAMU 91, Sud Francilien Hospital, Corbeil-Essonnes, France; 11. SAMU
93 Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, Bobigny, France; 12. Université Paris 13, Bobigny, France;
13. Fire Department of Paris, Paris, France; 14. University Hospital Department FIRE, AP-HP, Bichat Hospital, University
Paris-Diderot, Sorbonne Paris-Cité, INSERM U-1148, Paris, France; 15. SAMU 77, Melun Hospital, Melun, France; 16. SAMU
92, Garches Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France; 17. SAMU 94 Mondor Hospital, Assistance
Publique-Hôpitaux de Paris, Créteil, France; 18. Cardiology Department, Institut Mutualiste Montsouris, Paris, France;
19. European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; 20. SAMU 78, Versailles
Hospital, Le Chesnay, France
** The full list of the e-MUST Registry Investigators is shown in the Appendix.
KEYWORDS
• mortality
• myocardial
infarction
• time to reperfusion
• women
Abstract
Aims: The mortality rate in patients with STEMI is higher in women than in men. This higher mortality
rate is partly accounted for by certain known characteristics inherent in the female population (age, diabetes). Using data from the e-MUST registry on STEMI patients in the Greater Paris area, we assessed the
differences between men and women treated with reperfusion strategies.
Methods and results: Patients presenting within 24 hours of pain onset between 2006 and 2010 were
included in the study. The male and female subpopulations were compared according to their baseline characteristics, their management delays and their early outcomes. Five thousand eight hundred and forty males
(78.9%) and 1,557 females (21.1%) were included in the study. In-hospital mortality was significantly
higher in women than in men, 143 (9.4%) vs. 254 (4.4%), p<0.0001, with a longer time to treatment initiation, symptoms to call (2.7±3.6 vs. 2.2±3.4 hours, p<0.0001), symptoms to first medical contact (FMC)
(3.1±3.7 vs. 2.6±3.4 hours, p<0.0001), and call to FMC (25.6±23.5 vs. 23.6±18.3 min, p=0.02). After
adjustment for clinical factors, severity criteria, myocardial infarction (MI) location and delays, mortality
remained higher in women than in men with an odds ratio of 1.40 [1.06-1.84], p=0.017.
DOI: 10.4244/EIJV12I5A93
Conclusions: We demonstrated longer pre-hospital delays and higher in-hospital mortality in women. The
increase in the time to treatment alone does not completely explain the persistent increase in mortality.
Further studies, public awareness programmes and physician education are necessary to reduce delays and
improve the prognosis of STEMI in women.
*Corresponding author: European Hospital of Paris - La Roseraie, 120 avenue de la République, 93300 Aubervilliers, France.
E-mail: h.benamer@icps.com.fr
© Europa Digital & Publishing 2016. All rights reserved.
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SUBMITTED ON 10/09/2015 - REVISION RECEIVED ON 26/01/2016 - ACCEPTED ON 15/04/2016
Longer delays and higher mortality in women in STEMI
In patients presenting with ST-elevation myocardial infarction (STEMI), reduced time to treatment initiation and reperfusion (thrombolysis or primary percutaneous coronary intervention
[pPCI]) have been shown to improve survival significantly. Rescue
and adjunctive PCI are effective therapies after thrombolytic
therapy1,2. Studies of sex differences in mortality after myocardial infarction (MI) have consistently indicated that women have
higher death rates, especially in short-term follow-up. The differences in baseline and procedural characteristics, such as more
advanced age, a higher percentage of diabetics and cardiogenic
shock, cannot wholly explain the discrepancy in outcome3. Late
presentation and a lower rate in the use of reperfusion therapy may
account for increased mortality.
The purpose of this study was to evaluate differences in the
therapeutic management of females and males prior to their admission to a cardiology unit for thrombolysis and/or coronary angioplasty, and to assess the average time to treatment implementation
and the impact of the delays on the prognosis using data from
a prospective pre-hospital management registry of patients with
STEMI of less than 24 hours managed by mobile intensive care
units (MICU) in the Greater Paris area.
Editorial, see page 536
driver on board. If a diagnosis of STEMI is confirmed by the physician on-site, the patient is transferred to the cathlab, with or
without pre-hospital thrombolysis4.
POPULATION
Patients initially managed by MICUs and presenting with a STEMI
with a time delay of less than 24 hours between pain onset and
first medical contact (FMC) were included in the analysis. For the
purposes of the analysis they were divided according to gender.
EuroIntervention 2016;12:e 542- e 549
Introduction
STATISTICAL ANALYSIS
Data were summarised as means (standard deviation) or median
(interquartile interval) where appropriate for continuous variables
and percentages for categorical variables. Men and women’s data
were compared using the χ² test or Fisher’s exact test for categorical
variables and the Wilcoxon rank-sum test for continuous variables.
We assessed whether gender was an independent risk of in-hospital
mortality by performing a step-by-step multivariate logistic regression successfully adjusted for age, cardiovascular risk factors,
severity criteria, myocardial infarction (MI) location and delays.
Statistical analysis was performed using SAS statistical software,
version 9.3 (SAS Institute Inc., Cary, NC, USA). A p-value <0.05
was considered as statistically significant. Tests were two-sided.
Methods
Results
DATA SOURCE
Our data were collected between 2006 and 2010 from the e-MUST
registry, a prospective multicentre registry from the Regional
Health Agency of the Greater Paris Area (ARSIF), which includes
all patients presenting within 24 hours of an acute STEMI and
who were managed by MICUs. All MICU departments of the
Greater Paris area took part in this study and enrolled the patients
consecutively.
The Greater Paris area is the most populated region of France
(11.7 million inhabitants). The emergency physician on site fills
in the patient’s medical form on presentation, then adds data on
in-hospital outcomes (time of angioplasty when applicable, death
and early complications). In-hospital mortality is cross-checked
using another hospital database (PMSI). The database is sent to the
ARSIF registry department every four months. An external audit
was carried out every year in every centre to assess the quality and
the completeness of the database. Random selection of patient files
was performed over a two-week period with the aim of checking
the records of patients admitted for chest pain. The auditors verified that patients presenting with STE-ACS were duly included
in the registry. The exhaustiveness of the registry exceeded 90%.
MICUs are special French medical emergency systems. A dispatch centre centralises emergency medical calls via a dedicated
telephone number (which is the number 15) and organises an
appropriate response with the intention of ensuring the shortest
delay between the initial call and the appropriate treatment. In the
event of an emergency medical call for chest pain, the medical
dispatcher sends a MICU with a physician, a nurse, and a trained
From 2006 to 2010, 10,362 patients with STEMI within 24 hours
after onset of chest pain were identified in our database. We
excluded 2,361 patients who were transferred from another hospital for rescue or primary angioplasty and 604 patients without reperfusion strategy (7.5%). The rate of no reperfusion therapy was
10.4% in women and 5.7% in men (p<0.0001). We included in
the study 7,397 patients with primary reperfusion therapy, 1,557
(21.1%) women and 5,840 (78.9%) men.
Clinical data and severity criteria are shown in Table 1. Clinical
predictors of worse clinical outcome such as old age, diabetes
mellitus or cardiogenic shock were significantly higher in women.
The description of the call to the dispatch centre and the delays
before the call are shown in Table 1. A significantly longer delay
before calling with an increased delay of onset of chest pain to
FMC was noted in women. The median delay between symptoms
to call and symptoms to FMC was also significantly increased in
women (Figure 1, Figure 2).
The reperfusion strategy and the in-hospital mortality are
described in Table 1. Reperfusion is performed significantly less
in the female population. Thrombolytic therapy was administered
significantly less often in women.
A worse in-hospital outcome in women was noted with a higher
mortality rate than in men (9.4% versus 4.4%, p<0.0001).
Multivariate analysis, including step-by-step, age, cardiovascular risk factors (personal history of CAD, family history of
CAD, smoking, diabetes, hypertension, dyslipidaemia, obesity),
severity criteria (cardiac arrest, catecholamine use or heart failure Killip class III or IV), MI location and delays (symptoms to
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EuroIntervention 2016;12:e 542- e 549
Table 1. Descriptive data.
Men (N=5,840)
Women (N=1,557)
p-value
Age, mean (SD)
Age (years)
59.5 (13.0)
69.6 (14.5)
<0.0001
History and
cardiovascular
risk factors, n (%)
Personal history of CAD
1,101 (19.6)
230 (15.4)
0.0002
Family history of CAD
1,101 (19.6)
282 (18.8)
Smoking
3,364 (60.0)
513 (34.2)
Diabetes
823 (14.7)
251 (16.8)
0.046
Hypertension
2,037 (36.3)
830 (55.4)
<0.0001
Dyslipidaemia
2,106 (37.6)
506 (33.8)
0.007
Obesity
1,446 (25.8)
374 (24.9)
0.51
357 (5.8)
127 (7.5)
56 (1.0)
11 (0.7)
Anterior
2,673 (45.8)
722 (46.4)
Inferior
2,795 (47.9)
715 (45.9)
372 (6.4)
120 (7.7)
No risk factors
Information not available
MI location, n (%)
Unidentified
Severity criteria, n (%)
0.35
0.11
Heart failure (Killip class III or IV)
169 (2.9)
70 (4.5)
0.001
214 (3.7)
72 (4.6)
0.08
715 (12.2)
185 (11.9)
0.70
Cardiac arrest
330 (5.7)
81 (5.2)
0.49
IOT/VC
189 (3.2)
57 (3.7)
0.41
3,651 (62.5)
942 (60.5)
724 (12.4)
254 (16.3)
Patient or parent
General practitioner
Cardiologist
Fireman
Other
Delays, median (Q1-Q3)
0.004
Catecholamine use
Rhythm disorder or conduction
Person calling the
dispatch centre, n (%)
0.4
<0.0001
122 (2.1)
53 (3.4)
1,187 (20.3)
259 (16.6)
<0.0001
156 (2.7)
49 (3.1)
Symptoms to call (hours)
0.9 [0.4-2.4]
1.3 [0.5-3.3]
<0.0001
Symptoms to FMC (hours)
1.3 [0.8-2.8]
1.8 [1.0-3.8]
<0.0001
20 [14-27]
20 [14-30]
Call to FMC (minutes)
0.02
Reperfusion strategy,
n (%)
Pre-hospital thrombolysis
1,113 (19.1)
188 (12.1)
Primary PCI
4,727 (80.9)
1,369 (87.9)
Delays to treatment,
median (Q1-Q3)
FMC to pre-hospital thrombolysis (minutes) (for
pre-hospital thrombolysis patients)
25 [20-34]
28 [21-35]
0.0159
FMC to guide (minutes) (for primary PCI patients)
<0.0001
Other treatments
91 [77-109]
97 [82-115]
IV nitrates
748 (12.8)
209 (13.4)
0.5
Analgesic
3,233 (55.4)
840 (53.9)
0.3
107 (1.8)
27 (1.7)
0.8
UFH
3,888 (66.6)
1,083 (69.6)
LMWH
1,534 (26.3)
334 (21.4)
Aspirin
5,490 (94.0)
1,448 (93.0)
0.14
Clopidogrel
4,124 (72.1)
1,027 (67.2)
0.0002
GP IIb/IIIa inhibitors
1,003 (17.2)
231 (14.8)
Other anti-aggregate
60 (1.0)
17 (1.1)
254 (4.4)
143 (9.4)
Beta-blockers
Hospital outcome, n (%)
<0.0001
Hospital death
0.026
0.0001
0.03
0.8
<0.0001
CAD: coronary artery disease; FMC: first medical contact; GP IIb/IIIa inhibitors: glycoprotein IIb/IIIa receptor inhibitors; IOT/VC: orotracheal intubation/
mechanical ventilation; IV: intravenous; LMWH: low molecular weight heparin; MI: myocardial infarction; PCI: percutaneous coronary intervention;
QI and Q3: 1st quartile and 3rd quartile; SD: standard deviation; UFH: unfractionated heparin
call [five groups: 0’-30’-60’-90’-120’->120’] and call to FMC
[four groups 0’-15’-30’-60’->60’]), showed a persistent but less
significant increase of mortality in women (Table 2).
Discussion
In-hospital mortality of patients with STEMI treated by a pre-hospital medical system was significantly higher in women than in men:
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4.4% vs. 9.4%, p<0.0001. Pre-hospital delays and time to treatment initiation were significantly longer: symptoms to call (2.7±3.6
vs. 2.2±3.4 hours, p<0.0001); symptoms to FMC (3.1±3.7 vs.
2.6±3.4 hours, p<0.0001), call to FMC (25.6±23.5 vs. 23.6±18.3 min,
p=0.02). After adjustment for age, cardiovascular risk factors, severity criteria, MI location and delays, mortality remained higher in
women than in men with an odds ratio of 1.40 [1.06-1.84], p=0.017.
Longer delays and higher mortality in women in STEMI
40
30
20
30
20
10
10
0
0
0
500
1,000
0
1,500
The higher mortality rate in women with acute STEMI has been
widely reported3,5-7. The multivariate analysis carried out in our
previously reported study showed that higher hospital mortality
persists even after eliminating the numerous confounding factors
inherent in this population5 .
Previous studies have suggested that a lower use of pPCI is
a major cause of the increased mortality noted in women. Milcent
et al studied data extracted from a French national health payment database8. All hospital admissions in France with a discharge diagnosis of acute myocardial infarction were extracted
from the database. Women were older (75 vs. 63 years of age;
p<0.001) and had a higher rate of hospital mortality (14.8% vs.
6.1%; p<0.0001) than men. Percutaneous coronary interventions
were more frequent in men (7.4% vs. 4.8%; 24.4% vs. 14.2% with
stent; p<0.001). Mortality adjusted for age and comorbidities was
higher in women (p<0.001), with an excess adjusted absolute mortality of 1.95%. Simulation models related 0.46% of this excess to
reduced use of procedures. The survival benefit related to percutaneous coronary intervention was lower among women. Similar
results were observed in the Swiss Registry in which women were
500
1,000
1,500
Minutes between symptoms to call
Minutes between symptoms to FMC
Figure 1. Frequency distribution and box plot of median delays
between symptoms to call by gender. Q1 and Q3 (1st quartile and 3rd
quartile). Men are represented in blue, and women are represented in
red. Curves represent non-parametric kernel density estimate. Box
plot indicates the median, upper and lower quartiles (lines), mean
(diamond), 1.5 interquartile range (whiskers) and outliers (“+”
markers).
Median (Q1-Q3)
Men
55 (23-142)
Women 77 (30-199)
40
Percent
Percent
50
Median (Q1-Q3)
Men
79 (45-169)
Women 105 (57-230)
EuroIntervention 2016;12:e 542- e 549
50
Figure 2. Frequency distribution and box plot of median delays
between symptoms to first medical contact (FMC) by gender. Men
are represented in blue, and women are represented in red. Curves
represent non-parametric kernel density estimate. Box plot indicates
the median, upper and lower quartiles (lines), mean (diamond), 1.5
interquartile range (whiskers) and outliers (“+” markers).
older with a higher rate of comorbidities, a longer time to treatment implementation and less coronary angioplasty (odds ratio
0.65 [0.61-0.69])9. In-hospital mortality was higher (10.7% vs.
6.3%, p<0.001), even in patients undergoing primary angioplasty
(4.2% vs. 3.0%, p<0.018). In the New York registry of 11,162
males and 2,561 females under 50 years of age who underwent
primary angioplasty for treatment of acute coronary syndrome
(ACS) with STEMI, female gender was found to be an independent risk factor of in-hospital mortality10, although the PCI success
rate was comparable in both genders. It is to be noted, however,
that the use of GP IIb/IIIa inhibitors and stents was lower in the
female group (58.6% vs. 65.1%, p<0.0001, and 92.5% vs. 94.9%,
p<0.0001, respectively).
In contrast, in our study pPCI was used more often as a reperfusion therapy compared to thrombolysis. All patients were triaged by a pre-hospital physician. Coronary angiography followed
if necessary by pPCI may have been preferred in women in this
setting due to uncertainty in the diagnosis of STEMI or fear of
bleeding complications, which are both more frequent in women5.
However, despite a higher use of pPCI, in-hospital survival was
lower in women.
Table 2. Step-by-step multivariate analysis for in-hospital mortality in women.
N
OR [95% CI]
p-value
M1: Unadjusted
Model
7,213
2.13 [1.73-2.63]
<0.0001
M2: M1+age, cardiovascular risk factors, severity criteria*
6,915
1.45 [1.11-1.89]
0.0067
M3: M2+MI location
6,915
1.46 [1.12-1.91]
0.0054
M4: M3+delays
6,737
1.40 [1.06-1.84]
0.017
M1 to M4 are models 1 (M1) to 4 (M4); each additional model is adjusted on the variables of the previous model + the additional specified variable.
*Age, cardiovascular risk factors (personal history of CAD, family history of CAD, smoking, diabetes, hypertension, dyslipidaemia, obesity), severity
criteria (cardiac arrest, catecholamine use, heart failure Killip class III or IV). CAD: coronary artery disease; MI: myocardial infarction; OR: odds ratio
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In our previous study5, we analysed in-hospital data in women
with STEMI. A longer delay in the implementation of reperfusion was suggested as a cause for the higher mortality reported
in women. The current study integrated data from the pre-hospital
phase, including delays before hospital admission. A longer delay
between chest pain onset and the first call to an emergency unit
was clearly evidenced in women. This delay is probably due to an
underestimation of symptoms which are often considered atypical
in this population. It seldom occurs to female patients and their
families that the symptoms are related to STEMI, which requires
urgent care. Consequently, as reported in our study, women tend
to contact their GP or a cardiologist rather than use the dedicated
phone number for medical emergencies, which would shorten
delays to hospital admission and reperfusion. Our study also
demonstrated that, once the first contact has been made, the time
elapsed before female patients receive medical attention is also
longer. In a Spanish study in which patients were matched by age,
no difference was found by gender in the time to seeking healthcare11. In contrast, most studies performed to date have reported
longer delays in women12,13.
Longer delays in the management of patients with acute STEMI
are associated with excess mortality: each additional minute
elapsed before treatment initiation increases the mortality rate1416
. The impact of time is even more significant at the onset of
symptoms14. Reperfusion strategies are more efficient when they
are initiated as early as possible.
One very interesting study published by Pelletier et al showed
that, among younger adults (n=1,123 patients [18-55 years]) with
ACS, women and men had different access to care. Women were
less likely than men to receive care within benchmark times for
electrocardiography (≤10 min: 29% vs. 38%, p=0.02) or fibrinolysis (≤30 min: 32% vs. 57%, p=0.01). Women with STEMI
were less likely than men to undergo reperfusion therapy (pPCI
or fibrinolysis) (83% vs. 91%, p=0.01). Clinical determinants
of poorer access to care included anxiety, increased number of
risk factors and absence of chest pain. Gender-related determinants included feminine traits of personality and responsibility
for housework17. Among the clinical determinants of procedure
delays, anxiety was associated with failure to meet the 10-minute
benchmark for ECG in women but not in men. Patients with anxiety who present to the emergency department with non-cardiac
chest pain tend to be women, and the prevalence of ACS is lower
among young women than among young men. These findings suggest that triage personnel might initially dismiss a cardiac event
among young women with anxiety, which would result in a longer
door-to-ECG interval
In our study, adjustment for delays in treatment reduced the OR
for mortality in women versus men but only by 0.4 (model 3 to
model 4). Consequently, delays in treatment implementation seem
to account only partially for the higher mortality rate observed in
women.
Differences in the physiopathology of STEMI between men and
women have been suggested to explain this increased mortality.
Because oestrogen has protective effects on the cardiovascular system18, women’s myocardium may be more vulnerable to
abrupt ischaemia19. A higher occurrence of plaque rupture in men
and more frequent plaque erosions with microvascular embolisation in women have been reported20. Moreover, young women
share a significantly lower plaque burden and amount of necrotic
core than men, but have significantly higher microvascular coronary and cardiac endothelial dysfunction21,22. In women, the rate
of spontaneous coronary artery dissection (SCAD) is higher than
in men. Vanzetto et al reported a very interesting study and concluded that, although SCAD is an uncommon disease in the general population, especially in men, it may be responsible for more
than 10% of ST-elevation ACS in women below 50 years of age23.
Contrary to what is usually thought, this disease does not exclusively affect younger women in the peripartum period, or those
carrying inflammatory or collagen disease, but can also be seen
in middle-aged females with one or more cardiovascular risk factors. The use of intraluminal imaging devices will probably result
in a higher rate of SCAD and intraparietal haematoma being
highlighted in this population24. The pathophysiology of SCAD
probably involves the formation of an intramural haematoma on
the basis of constitutional or acquired arterial wall fragility and
mechanical stress, with a risk of longitudinal and axial extension
with true lumen compression and possibility of intimal rupture24.
The initial treatment of SCAD is not standardised, and the use of
antithrombotic and antiplatelet therapy has not been clearly established in this setting23,24. This difference in the physiopathology
could partially explain the prognostic difference between women
and men.
Our results suggest that public awareness programmes focused
on women could improve the outcome of STEMI in this population. Women must be made aware that symptoms such as
chest pain and shortness of breath can be indicative of STEMI
and require a call to an emergency medical system (EMS) in
order to reduce delays to treatment. Puymirat et al demonstrated
a striking reduction in STEMI mortality in the French USIC and
FAST-MI registries between 1995 and 2010. However, there was
an increase in the proportion of women younger than 60 years
with STEMI25. In addition, Juliard et al demonstrated for STEMI
<6 hours that gender was correlated with hospital mortality in
the subgroup of women aged >65 years26. This difference, which
was found to be more pronounced in older women, was also
demonstrated in the publication by Corrada et al27. Physicians
must therefore also be educated to detect symptoms suggesting a STEMI in women. As stated in the paper by Weissler-Snir
et al, greater efforts should be devoted to increasing women’s
awareness of cardiac symptoms during the pre-hospital course
of STEMI28.
Limitations
Partial clinical data were entered in the database. This approach
was chosen to facilitate external audits and to obtain a high rate of
patients with complete and reliable data.
Longer delays and higher mortality in women in STEMI
Conclusion
In conclusion, using data from a pre-hospital registry on STEMI
in the Greater Paris area, we demonstrated longer pre-hospital
delays and higher in-hospital mortality in women. The increase
in the time to treatment impacted on the prognosis but this factor alone does not explain the persistently higher mortality rate
reported in female patients. Further studies, public awareness programmes and physician education are necessary to reduce delays
and improve the prognosis of STEMI in women.
Impact on daily practice
Emergency physicians and interventional cardiologists must be
aware of the increase in early pre-hospital delays and higher inhospital mortality in STEMI in women in order to improve management of chest pain in women. Public education programmes
targeting women are necessary. STEMI in-hospital mortality can
probably be further reduced by lowering vascular complications
with an increased use of the radial approach and tailored management of antithrombotic and anticoagulant treatment.
Funding
Funding of this registry was provided entirely by the Regional
Health Agency of the Greater Paris Area (ARSIF), a French
Government Agency.
Conflict of interest statement
The authors have no conflicts of interest to declare.
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– Although not analysed in the present study, the characteristics
of typical vs. atypical chest pain could partly explain the variations in the delays between calls and management of patients
with ACS.
– Comorbidities such as renal insufficiency and pathologies of the
higher functions which are potentially more frequent in elderly
patients and may influence the outcome were not recorded in
our study.
– When this study was carried out, new-generation thienopyridine
agents were less widely used than today. This may have influenced the outcomes of the female as well as the male patients.
– Medical treatments associated with coronary reperfusion such
as aspirin, statins and beta-blockers were not compared in the
present study.
– Criteria of angiographic complexity and the types of stent
implanted were not recorded in this study.
Follow-up was limited to the hospital stay. 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.
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Time delay to treatment and mortality in primary angioplasty for
acute myocardial infarction: every minute of delay counts.
Circulation. 2004;109:1223-5.
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Hoorntje JC, Dambrink JH, Gosselink AT, Ottervanger JP, Zijlstra F.
Prognostic assessment of patients with acute myocardial infarction
treated with primary angioplasty: implications for early discharge.
Circulation. 2004;109:2737-43.
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18. Mendelsohn ME, Karas RH. The protective effects of estrogen
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with myocardial infarction. Am J Epidemiol. 1984;119:610-23.
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(WISE) Study: Part I: gender differences in traditional and novel
risk factors, symptom evaluation, and gender-optimized diagnostic
strategies. J Am Coll Cardiol. 2006;47:S4-S20.
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Appendix. Main investigators of the e-MUST
Registry (hospitals, emergency physicians and
public health physicians)
CH François Quesnay (Mantes la Jolie): Dr Goldman,
Dr Hazan, Dr Hoffman, Dr Pasquereau, Dr Viso; Dr Meyer; CH
Robert Ballanger (Aulnay sous Bois): Dr Biens, Dr Charestan,
Dr Mezard, Dr Raphaël; Dr Benaceur, Dr Guerout; CH Simone Veil
(Eaubonne): Dr Belotte, Dr Lefevre, Dr Monfroy, Dr Pouradier,
Dr Peyron Fourcade; CH Sud Francilien (Corbeil-Essonnes):
Dr Briole, Dr Capitani, Dr Desclefs, Dr Laborne, Dr Pouges,
Dr Roignant; Dr Cabo, Dr Lairy; CH Victor Dupouy (Argenteuil):
Dr Cuvier; Dr Chevalier; CH d’Etampes (Etampes): Dr Benaicha,
Dr Gaffinel, Dr Jeufraux, Dr Nguyen, Dr Pone; Dr Mirolo; CH
de Coulommiers (Coulommiers): Dr Compagnon; Dr Echard;
CH de Fontainebleau (Fontainebleau): Dr Fossay, Dr Grippon;
Dr Bicharzon; CH de Gonesse (Gonesse): Dr Birlouez,
Dr Sebbah, Dr Thevenin; Dr Desrues, Dr Hakim; CH de Juvisy
sur Orge (Juvisy sur Orge): Dr Aubert, Dr Clavie, Dr Ducommun,
Dr Faggianelli, Dr Schvahn; Dr Pillant; CH de Longjumeau
(Longjumeau): Dr Coudray, Dr Hautefeuille, Dr Rousseau, Dr Ta;
Dr Solvignon; CH de Marne la Vallée (Jossigny): Dr Mathieu,
Dr Porcher, Dr Stibbe; Dr Echard; CH de Meaux (Meaux):
Dr Bouvet, Dr Goes, Dr Limoges; Dr Echard; CH de Melun
(Melun): Dr Letarnec, Dr Rebillard, Dr Tazarourte; Dr Luquet; CH
de Montereau (Montereau): Dr Amokrane, Dr Cadot; Dr Derosin;
CH de Nemours (Nemours): Dr Coletta, Dr Demiere; Dr Narcisse;
CH de Provins (Provins): Dr D’Araujo, Dr Roy, Dr Tarlier;
Dr Drevillon; CH de Rambouillet (Rambouillet): Dr Chevrier,
Dr Clero, Dr Lederlin; CH de Versailles (Le Chesnay): Dr Boutot,
Dr Lambert, Dr Moro, Dr Richard, Dr Sammut; Dr Jourdan,
Dr Vinas; CH du Dr Delafontaine (Saint-Denis): Dr Hennequin;
Dr Heurte; CH d’Arpajon (Arpajon): Dr Bensalem, Dr Rivoal,
Longer delays and higher mortality in women in STEMI
Dr Ernouf, Dr Lefort, Dr Mlynski; BSPP G3 Plessis-Clamart
(Clamart): Dr Bon, Dr Culoma, Dr Maurin, Dr Rivet; BSPP
Service Médical d’Urgence (Paris): Dr Domanski, Dr Jost,
Pr Tourtier; CH André Grégoire (Montreuil): Dr Menguy; CMC
Foch (Suresnes): Dr Leclerc; CMC Marie Lannelongue (Le Plessis
Robinson): Dr Vallet; CMC Parly 2 (Le Chesnay): Dr Baget,
Dr Debris, Dr de Livron; Centre Cardiologique d’Evecquemont
(Evecquemont): Dr Herman; Clinique Alleray Labrouste (Paris):
Dr Herman, Dr Pioger; Clinique Ambroise Paré (Neuilly sur Seine):
Dr Bucquoit; Clinique Bizet (Paris): Dr Housni, Dr Rousseau;
Clinique Cardiologique du Nord (Saint-Denis): Dr Carradot;
Clinique Turin (Paris): Dr Gueyouche, Dr Leminou, Dr Morange;
Clinique les Fontaines (Melun): Dr Grandcoin; Hôpital Ambroise
Paré (Boulogne Billancourt): Dr Lot; Hôpital Américain de Paris
(Neuilly sur Seine): Dr Richard; Hôpital Bichat-APHP (Paris):
Dr Buzzi, Dr Deoliveira, Dr Gardesse, Dr Lê-leplat; Hôpital
Cochin-APHP (Paris): Dr Dreau, Dr Frenkiel; Hôpital Européen
Georges Pompidou-APHP (Paris): Dr Heudes, Dr Karafilovic,
Pr Chatellier; Hôpital Européen de Paris - La Roseraie (Aubervilliers): Dr Allouch, Dr Lebovisci; Hôpital Privé d’Antony
(Antony): Dr Gedin; Hôpital Saint-Joseph (Paris): Dr Gaillard,
Dr Rejasse; Hôpital Tenon-APHP (Paris): Dr Lukacs; Hôpital
d’Instruction des Armées du Val de Grace (Paris): Dr Romary;
Institut Cardiovasculaire Paris Sud - Claude Galien (Quincy
sous Sénart): Dr Servigne, Dr Vollaire; Institut Cardiovasculaire
Paris Sud - Jacques Cartier (Massy): Dr Cohen-Attia, Dr Gedin,
Dr Lequeu, Dr Vollaire; Institut Mutualiste Montsouris (Paris):
Dr Gayer, Dr Germain.
EuroIntervention 2016;12:e 542- e 549
Dr Touitou, Mme Rodriguez; Dr Durand; CH d’Orsay
(Orsay): Dr Alayrac, Dr Hellio, Dr Nunes; Dr Manet; CHI Le
Raincy-Montfermeil (Montfermeil): Dr Beruben, Dr Cavagna,
Dr Kergueno; Dr Hennion, Dr Lesgourgues; CHI Poissy-Saint
Germain en Laye (Poissy): Dr Getti, Dr Lefevre, Dr Ramaut,
Dr Ruiz; Dr Lellouch, Dr Razafimamonjy; CHI de Villeneuve
Saint Georges (Villeneuve Saint Georges): Dr Auger, Dr Bergeron,
Dr Meinadier, Dr Tshisumbule; Dr Casciani; CHI des Portes de
l’Oise (Beaumont): Dr Binda, Dr Le Foll-Llanas, Dr Rakotonirina;
Dr Bertiaux; Hôpital Avicenne-APHP (Bobigny): Dr Lenoir,
Pr Adnet, Pr Lapostolle; Dr Duclos; Hôpital Beaujon-APHP
(Clichy): Dr Devaud, Dr Duchateau, Pr Mantz; Dr Bendersky;
Hôpital Henri Mondor-APHP (Créteil): Dr Aurore, Dr Bertrand,
Dr Boche, Dr Goldstein, Dr Jacob, Dr Ladka, Dr Penet, Pr Marty;
Dr Hemery; Hôpital Hôtel Dieu-APHP (Paris): Dr Boizat,
Dr Bourgeois, Dr Eche, Dr Kierzek, Dr Sahakian, Pr Pourriat;
Dr Bouam; Hôpital Lariboisière-APHP (Paris): Dr Chaplain,
Dr Gueye, Dr Payen; Dr Brechat, Dr Lebrun, Dr Segouin;
Hôpital Necker-APHP (Paris): Dr Greffet, Dr Jaffry, Dr Lamhaut,
Pr Carli; Dr Le Bihan-Benjamin; Hôpital Pitié-SalpétrièreAPHP (Paris): Dr Boon, Dr Delay, Dr Ecollan, Dr Kergueno;
Dr Rufat, Pr Baudelou; Hôpital Raymond Poincaré-APHP
(Garches): Dr Baer, Dr Cahun-Giraud, Dr Goddet, Dr Lebail;
Dr Maillard; Hôpital Saint-Antoine-APHP (Paris): Dr Bourquard,
Dr Brard; Dr Boule, Dr Marty; Hôpital de Pontoise (Pontoise):
Dr Boukacem, Dr Dupas, Dr Giroud, Dr Ricard-Hibon; Dr Decup;
BSPP G1 Montreuil (Montreuil): Dr Bartou, Dr Caballe,
Dr Courtiol, Dr Ramdani, Dr Violin; BSPP G2 Vitry (Vitry):
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