Less prescription of potent P2Y₁₂i and worse outcomes in women with STEMI versus men
Sex-Specific Differences in Potent P2Y12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI PatientsLiterature - Burgess SN, Shoaib A, Sharp ASP, et al. - Circ Cardiovasc Interv. 2023 Sep;16(9):e012447. doi: 10.1161/CIRCINTERVENTIONS.122.012447
Introduction and methods
According to current European and American guidelines, patients with STEMI undergoing primary PCI should be treated with a high-potency P2Y₁₂ inhibitor (ticagrelor or prasugrel) in combination with aspirin [1,2]. It is known that women with STEMI have worse outcomes than men [3-10], and that women are less frequently prescribed potent P2Y₁₂ inhibitors than men [6-8,11]. However, the role of prescription differences play in sex-based outcome disparities in STEMI is not well known.
Aim of the study
The study aim was to evaluate sex-based differences in potent P2Y₁₂ inhibitor prescription among STEMI patients treated with primary PCI in order to assess the potential role they play in outcome disparities for women with STEMI.
For this observational study, data from 168,818 STEMI patients treated with primary PCI from 2010 to 2020 were collected from the British Cardiovascular Intervention Society national PCI database. Of these patients, 125,687 (74.45%) were male and 43,131 (25.54%) were female.
The primary endpoint was in-hospital mortality. Additional endpoints included: (1) major adverse CV and cerebrovascular events (MACCE), defined as a composite outcome of in-hospital mortality, in-hospital myocardial reinfarction (including Q-wave and non-Q wave MI), and stroke; and (2) in-hospital major bleeding, defined as a composite outcome of clinical major bleeding requiring blood or platelet transfusions, hemorrhagic stroke, tamponade, retroperitoneal hemorrhage, and access-site complication requiring delayed discharge, intervention, or surgery.
- Potent P2Y₁₂ inhibitors were prescribed less often to women than men (51.71% vs. 55.18%; P<0.001).
- The in-hospital mortality rate was higher in women than men (6.45% vs. 4.05%; P<0.001; adjusted OR (aOR): 1.213; 95%CI: 1.141–1.290). It was highest in women treated with clopidogrel (7.57%), followed by women receiving potent P2Y₁₂ inhibitors (5.39%), men treated with clopidogrel (4.60%), and men treated with potent P2Y₁₂ inhibitors (3.61%) (P<0.001 for all comparisons).
- Multivariate analysis showed treatment with potent P2Y₁₂ inhibitors was associated with a decreased risk of in-hospital mortality compared with clopidogrel (aOR: 0.943; 95%CI: 0.891–0.999). The largest in-hospital mortality benefit was seen for prasugrel compared with clopidogrel (aOR: 0.819; 95%CI: 0.752–0.893), whereas the in-hospital mortality benefit for ticagrelor versus clopidogrel was not significant (aOR: 0.991; 95%CI: 0.932–1.054).
- Compared with men, women also had higher rates of MACCE (4.37% vs. 6.88%; P<0.001) and in-hospital major bleeding (0.56% vs. 1.17% ; P<0.001), with similar patterns as seen for the primary endpoint when unadjusted outcomes were stratified by both sex and potent P2Y₁₂ inhibitor use.
- In a multivariate analysis adjusted for baseline characteristics and procedural factors (16-factor model), the strongest independent predictors of prescription of potent P2Y₁₂ inhibitors instead of clopidogrel were radial access (aOR: 2.368; 95%CI: 2.312–2.425; P<0.001), use of drug-eluting stents (aOR: 1.895; 95%CI: 1.845–1.946; P<0.001), and prior CABG (aOR: 1.259; 95%CI: 1.188–1.336; P<0.001). Female sex was not a significant predictor of potent P2Y₁₂ inhibitor use (aOR: 1.015; 95%CI: 0.991–1.039; P=0.224).
- When the procedural factors (i.e., access site, stent type, and glycoprotein IIb/IIIa inhibitor use) were excluded from the model in a sensitivity analysis (13-factor model), women were less likely to be treated with potent P2Y₁₂ inhibitors than men (aOR: 0.957; 95%CI: 0.935–0.979).
- Although sex-based differences in prescription rates decreased during the study period, they remained significant each year, with absolute differences in prescription rate ranging from 2% to 6%.
This large observational study using data on STEMI patients undergoing primary PCI from the UK national PCI database showed that women were less likely to receive a potent P2Y₁₂ inhibitor (prasugrel or ticagrelor), were less likely to be treated using radial access , and had higher rates of in-hospital mortality and major bleeding and MACCE compared with men. The authors believe “[t]his study suggests that both closer adherence to guideline-recommended [potent] P2Y₁₂ inhibitors and more frequent use of radial access for women may help to decrease sex-based outcome disparities for patients with STEMI.”