Sex bias in admission to tertiary-care centers for acute myocardial infarction and cardiogenic shock

Sex-bias in admitting women to highly specialized cardiac care units and the use of percutaneous coronary intervention (PCI) that resulted in higher in-hospital mortality for women was found in a study by Ralph Brindis, MD, MPH and Renee Hsia, MD, MSc and colleagues.

In a recent European Journal of Clinical Investigation article, the researchers detailed their findings from the first study to examine the impact of admission in tertiary hospitals on in-hospital mortality for cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI) by sex. Using the Spanish National Health System Minimum Basic Data from 2003 to 2015 to identify CS-STEMI patients, the researchers investigated whether any sex bias exists in the admission to revascularization capable hospitals (RCH) or intensive cardiac care units (ICCU) and its impact on in-hospital mortality.

Cardiogenic shock (CS) is the most common cause of death after ST-elevation myocardial infarction (STEMI) for both women and men.  American College of Cardiology/American Heart Association recommend urgent revascularization in patients with CS after STEMI.  Existing studies of sex differences in CS-STEMI patient outcomes show a trend for higher mortality among women.  The studies attribute this to higher rates of CS among women, undertreatment of women and differences in age and comorbidities.  However, no studies have looked at sex-bias in admission of admission to tertiary care that is proven to be highly effective.

This wide national study shows women were less frequently admitted into RCH or highly specialized centers with ICCU, received less PCI and suffered from higher in-patient risk-adjusted mortality than men.  These sex disparities did not disappear over the study period.  The researchers believe the study fills a critical gap in addressing the likelihood of admission into highly specialized cardiac care units and the use of PCI in women with CS-STEMI. Intensive cardiac care and PCI should be offered equally to women and men presenting with similar clinical scenarios.

Renee Hsia, MD, MSc

Dr. Hsia is a Professor and Associate Chair of Health Services Research of the Department of Emergency Medicine. She is also a core faculty member of the UCSF Philip R. Lee Institute for Health Policy Studies (IHPS), as well as a member of the UCSF Center for Healthcare Value and the UCSF Global Health Economics Consortium. Dr. Hsia’s broad research interests are in health services issues related to increasing access to emergency care and regionalization of care.




Ralph Brindis, MD, MPH

Dr. Brindis is a Clinical Professor of Medicine at the University of California, San Francisco and is affiliate faculty of the Phil R. Lee Institute of Health Policy Studies at UCSF. Dr. Brindis is a general adult cardiologist following a career as an interventional cardiologist presently performing CCU and consultative cardiology with the UCSF medical residency and cardiology fellowship program. His major interest in process measures and outcomes assessment in cardiovascular care had led to helping create and implement various Cardiovascular Guidelines for Northern California Kaiser Permanente.



Sex bias in admission to tertiary-care centers for acute myocardial infarction and cardiogenic shock.

Sambola A, Javier Elola F, Buera I, Fernández C, Bernal JL, Ariza A, Brindis R, Bueno H, Rodríguez-Padial L, Marín F, Barrabés JA, Hsia R, Anguita M.Eur J Clin Invest. 

2021 Feb 23;e13526.doi: 10.1111/eci.13526. Online ahead of print.