Gender-Specific Ambulance Priority and Delays to Primary PCI
Gender-Specific Ambulance Priority and Delays to Primary PCI
The present study indicates that men and women presenting with STEMI are similar with regard to presenting symptoms, history, and clinical findings. Despite this, women tend to have longer overall ischemic delay and lower priority for emergent ambulance service after calling an EMC center.
It is commonly believed that women with AMI present differently than men. However, recent studies as well as a systematic comprehensive review of gender-specific symptoms in acute coronary syndromes (ACS) showed no significant differences in presentation. Typical cardiac symptoms are the strongest predictors of ACS in women, and atypical symptoms are equally common in both men and women. Many of these studies have, however, limitations. Most are retrospective studies based on review of medical records and often do not record other symptoms than chest pain and are therefore prone to recall bias. Lack of standardization in the collection and recording of symptoms and in the AMI definition and classification complicates the interpretation of the studies. Most studies include a mix of STEMI, non-STEMI ACS, and patients with non-ACS chest pain.
The strength of the present study is that we had detailed first-hand account of presenting symptoms, detailed chronology, medical history, and interventional data on all patients. The study population was highly symptomatic and included many high-risk patients. Our findings suggest that men and women with STEMI have similar presentations and do not provide evidence that women present with a constellation of symptoms other than chest pain more often than men. Women in our study, in fact, reported chest discomfort as the initial symptom in STEMI more often than men. More pronounced symptoms in some women may be due to longer delays before calling the EMC center.
Acute myocardial infarction patients' delays are still long despite widespread availability of mobile phones and easily accessible EMC services in most health care services. In the relatively few studies investigating the causes of treatment delays in AMI, which include gender, delays are longer in women. In particular, women with STEMI still have longer process-related delays and less revascularization therapy compared with men, which is associated with excess early mortality. Factors contributing to shorter delays for men on both the patients' and the caretakers' side have been ascribed to men feeling more vulnerable to suffer AMI, are more sensitive to somatic changes, or have a generally higher perceived threat from illness. In our study of STEMI patients, in a region with good ambulance capacity and short transport distances, we did not detect a gender-specific system time delay for women. The most common reason for longer total ischemic time in women was delays in contacting the EMC service (Figure).
Significantly less women than men were given the highest priority for ambulance by the dispatchers. This may indicate that the EMC dispatchers more often had difficulties in reaching action decisions in women. However, in this STEMI population, clinical features and presentation were very much alike for both gender, and it raises the possibility of also a gender-specific bias in ambulance priority.
Previous campaigns to increase the public use of EMC services in medical emergencies have not been successful. The proportion of patients with STEMI calling the EMC varies from 10% to 56%, and efforts to increase the proportion have been difficult to sustain over time. Aside of this, it is important to increase the sensitivity and specificity of the dispatch and avoid gender biases in system processes. Overall, in our study, use of a structured criteria-based dispatch system seemed to increase the performance of dispatching in STEMI patients. Utilization of a structured dispatch system should, therefore, be encouraged when patients with suspected heart disease call the EMC service. Furthermore, our findings indicate that there is no need to include gender as a criterion to identify an STEMI emergency call.
Study Limitation. In our consecutive series of STEMI patients presenting to a single primary PCI-enabled hospital, only patients who called the EMC service directly were included. This resulted in a relatively small sample, especially for women. The study period ran from 2004, but the same EMC service logistics and organization apply today. This study only compares symptomatic STEMI patients. Women are known to more often have silent or unrecognized AMI.
Although EMC dispatch services are widespread, cultural differences and differences in the organization of health services imply that Norwegian conditions cannot simply be said to be representative for other countries.
Discussion
The present study indicates that men and women presenting with STEMI are similar with regard to presenting symptoms, history, and clinical findings. Despite this, women tend to have longer overall ischemic delay and lower priority for emergent ambulance service after calling an EMC center.
Gender-specific Symptoms in STEMI
It is commonly believed that women with AMI present differently than men. However, recent studies as well as a systematic comprehensive review of gender-specific symptoms in acute coronary syndromes (ACS) showed no significant differences in presentation. Typical cardiac symptoms are the strongest predictors of ACS in women, and atypical symptoms are equally common in both men and women. Many of these studies have, however, limitations. Most are retrospective studies based on review of medical records and often do not record other symptoms than chest pain and are therefore prone to recall bias. Lack of standardization in the collection and recording of symptoms and in the AMI definition and classification complicates the interpretation of the studies. Most studies include a mix of STEMI, non-STEMI ACS, and patients with non-ACS chest pain.
The strength of the present study is that we had detailed first-hand account of presenting symptoms, detailed chronology, medical history, and interventional data on all patients. The study population was highly symptomatic and included many high-risk patients. Our findings suggest that men and women with STEMI have similar presentations and do not provide evidence that women present with a constellation of symptoms other than chest pain more often than men. Women in our study, in fact, reported chest discomfort as the initial symptom in STEMI more often than men. More pronounced symptoms in some women may be due to longer delays before calling the EMC center.
Ambulance Priority and Delays to Therapy
Acute myocardial infarction patients' delays are still long despite widespread availability of mobile phones and easily accessible EMC services in most health care services. In the relatively few studies investigating the causes of treatment delays in AMI, which include gender, delays are longer in women. In particular, women with STEMI still have longer process-related delays and less revascularization therapy compared with men, which is associated with excess early mortality. Factors contributing to shorter delays for men on both the patients' and the caretakers' side have been ascribed to men feeling more vulnerable to suffer AMI, are more sensitive to somatic changes, or have a generally higher perceived threat from illness. In our study of STEMI patients, in a region with good ambulance capacity and short transport distances, we did not detect a gender-specific system time delay for women. The most common reason for longer total ischemic time in women was delays in contacting the EMC service (Figure).
Significantly less women than men were given the highest priority for ambulance by the dispatchers. This may indicate that the EMC dispatchers more often had difficulties in reaching action decisions in women. However, in this STEMI population, clinical features and presentation were very much alike for both gender, and it raises the possibility of also a gender-specific bias in ambulance priority.
Previous campaigns to increase the public use of EMC services in medical emergencies have not been successful. The proportion of patients with STEMI calling the EMC varies from 10% to 56%, and efforts to increase the proportion have been difficult to sustain over time. Aside of this, it is important to increase the sensitivity and specificity of the dispatch and avoid gender biases in system processes. Overall, in our study, use of a structured criteria-based dispatch system seemed to increase the performance of dispatching in STEMI patients. Utilization of a structured dispatch system should, therefore, be encouraged when patients with suspected heart disease call the EMC service. Furthermore, our findings indicate that there is no need to include gender as a criterion to identify an STEMI emergency call.
Study Limitation. In our consecutive series of STEMI patients presenting to a single primary PCI-enabled hospital, only patients who called the EMC service directly were included. This resulted in a relatively small sample, especially for women. The study period ran from 2004, but the same EMC service logistics and organization apply today. This study only compares symptomatic STEMI patients. Women are known to more often have silent or unrecognized AMI.
Although EMC dispatch services are widespread, cultural differences and differences in the organization of health services imply that Norwegian conditions cannot simply be said to be representative for other countries.
Source...