Elsevier

Resuscitation

Volume 114, May 2017, Pages 7-13
Resuscitation

Clinical paper
Gender differences in early invasive strategy after cardiac arrest: Insights from the PROCAT registry

https://doi.org/10.1016/j.resuscitation.2017.02.005Get rights and content

Abstract

Aim

Early invasive strategy, including percutaneous coronary intervention (PCI), may improve survival in out-of-hospital-cardiac-arrest (OHCA) due to coronary artery disease but selection of suitable patients is challenging. Differences and results across gender remain unknown. We aimed to assess the relationship between gender and the use of an early invasive strategy after OHCA, and the relationship with outcome according to gender.

Methods

All patients admitted after OHCA were prospectively included (2000–2013). Using a gender-independent algorithm for its indication, we assessed the association between the use of an early invasive strategy and the outcome at hospital discharge (using the Cerebral Performance Category scale), according to gender.

Results

1817 patients were included (520 women, 29%). Women were older (62.8 vs 59.1 years, P < 0.0001). They had less shockable rhythm (42% vs 61%, P < 0.001). After multivariate logistic regression, female gender was negatively associated with early coronary angiogram (OR = 0.57, 95%CI 0.41–0.79, P = 0.001). Results after propensity-score matching were consistent (P = 0.02). Among 1157 patients who underwent coronary angiogram, rates of PCI did not differ between men and women (adjusted OR = 1.26, 95%CI 0.87–1.82, P = 0.23). Early invasive strategy was associated with favorable outcome in multivariate logistic regression (OR = 1.43, 95%IC 1.02–2.0, P = 0.04) with no interaction between gender and PCI (P for interaction = 0.11). Association between PCI and outcome was consistent across genders.

Conclusions

After OHCA, women are less likely to undergo early invasive strategy. However, rates of PCI after coronary angiogram do not differ across gender, and the association between PCI and outcome is similar across gender.

Introduction

Out-of-hospital cardiac arrest (OHCA) is a major public health concern, with 200,000–300,000 cases reported annually in the United States,1, 2 or in Europe.3 Survival rates remain low,4 but recent data suggest that outcome improved.5 This improvement is mainly attributable to higher prehospital survival rates,6 but might be also due to post-resuscitation care. Thus, early invasive strategy (coronary angiogram (CAG) and percutaneous coronary intervention (PCI)) is associated with an improvement in both short and long-term outcomes in OHCA patients.7, 8

Selection of the best candidates for an early invasive strategy is still debated. By analogy with acute coronary syndromes, gender could influence the management of these patients and particularly the decision for CAG. Important differences have been reported between men and women in management of myocardial infarction.9, 10 Accordingly, an enhanced survival benefit from restoring myocardial perfusion for women compared with men during primary angioplasty has been reported.11 In the field of OHCA, several gender specificities have been identified,12, 13, 14, 15, 16 but to the best of our knowledge, no data regarding gender differences in the coronary management of survivors of OHCA are available, and studies leading to current guidelines mainly included men.7, 8 The need for specific gender-studies has been recently emphasized.17 Highlighting gender differences in coronary management of OHCA could lead to specific recommendations for women, and therapeutic strategies could differ according to gender.

We used the large prospective PROCAT (Parisian Registry out-of-hospital cardiac arrest) registry in order to assess the relationship between an early invasive strategy and outcome according to gender in patients admitted after OHCA

Section snippets

Study setting

In Paris (France), management of OHCA involves mobile emergency units and fire departments.18 They cover a population of approximately 6.6 million during the day and 2.5 million at night. Upon witnessed call and in suspected cases of OHCA, the closest emergency unit is dispatched on the scene. Out-of-hospital resuscitation is delivered by an emergency team, which includes at least one trained physician in emergency medicine according to the international guidelines.19 Patients in whom return of

Population characteristics

From January 2000 to December 2013, 1817 patients with OHCA were included (Fig. 1). Baseline characteristics of patients according to gender are presented in Table 1. Women were older (62.8 vs 59.1 years, P < 0.0001), with less cardiomyopathy and less cardiovascular risk factors. Women had less initial shockable rhythm (42% vs 61%, P < 0.001) and had more post-OHCA shock. Post-resuscitation ECG found ST-elevation more often among men than women (21% vs 13%, P < 0.001). Women were more likely to have

Discussion

In this study, we reported the use and outcome of early invasive strategy for patients admitted after OHCA according to gender. First, after adjustment and matching on baseline characteristics, women were less likely to undergo early invasive strategy after OHCA but this did not result in a higher rate of missed ischemic diagnosis. Second, when an early invasive strategy was employed, women and men had the same rate of PCI. Finally, association between early invasive strategy and favorable

Conclusion

After resuscitated OHCA, women are less likely to undergo early invasive strategy, due to a less agressive approach. However, rates of PCI after early invasive strategy and association between PCI and favorable outcome are similar in men and women. Hence, women should receive the same standard of care as men after OHCA.

Conflicts of interest statement

None.

Sources of funding

None.

Acknowledgment

None.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2017.02.005.

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