Shelley Wood

May 22, 2013

PARIS, France — At a meeting famous for showcasing flashy new interventional devices, one session sought to shine a light on a tenacious old problem: underdiagnosis and delayed treatment of STEMI in women.

Study after study has documented delays and undertreatment of heart disease in women, but AMI in particular is getting renewed attention in the wake of new stats showing that STEMI is growing increasingly more common in younger women and that the risk of death is actually higher. And that remains the case, despite newer imaging tests that can help with diagnosis and course of treatment, the crowd attending the session at EuroPCR 2013 heard today.

Dr Alaide Chieffo

"The number of STEMI in young women is increasing, and it is increasing everywhere in the world," session cochair Dr Alaide Chieffo (San Raffaele Hospital, Milan, Italy) said in her closing remarks. "This is a subset of patients we should be very careful to evaluate, because it is clearly not acceptable when anybody with STEMI does not get the standard-of-care therapy. And especially in young people, it is even more unacceptable. I hope after this session today, everyone here will think, when they have a young woman coming in with atypical symptoms--atypical chest pain, vomiting, weakness, shortness of breath--they will get the ECG done."

And not just simply order an ECG, chimed in her cochair, Dr Josepa Mauri (Hospital Universitari Germans Trias i Pujol, Barcelona, Spain), but actually take the time to read it.

Not Your Run-of-the-Mill STEMI

The EuroPCR session was entitled Unusual causes of STEMI in young women and featured "quite scary cases," as Chieffo put it to heartwire .

In one case, a 16-year-old with no history of smoking or cocaine use was rushed for emergency PCI; in another, a 30-year-old woman was admitted for AMI during her 36th week of pregnancy and found to have diffuse atherosclerosis in her proximal LAD. In yet another, a 39-year old woman with no risk factors was found to have ST-segment elevation on an ECG but a normal angiogram. Not reassured, her physician ordered optical coherence tomography (OCT), which picked up spontaneous coronary artery dissection (SCAD).

"This is a great example of where OCT can shed light on a case," the presenter, Dr Rafidah Abu Bakar (Mercy University Hospital, Cork, Ireland), concluded. OCT and intravascular ultrasound (IVUS) can be helpful and should be considered in cases where angiography is normal but there is a high index of suspicion for SCAD, she added.

It is clearly not acceptable when anybody with STEMI does not get the standard-of-care therapy.

The pathophysiology of STEMI in young women is often different from that in men, as the cases in today's session showed. "It may be atherosclerosis, but it may also be SCAD, vasculitis, or spasm. So it may be helpful to use adjunctive tools [like OCT and IVUS] to be able to look inside the artery," Chieffo commented. "But in the end even if pathophysiology is different, the diagnosis is the same: STEMI. And clearly we need to give to these women the standard-of-care treatment."

As for why STEMI is occurring earlier in women, increasing rates of smoking, obesity, poor nutrition, stress, and generally "a lifestyle more similar to men" are all contributors, Chieffo and Mauri explain.

Fresh Attention for an Old and Worsening Problem

Dr Josepa Mauri

Chieffo and Mauri are both members of the Women in Innovations initiative launched by the Society for Cardiovascular Angiography and Intervention (SCAI). It's not by accident that they ended up chairing the session at EuroPCR: they have been pushing congress planners to include sessions on STEMI undertreatment in women at as many meetings as possible over the past five years, they told heartwire . Chieffo and Mauri estimated that the room for today's session was more than 75% full--not bad for an 8 am session at this meeting--hinting that people are starting to take an interest.

"This is a very important social problem. We need to ask ourselves, why are we missing this population?" Chieffo said.

Interventionalists need to be trying to answer that question just as much as GPs and admitting cardiologists, not to mention the young women themselves. "That's the reason we are saying this at this meeting: we want to take the time to remind interventionalists that this is an urgent issue," Mauri said. "This is a question of saving lives."

Registry data published in JAMA last year showed that among women who develop an MI, 25% are now under the age of 60. That's up from 12% in 1995. Other research has shown that young women are more likely to die from STEMI than men the same age.

Chieffo, Mauri, and Abu Bakar had no relevant disclosures.


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