Research Article| Volume 58, P6-12, March 2023

Association of sex and age and delay predictors on the time of primary angioplasty activation for myocardial infarction patients in an emergency department

Published:November 03, 2022DOI:


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        Time delays in STEMI patients admitted to Emergency Department (ED) are longer in women and elderly.
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        STEMI delays are longer particularly in women and elderly with atypical presentation.
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        Older and first medical contact outside the ED have longer activation time.
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        Gender and age are not associated with a longer activation time in young people.
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        Activation time is particularly longer in older women.



      : Time between Emergency Department (ED) and ST-segment elevation acute myocardial infarction (STEMI) activation time is a good indicator of ED quality. STEMI delays are of particular importance in some subgroups, such as women and the elderly.


      : To determine the association of sex and age with activation time in STEMI patients admitted to the ED.


      : An observational retrospective study was conducted including all patients admitted to the ED activated as a STEMI. The main variable was activation time. To evaluate the independent predictors of activation time, a multivariate logistic regression analysis was carried out, variables were sex, age, sex and age combined, chest pain, ST elevation in the electrocardiogram, and first medical contact (FMC) at the hospital's ED.


      : A total of 330 patients were included. They were classified by sex: 23.9% (78) women and 76.1% (249) men; and age: 51.1% (167) <65 yo and 48.9% (160) ≥65 yo. Women and elderly patients exhibited a more atypical presentation. Multivariate analysis shows that showed that elderly age (OR=1.976 95%; CI=1.257–3.104; p = 0.003) and FMC prior to attending the ED (OR=1.762; 95% CI=1.117–2.779; p = 0.015) were associated with a longer activation time. Women older than 65 years old showed the longest activation time.


      : STEMI delays are longer in women and the elderly with atypical presentation. Age ≥65 and FMC outside the ED were associated with an increase in the activation time. This highlights the need to develop strategies to improve activation time for these specific patient groups.



      CAD (coronary artery disease), CRA (cardiorespiratory Arrest), DLP (dyslipidaemia), DM (diabetes mellitus), ECG (electrocardiogram), ED (emergency department), ESC (European Society of Cardiology), FMC (first medical contact), GPC (general poor condition), HTA (arterial hypertension), IC (interventional cardiology), Min (minutes), PCI (percutaneous coronary intervention), STEMI (St-Segment Elevation Acute Myocardial Infarction), Yo (years old)
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        • GBD 2016 Causes of Death Collaborators
        Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study.
        Lancet. 2016; 390 (2017): 1151-1210
        • Kawecki D.
        • Gierlotka M.
        • Morawiec B.
        • et al.
        Direct admission versus interhospital transfer for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction.
        JACC. 2017; 5: 438-447
        • Carol Ruiz A.
        • Masip Utset J.
        Ariza Solé A—researchers of the Codi Infart registry of Catalonia. Predictors of late reperfusion in STEMI patients undergoing primary angioplasty. Impact of the place of first medical contact.
        Rev Esp Cardiol. 2017; 70: 162-169
      1. Ibanez B., James S., Agewall S., et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2018; 39: 119-177
        • Sim W.J.
        • Ang A.S.
        • Tan M.C.
        • et al.
        Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention.
        PloS One. 2017; 12e0185186
        • Foo C.Y.
        • Bonsu K.O.
        • Nallamothu B.K.
        • et al.
        Coronary intervention door-to-balloon time and outcomes in ST-elevation myocardial infarction: a meta-analysis.
        Heart. 2018; 104: 1362-1369
        • Mehta L.S.
        • Beckie T.M.
        • De Von H.A.
        • et al.
        Acute myocardial infarction in women: a scientific statement from the American Heart Association.
        Circulation. 2016; 133: 916-947
        • Stehli J.
        • Martin C.
        • Brennan A.
        • Dinh D.T.
        • Lefkovits J.
        • Zaman S.
        Sex differences persist in time to presentation, revascularization and mortality in myocardial infarction treated with percutaneous coronary intervention.
        J Am Heart Assoc. 2019; 8e012161
        • Hao Y.
        • Liu J.
        • Liu J.
        • et al.
        Sex differences in in-hospital management and outcomes of patients with acute coronary syndrome.
        Circulation. 2019; 139: 1776-1785
        • De Luca L.
        • Marini M.
        • Gonzini L.
        • et al.
        Contemporary trends and age-specific sex differences in management and outcome for patients with ST-segment elevation myocardial infarction.
        J Am Heart Assoc. 2016; 5e004202
        • Alabas O.A.
        • Gale C.P.
        • Hall M.
        • et al.
        Sex differences in treatments, relative survival, and excess mortality following acute myocardial infarction: national cohort study using the SWEDEHEART registry.
        J Am Heart Assoc. 2017; 6e007123
        • D'Onofrio G.
        • Safdar B.
        • Lichtman J.H.
        • et al.
        Sex differences in reperfusion in young patients with ST-segment-elevation myocardial infarction: results from the VIRGO study.
        Circulation. 2015; 131: 1324-1332
        • Haller P.M.
        • Jäger B.
        • Farhan S.
        • et al.
        Impact of age on short– and long–term mortality of patients with ST–elevation myocardial infarction in the VIENNA STEMI network.
        Wien Klin Wochenschr. 2018; 130: 172-181
        • Pek P.P.
        • Zheng H.
        • Ho A.F.W.
        • et al.
        Comparison of epidemiology, treatments and outcomes of ST-segment elevation myocardial infarction between young and elderly patients.
        Emerg Med J. 2018; 35: 289-296
        • Sabaté M.
        No es país para viejos” con infarto agudo de miocardio y elevación del segmento ST.
        Rev Esp Cardiol. 2017; 70: 70-71
        • Sederholm Lawesson S.
        • Isaksson R.-.M.
        • Ericsson M.
        • et al.
        Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study.
        BMJ Open. 2018; 8e020211
        • McKee G.
        • Mooney M.
        • O'Donnell S.
        • O'Brien F.
        • Biddle M.
        • Moser D
        A cluster and inferential analysis of myocardial infarction symptom presentation by age.
        Eur J Cardiovasc Nurs. 2018; 17: 637-644
        • Dreyer R.P.
        • Beltrame J.F.
        • Tavella R.
        Evaluation of gender differences in Door-to-Balloon time in ST-elevation myocardial infarction.
        Heart Lung Circ. 2013; 22: 861-869
        • Ladwig K.H.
        • Fang X.
        • Wolf K.
        • et al.
        Comparison of delay times between symptom onset of an acute ST-elevation myocardial infarction and hospital arrival in men and women <65 years versus ≥65 years of age. Findings from the multicenter munich examination of delay in patients experiencing acute myocardial infarction (MEDEA) study.
        Am J Cardiol. 2017; 120: 2128-2134
        • Regueiro A.
        • Fernández-Rodríguez D.
        • Freixa X.
        • et al.
        Falsos positivos en la activación por IAMCEST en una red regional: análisis integral e impacto clínico. Resultados del registro Codi Infart de Cataluña.
        Rev Esp Cardiol. 2018; 71: 243-249
        • Lichtman J.H.
        • Leifheit E.C.
        • Safdar B.
        • et al.
        Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study.
        Circulation. 2018; 137: 781-790
        • Ricci B.
        • Cenko E.
        • Varotti E.
        • Puddu P.E.
        • Manfrini O.
        Atypical chest pain in ACS: a trap especially for women.
        Curr Pharm Des. 2016; 22: 3877-3884
        • Gulati M.
        • Levy P.D.
        • Mukherjee D.
        • et al.
        AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.
        Circulation. 2021; 144: e368-e454
        • Choi K.
        • Shofer F.S.
        • Mills A.M.
        Sex differences in STEMI activation for patients presenting to the ED 1939.
        Am J Emerg Med. 2016; 34: 1939-1943
        • De la Torre Hernández J.M.
        • Brugaletta S.
        • Gómez Hospital J.A.
        • et al.
        Primary angioplasty in patients older than 75 years. Profile of patients and procedures, outcomes, and predictors of prognosis in the ESTROFA IM + 75 Registry.
        Rev Esp Cardiol. 2017; 70: 81-87
        • DeVon H.A.
        • Mirzaei S.
        • Zègre-Hemsey J.
        Typical and atypical symptoms of acute coronary syndrome: time to retire the terms?.
        J Am Heart Assoc. 2020; 9e015539
        • McCormick K.M.
        • Bunting S.M.
        Aplication of feminist theory in nursing research: the case of women and cardiovascular disease.
        Health Care Women Int. 2002; 23: 820-834
        • Çinar T.
        • Tanik V.O.
        • Simsek B.
        • Güngör B.
        • Zeren G.
        • Karabay C.Y.
        In-hospital mortality of STEMI patients: a comparison of transportation modes to PCI and non-PCI centers.
        Am J Emerg Med. 2021; 40: 222-224
        • Song P.S.
        • Kim M.J.
        • Seong S.W.
        • et al.
        Gender differences in all-cause mortality after acute myocardial infarction: evidence for a gender-age interaction.
        J Clin Med. 2022; 11: 541
        • Liu J.
        • Elbadawi A.
        • Elgendy I.Y.
        • et al.
        Age-stratified sex disparities in care and outcomes in patients with ST-elevation myocardial infarction.
        Am J med. 2020; 133: 1293-1301
        • Yudi M.B.
        • Hamilton G.
        • Farouque O.
        • et al.
        Trends and impact of door-to-balloon time on clinical outcomes in patients aged <75, 75 to 84, and ≥85 years with ST-elevation myocardial infarction.
        Am J Cardiol. 2017; 120: 1245-1253
        • Levine G.N.
        • Dai X.
        • Henry T.D.
        • et al.
        In-Hospital STEMI quality improvement project. In-Hospital ST-segment elevation myocardial infarction: improving diagnosis, triage, and treatment.
        JAMA Cardiol. 2018; 3: 527-531
        • De Luca G.
        • Verdoia M.
        • et al.
        Impact of COVID-19 pandemic on mechanical reperfusion for patients with STEMI.
        J Am Coll Cardiol. 2020; 76: 2321-2330
        • Pacheco C.
        • Boivin-Proulx L.A.
        • Bastiany A.
        • et al.
        Impact of STEMI diagnosis and catheterization laboratory activation systems on sex- and age-based differences in treatment delay.
        CJC Open. 2021; 3: 723-732