Background: Sex gaps in STEMI care persist but are shrinking
Cardiovascular disease remains a leading cause of death for both men and women, yet women historically received less invasive care and preventive therapy for acute coronary syndromes. This retrospective cohort study from New South Wales (NSW), covering 2011–2020, examines whether sex differences in the management and outcomes of ST-elevation myocardial infarction (STEMI) have decreased over time as awareness and guidelines evolved.
Data and methods: A comprehensive NSW STEMI cohort
The study analysed all adults (18+) admitted with STEMI for the first time across NSW public and private hospitals from January 1, 2011, to December 31, 2020. Data came from the NSW Admitted Patient Data Collection, linked to mortality data. STEMI was defined as a continuous emergency admission sequence with an initial STEMI diagnosis or a subsequent STEMI within 24 hours. The researchers tracked invasive procedures (angiography, PCI, and CABG) within seven days, plus outcomes including major adverse cardiovascular events (MACE) and mortality up to 12 months post-discharge. Socioeconomic status, comorbidities, and Charlson comorbidity index (CCI) were considered to adjust comparisons by sex and age.
Key findings: Persistent sex gaps, but decreasing disparities
From 29,435 first-time STEMI admissions (2011–2020), 28.8% were women and 71.2% men. Women were older at presentation (mean age 72.4 vs 63.6 years) and had higher comorbidity burdens (higher CCI) overall. Female patients also had higher rates of heart failure, cerebrovascular disease, dementia, chronic pulmonary disease, and diabetes, contributing to a greater need for comprehensive secondary prevention strategies.
Procedural access showed clear sex differences in 2011–2013, with women less likely to undergo coronary angiography (71.9% vs 85.1%), PCI (54.4% vs 70.0%), or CABG (3.3% vs 6.3%) within seven days. Encouragingly, angiography rose to 89.7% and PCI to 67.4% by 2019–2020, with faster growth among women. After adjustment for age, ICU admission, and CCI, the annual increase in angiography was 2.7 percentage points per year for women vs 1.5 for men; PCI rose by 3.2 vs 2.5 points per year, signaling a narrowing gap in timely revascularisation.
Outcomes also improved. Women were less likely to be admitted to the ICU (8.1% vs 9.5%), yet they experienced higher rates of MACE (18.4% vs 15.0%), cardiovascular death (7.0% vs 3.6%), and all-cause death (14.7% vs 8.5%) within 12 months of discharge. Importantly, the declines in MACE and mortality over time were sharper for women: MACE fell from 15.5% to 13.3%; all-cause mortality dropped from 15.8% to 3.5%. After adjustment, the yearly declines were larger for women (MACE -0.8 percentage points; cardiovascular death -0.4; all-cause mortality -1.0) than for men.
Analyses also revealed that the speed and uptake of reperfusion strategies benefited younger women (<85 years) more noticeably than older patients, suggesting age-related barriers persist but are diminishing in younger cohorts.
Interpretation: What drove the improvements?
The researchers attribute gains to multiple factors, including heightened awareness of sex differences in CVD, national campaigns, and structural changes such as the expansion of primary PCI networks and standardized STEMI protocols. A protocol-driven approach—rapid ED-to-PCI activation, streamlined handoffs, and radial-first PCI—has shown promise in reducing sex-related disparities in other settings, and NSW appears to be benefiting from similar system-wide improvements.
Despite progress, the study notes ongoing gaps: older women still present with higher comorbidity, and some differences in treatment persist. The authors advocate continued education for clinicians, female-specific cardiovascular research, and targeted policy efforts to sustain momentum toward equity in STEMI care.
Implications for patients and policy
- Systemic improvements can reduce sex disparities in acute coronary care, benefiting all patients.
- Public health campaigns and physician education are crucial to recognizing and treating ACS equally in men and women.
- Expanding networks for primary PCI and standardizing reperfusion protocols may accelerate equitable outcomes across age groups.
Limitations
As an administrative data study, granular clinical details were unavailable. Some interstate data may be missing for PCI procedures performed outside NSW. Coding changes over the decade could influence reported comorbidity and treatment rates, though the authors contend these would affect sexes similarly.
Conclusion
The NSW STEMI study from 2011–2020 provides important evidence that sex differences in management and outcomes can be narrowed through system-level changes and ongoing clinical emphasis on equitable care. While gaps remain, the observed improvements—especially in timely angiography and PCI for women—offer optimism and a roadmap for other regions aiming to close sex gaps in acute cardiovascular care.
