Sex-specific differences in the prognostic value of ischemic pre-hospital ECGs

Background The identification of myocardial infarction (MI) requiring target lesion revascularization (TLR) in women remains challenging. Objective To investigate sex-specific differences in value of preclinical ischemic ECGs for identification of MI requiring TLR and mortality. Methods Patients with suspected MI (ST-elevation MI [STEMI] excluded) and preclinical ECGs (1/2014–11/2021), who underwent coronary angiography (CA) were identified. Ischemic ECG was defined as composite of: ST-depression/elevation (not STEMI), T-wave inversion, left bundle branch block or ventricular fibrillation/tachycardia. The primary endpoint was MI requiring TLR, secondary endpoints were 30-day and 5-year all-cause mortality. The association between an ischemic ECG and endpoints was tested using logistic regression. Multivariable analysis was adjusted for age, previous percutaneous coronary intervention or MI, hypertension, diabetes, severely reduced left ventricular ejection fraction, renal failure and time to CA. Results 1,963 patients were included in the study (age 72 [IQR 61-80], 654 [33.3%] females). Men presented with an ischemic ECG (63 vs. 52%; p < 0.001) and need for TLR (68.4% vs. 53.9%; p < 0.001) more frequently than women. Ischemic ECG only predicted TLR in female patients (OR 1.86; 95% CI 1.38−2.54; p < 0.001 vs. OR 1.12; 95% CI 0.88–1.43; p = 0.351; p -interaction=0.012). This remained stable after adjustment using multivariable analysis (OR 1.79, 95%CI 1.22–2.60, p = 0.003). 30-day mortality was 139 (7%), 5-year mortality was 59%. There was a significant association between ischemic ECG changes and intrahospital and 5-year mortality in both sexes. Conclusion An ischemic prehospital ECG predicts MI requiring TLR in female patients and identifies high-risk patients for mortality in both sexes.