GSBS Dissertations and Theses

Approval Date

5-7-2010

Document Type

Doctoral Dissertation

Department

Graduate School of Biomedical Sciences, Clinical and Population Health Research Program

Keywords

Acute myocardial infarction, pre-hospital delay, evidence-based treatment, hospital complications, hospital mortality, 30-day mortality, age and sex differences

Subjects

Health Knowledge, Attitudes, Practice; Healthcare Disparities; Myocardial Infarction; Acute Coronary Syndrome; Age Factors; Sex Factors; Patient Acceptance of Health Care; Hospital Mortality; Transportation of Patients; Dissertations, UMMS

Abstract

Background
The prompt seeking of medical care after the onset of symptoms suggestive of acute coronary syndromes (ACS)/acute myocardial infarction (AMI) is associated with the receipt of coronary reperfusion therapy, and effective cardiac medications in patients with an ACS/AMI and is crucial to reducing mortality and the risk of serious clinical complications in these patients. Despite declines in important hospital complications and short-term death rates in patients hospitalized with an ACS/AMI, several patient groups remain at increased risk for these adverse outcomes, including women and the elderly. However, recent trends in age and sex differences in extent of pre-hospital delay, hospital management practices, and short-term outcomes associated with ACS/AMI remain unexplored.

The objectives of this study were to examine the overall magnitude, and changing trends therein, of age and sex differences in duration of pre-hospital delay (1986-2005), hospital management practices (1999-2007), and short-terms outcomes (1975-2005) in patients hospitalized with ACS/AMI.

Methods
Data from 13,663 residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers for AMI 15 biennial periods between 1975 and 2005 (Worcester Heart Attack Study), and from 50,096 patients hospitalized with an ACS in 106 medical centers in 14 countries participating in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007 were used for this investigation.

Results
In comparison with men <65 >years, patients in other age-sex strata exhibited significantly longer pre-hospital delay, with the exception of women < 65 years; had a significantly lower odds of receiving aspirin, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, statins, and undergoing coronary artery bypass graft surgery (CABG) surgery or percutaneous coronary intervention (PCI), and were significantly more likely to develop atrial fibrillation, cardiogenic shock, heart failure, and to die during hospitalization and in the first 30 days after admission. There was a significant interaction between age and sex in relation to the use of several medications and the development of several of these outcomes; in patients <65 years, women were less likely to have received these treatments and were more likely to develop these complications and die compared with men; in patients ≥ 65 years, however, there were no significant sex differences in these outcomes. Age and sex differences in duration of pre-hospital delay have narrowed over time; however, age and sex differences in hospital management practices and short-term outcomes have not changed significantly over time.

Conclusions
Our results suggest that the elderly were more likely to experience longer prehospital delay, were less likely to be treated with evidence-based treatments during hospitalization for acute coronary syndrome, and were more likely to develop adverse outcomes compared to younger persons. Younger women were less likely to be treated with effective treatments and were more likely to develop adverse outcomes compared with younger men while there was no sex difference in these outcomes. Interventions targeted at older patients, in particular, are needed to encourage these high-risk patients to seek medical care promptly to maximize the benefits of currently available treatment modalities. More targeted treatment approaches during hospitalization for ACS/AMI for younger women and older patients are needed to improve their hospital prognosis.

Rights and Permissions

Copyright is held by the author, with all rights reserved.

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