Research Article: Access to percutaneous transluminal coronary angioplasty and 30-day mortality in patients with incident STEMI: Differentials by educational level and gender over 11 years

Date Published: April 6, 2017

Publisher: Public Library of Science

Author(s): Laura Cacciani, Nera Agabiti, Anna Maria Bargagli, Marina Davoli, Andreas Zirlik.


Socioeconomic status and gender are associated with access to cardiac procedures and mortality after AMI, also in countries with universal health care systems. Our objective was to evaluate the association and trends of educational level or gender and the following outcomes: 1) access to PTCA; 2) 30-day mortality.

We conducted an observational study based on 14,013 subjects aged 35–74 years, residing in Rome in 2001, and hospitalised for incident STEMI within 2012 in the Lazio region. We estimated adjusted ORs of educational level or gender and: 1) PTCA within 2 days after hospitalisation, 2) 30-day mortality. We evaluated time trends of outcomes, and time trends of educational or gender differentials estimating ORs stratified by time period (two time periods between 2001 and 2012). We performed a hierarchical analysis to account for clustering of hospitals.

Access to PTCA among patients with incident STEMI increased during the study period, while 30-day mortality was stable. We observed educational differentials in PTCA procedure only in the first time period, and gender differentials in both periods. Patterns for 30-day mortality were less marked, with educational differentials emerging only in the second period, and gender differentials only in the first one, with patients with low educational level and females being disadvantaged.

Educational differentials in the access to PTCA disappeared in Lazio region over time, coherently with scientific literature, while gender differentials seem to persist. It may be important to assess the role of female gender in patients with STEMI, both from a social and a clinical point of view.

Partial Text

Although ischemic heart diseases are a leading cause of morbidity and mortality in most European countries [1] and worldwide [2], decreasing patterns of incidence and mortality in acute myocardial infarction (AMI) have been observed over time [3]. This could be due in part to the reduction of known cardiovascular risk factors [4], and to a decrease in the incidence of ST-segment elevation myocardial infarction (STEMI) [5], which exposes patients to a higher risk of short-term mortality compared to non–ST-segment elevation myocardial infarction (NSTEMI). On the other hand, a nationwide observational study conducted in 2007 in France showed that patients with NSTEMI and STEMI have comparable in-hospital and long-term prognoses [6].

We analysed 14,013 patients with STEMI discharged from 87 hospitals in Lazio region during the study period. The average number of PTCA90m by hospital (available only in 2008–2012) was 57 (range 1–236), while it was 199 for PTCA2d (1–1046), and 18 for the number of deaths (1–166).

Using data from a large census-based cohort of residents in Rome (Italy) over 11 years, we provide updated evidence on educational and gender differentials of access to PTCA and 30-day post-STEMI mortality, which was the central objective of our study. We used a valid exposure measure of individual educational level from census data.

We observed increased use of PTCA procedures and steady short-term prognosis after STEMI over an eleven-year follow-up. We observed educational differentials in PTCA only in the first time period, and women seemed disadvantaged, while we did not observe relevant educational or gender differentials in 30-day mortality, coherently with national and international literature. This study suggests that in the Lazio region there is equity of treatment in the access to PTCA, which indicates good quality of care in this area. Although gender differentials may be due to unaccounted clinical factors, it may be important to better assess the role of female gender in patients with STEMI both from a social and a clinical point of view.




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