Sex differences in the prehospital management of out-of-hospital cardiac arrest

doi:10.1016/j.resuscitation.2016.05.029

Resuscitation

Volume 105, August 2016, Pages 161-164

https://doi.org/10.1016/j.resuscitation.2016.05.029 Get rights and content

Abstract

Background

Sex differences exist in the diagnosis and treatment of several cardiovascular diseases. Our objective was to determine whether sex differences exist in the use of guideline-recommended treatments in out-of-hospital cardiac arrest (OHCA).

Methods

We included adult patients with non-traumatic OHCA treated by emergency medical services (EMS) in the Resuscitation Outcomes Consortium Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (ROC PRIMED) database during 2007−2009. Outcomes included prehospital treatment intervals, procedures, and medications. Data were analysed using multivariable linear and logistic regression models that adjusted for sex, age, witnessed arrest, public location, bystander cardiopulmonary resuscitation (CPR), and first known rhythm of ventricular tachycardia/fibrillation.

Results

We studied 15,584 patients; 64% were male and median age was 68 years (interquartile range 55−80). In multivariable analyses, intervals from EMS dispatch to first rhythm capture (p = 0.001) and first EMS CPR (p = 0.001) were longer in women than in men. Women were less likely to receive successful intravenous or intraosseous access (OR 0.78, 95% CI 0.71−0.86) but equally likely to receive a successful advanced airway (OR 0.94, 95% CI 0.86−1.02). Women were less likely to receive adrenaline (OR 0.81, 95% CI 0.74−0.88), atropine (OR 0.86, 95% CI 0.80−0.92), and lidocaine or amiodarone (OR 0.68, 95% CI 0.61−0.75).

Conclusion

Women were less likely than men to receive guideline-recommended treatments for OHCA. The reasons for these differences require further exploration, and EMS provider education and training should specifically address these sex differences in the treatment of OHCA.

Introduction

Out-of-hospital cardiac arrest (OHCA) is the most common cause of death from cardiac disease in the United States,¹ with 52.1 cases treated by emergency medical services (EMS) per 100,000 individuals annually.² The majority of patients with OHCA die before hospital admission.³ To improve outcomes, the International Liaison Committee on Resuscitation, American Heart Association, and European Resuscitation Council provide guidelines for OHCA treatment.4, 5, 6 These guidelines include cardiopulmonary resuscitation (CPR), intravenous (IV) or intraossesous (IO) access, medications, airway management, and defibrillation for shockable rhythms. Survival in OHCA is associated with several of these interventions, including high-quality CPR3, 7 and rapid defibrillation.3, 8

Sex differences in the prehospital management of other forms of cardiac disease exist9, 10, 11, 12 and are associated with increased morbidity and mortality in women.10, 11 Similarly, important sex differences may occur in prehospital interventions for OHCA. In this study, we use the Resuscitation Outcomes Consortium (ROC) Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (PRIMED) database to determine whether sex differences exist in prehospital treatment intervals, procedures, and medications among adults with OHCA. We hypothesise that women have longer prehospital treatment intervals and are less likely than men to receive procedures and medication.

Section snippets

Study design

We performed a retrospective cohort study using the ROC-PRIMED database. This study was exempt from review by our Institutional Review Board.

Population and setting

The ROC encompasses 11 regions in the United States and Canada serving approximately 23.7 million people.¹³ During 2007−2009, adults with OHCA were enrolled in the ROC-PRIMED impedance threshold device trial.¹⁴ In the current study, we included adults (≥18 years) with non-traumatic OHCA and complete sex and age data in the public-use ROC-PRIMED database

Results

After excluding patients with traumatic arrest (n = 100), exsanguination (n = 39), missing sex (n = 1,208), no cardiac arrest (n = 43), “do not resuscitate” orders (n = 199), legally dead (n = 219), age <18 years (n = 24), and missing age (n = 29), we studied 15,584 adult patients with OHCA. Of those, 10,023 (64%) were male (Table 1). In multivariable analyses, the interval from EMS dispatch to first advanced life support (ALS) crew arrival was similar in men and women (p = 0.438). However, intervals from

Discussion

Overall, women were less likely than men to receive timely prehospital CPR and rhythm capture, IV or IO access, and medications. Our data suggest that EMS providers are less adherent to guidelines4, 5, 6 and less aggressive in their resuscitation of women with OHCA. Our results are similar to smaller study demonstrating that women were less likely to receive prehospital post-resuscitation care in alignment with guidelines.¹⁶

We found longer times to first EMS rhythm capture and first EMS CPR,

Conclusion

Important sex differences exist in the prehospital care of patients with OHCA. Women experience longer times to CPR and cardiac rhythm capture, and they are less likely to receive IV/IO access and medications. The reasons for these differences should be explored further, and EMS provider education and training should specifically address sex differences in the treatment of OHCA.

Conflicts of Interest: None.

Sources of support: None.

Acknowledgements

This manuscript was prepared using ROC-PRIMED research materials obtained from the NHLBI and does not necessarily reflect the opinions or views of ROC or NHLBI.

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Cited by (37)

Sex disparities in bystander defibrillation for out-of-hospital cardiac arrest
2024, Resuscitation Plus
Previous studies have suggested that females experiencing out-of-hospital cardiac arrest (OHCA) receive lower rates of both bystander cardiopulmonary resuscitation (CPR) and defibrillation compared to males. Whether this disparity has improved over time is unknown.
A state-wide OHCA registry in Victoria, Australia collected data over twenty years (2002–2021) regarding rates of bystander interventions in OHCA. Characteristics and outcomes of each OHCA were compared with logistic regression according to sex and time (defined in two-year periods).
32,502 OHCAs were included (69.7% male). Both bystander CPR and defibrillation rates increased for females over time (p < 0.0001). There was no sex disparity in receipt of bystander CPR after adjustment for baseline differences. Females were less likely than males to receive bystander defibrillation, with sex disparity increasing from 2010 onwards (adjOR 0.26 (95%CI 0.09–0.80) in 2020–21 for females compared to males).
Initiatives to increase bystander CPR and defibrillation have resulted in higher overall rates of bystander interventions in the last two decades and no significant sex differences in provision of bystander CPR. However, females receive less bystander defibrillation than males, and sex disparity is increasing. Strategies to promote bystander defibrillation in females experiencing OHCA with a shockable rhythm should be a priority.
Gender-related differences in adults concerning frequency, survival and treatment quality after out-of-hospital cardiac arrest (OHCA): An observational cohort study from the German resuscitation registry
2024, Resuscitation
In Germany approximately 20,500 women and 41,000 men were resuscitated after out-of-hospital cardiac arrest (OHCA) each year. We are currently experiencing a discussion about the possible undersupply of women in healthcare. The aim of the present study was to examine the prevalence of OHCA in Germany, as well as the outcome and quality of resuscitation care for both women and men.
We present a cohort study from the German Resuscitation Registry (2006–2022). The quality of care was assessed for both EMS and hospital care based on risk-adjusted survival rates with the endpoints: “hospital admission with return of spontaneous circulation” (ROSC_admission) for all patients and ”discharge with favourable neurological recovery“ (CPC1/2_discharge) for all admitted patients. Risk adjustment was performed using logistic regression analysis (LRA). If sex was significantly associated with survival, a matched-pairs-analysis (MPA) followed to explore the frequency of guideline adherence.
58,798 patients aged ≥ 18 years with OHCA and resuscitation were included (men = 65.2%, women = 34.8%). In the prehospital phase the male gender was associated with lower ROSC_admission-rate (LRA: OR = 0.79, CI = 0.759–0.822). A total of 27,910 patients were admitted. During hospital care, men demonstrated a better prognosis (OR = 1.10; CI = 1.015–1.191). MPA revealed a more intensive therapy for men both during EMS and hospital care. Looking at the complete chain of survival, LRA revealed no difference for men and women concerning CPC1/2_discharge (n = 58,798; OR = 0.95; CI = 0.888–1.024).
In Germany, 80% more men than women experience OHCA. The prognosis for CPC1/2_discharge remains low (men = 10.5%, women = 7.1%), but comparable after risk adjustment. There is evidence of undersupply of care for women during hospital treatment, which could be associated with a worse prognosis. Further investigations are required to clarify these findings.
Frequency of resuscitation attempts with dying nursing home residents. A full survey in an urban district in Germany based on registry data from 2018–2021
2023, Resuscitation Plus
The realities of emergency care and resuscitation research involving nursing home (NH) residents suggest an overuse of resuscitation attempts in NHs. A complete analysis of all NH resident deaths is needed to provide a complementary perspective of potential underuse. The present research investigated whether residents of different NH homes died at the NH during attempted resuscitation or after transfer to hospital.
A full survey of resuscitation attempts and deaths among NH residents, via retrospective analysis of data from the death registry and the German Resuscitation Registry for the years 2018 to 2021.
Over the 4-year study period, 14,598 individuals died, of whom 3,288 (22.5%) were residents of 31 different NHs. The mean age of the deceased NH residents was 87 years (±8.6); 2,196 (66.8%) were female, 118 (3.6%) underwent a resuscitation attempt, and 58.5% died at the NH. NH averages were as follows: deaths per NH: 106 (±51; min–max: 36–292); number of beds: 102 (±39; 34–210); deaths per bed per year 0.27 (±0.07; 0.15–0.51); resuscitation attempts per 1,000 beds per year: 9.5 (±5.5; 0–21.1); and ratio of futile resuscitation attempts to deaths: 6.0% (0–12.5%). Considering the entire study region before and during the COVID-19 pandemic, a slight underuse of resuscitation attempts with female NH residents emerged. On a facility level, substantial disparities and opposing trends were found. The incidence of deaths and resuscitation attempts, as well as the place of death and the ratio of futile resuscitation attempts to deaths, varied considerably.
Resuscitation attempts are rarely administered to dying NH residents. However, their frequency varies considerably between NHs.
Sex disparities in prehospital advanced cardiac life support in out-of-hospital cardiac arrests in Japan
2023, American Journal of Emergency Medicine
Sex disparities in out-of-hospital cardiac arrest (OHCA) care processes have been reported. This study aimed to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services in Japan.
We analyzed data from January 1, 2013, to December 31, 2020, from the All-Japan Utstein Registry of patients with OHCA aged ≥18 years who were resuscitated by bystanders. The primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM) and epinephrine administration. Sex-based disparities in receiving prehospital ACLS interventions were assessed via multivariable logistic regression analyses.
Among 314,460 eligible patients, females with OHCA received fewer prehospital ACLS interventions than males: 83,571/187,834 (44.5%) males vs. 55,086/126,626 (43.5%) females (adjusted odds ratio [AOR] = 0.94, 95% confidence interval [CI] = 0.93–0.96) for AAM and 60,097/187,834 (32.0%) males vs. 35,501/126,626 (28.0%) females (AOR = 0.84, 95% CI = 0.83–0.85) for epinephrine administration. Similar results were also obtained in the subgroup analysis (groups included patients aged 18–74 years and ≥75 years and those with cardiac origin, ventricular fibrillation (VF), non-VF, non-family member witnessed, and family member witnessed).
Compared with males, females were less likely to receive prehospital ACLS. Emergency medical service staff must be made aware of this disparity, and off-the-job training on intravenous cannulation or AAM replacement must be conducted. Investigation of the impact of sex disparity on OHCA care processes can facilitate planning of future public health policies to improve survival outcomes.
Is all bystander CPR created equal? Further considerations in sex differences in cardiac arrest outcomes
2023, Resuscitation
Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study
2022, Mayo Clinic Proceedings
To assess the impact of patient’s sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA).
We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy.
Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40).
Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.05.029.

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Short communicationSex differences in the prehospital management of out-of-hospital cardiac arrest☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Population and setting

Results

Discussion

Conclusion

Acknowledgements

Resuscitation

Heart Lung Circ

Am Heart J

Prehosp Emerg Care

Resuscitation

Heart Lung

Resuscitation

Sudden cardiac death in the United States, 1989 to 1998

Circulation

Regional variation in out-of-hospital cardiac arrest incidence and outcome

JAMA

Short communication
Sex differences in the prehospital management of out-of-hospital cardiac arrest☆