|Year : 2022 | Volume
| Issue : 2 | Page : 67-72
Gender association with incidence, clinical profile, and outcome of out-of-hospital cardiac arrest: A middle east perspective
Fadi Khazaal, Abdulrahman Arabi, Ashfaq Patel, Rajvir Singh, Jassim Mohd Al Suwaidi, Awad Al-Qahtani, Salaheddin Omran Arafa, Nidal Asaad, Hajar A Hajar
Department of Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||09-Jul-2021|
|Date of Acceptance||07-Jun-2022|
|Date of Web Publication||23-Jul-2022|
Dr. Abdulrahman Arabi
Heart Hospital, Hamad Medical Corporation, Doha, Post Box: 3050
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide. However, there is limited information on the outcome of the OHCA in the Middle East population, and limited studies have been carried out in the Arab Gulf countries. Hence, we aim to study the incidence and rate of survival in the OHCA setting and to assess the impact of gender on the clinical outcome following OHCA.
Methods: Retrospective analysis of a prospective registry of all eligible, consecutive, and nontraumatic adult patients who successfully resuscitated (return of spontaneous circulation) from “Cardiac Arrest” occurring outside the hospital, Hospitalized in Doha, Qatar from January 1991 to June 2010.
Results: A total of 41,453 consecutive patients were admitted during the study, of whom 987 (2.4%) had a diagnosis of OHCA. Among them, 269 (27.3%) were women and 718 (72.7%) were men. Although the mortality rate was higher in females than in males (65.4% vs. 57.7%, P = 0.03), the logistic regression analysis did not show gender as an independent predictor of death in this clinical setting.
Conclusion: In this sample of the state population, women who have OHCAs had a lower rate of survival, but gender was not an independent predictor of mortality following OHCA.
Keywords: Cardiac arrest, cardiopulmonary resuscitation, gender, out-of-hospital cardiac arrest
|How to cite this article:|
Khazaal F, Arabi A, Patel A, Singh R, Al Suwaidi JM, Al-Qahtani A, Arafa SO, Asaad N, Hajar HA. Gender association with incidence, clinical profile, and outcome of out-of-hospital cardiac arrest: A middle east perspective. Heart Views 2022;23:67-72
|How to cite this URL:|
Khazaal F, Arabi A, Patel A, Singh R, Al Suwaidi JM, Al-Qahtani A, Arafa SO, Asaad N, Hajar HA. Gender association with incidence, clinical profile, and outcome of out-of-hospital cardiac arrest: A middle east perspective. Heart Views [serial online] 2022 [cited 2022 Dec 4];23:67-72. Available from: https://www.heartviews.org/text.asp?2022/23/2/67/351873
| Introduction|| |
More than 400,000 cases of out-of-hospital cardiac arrest (OHCA) have been identified annually in the United States. Many of these cases are due to coronary artery disease (CAD). Multiple studies have shown substantial gender differences in CAD presentation, management, complications, and outcomes. Ischemic heart disease occurs in women 7–10 years later as opposed to men. Acute coronary syndrome (ACS) occurs three to four times more frequently in men than in women below 60 years of age, but above 75 years of age, the majority of patients are women.
Women usually have atypical symptoms more frequently, up to 30% in some registries, and tend to present later than men. Women often have a greater chance of complications from bleeding with percutaneous coronary intervention (PCI). There is a major debate about poorer outcomes in women, and whether the poorer outcome is related to gender, old age, or more comorbidity among women with the ACS.,
Studies about the impact of gender on OHCA showed contradicting data; most of them are done in North America or Europe. There is no data available, to the best of our knowledge, in the Middle East population. In this study, we reviewed the impact of gender on the incidence, presentation, management, and outcomes of OHCA in Qatar.
| Methods|| |
This study is a retrospective analysis of a prospective registry of all eligible, consecutive, and nontraumatic adult patients who successfully resuscitated (return of spontaneous circulation) from “Cardiac Arrest” occurring outside the Hospital, Hospitalized in Doha, Qatar.
The mean and standard deviations are calculated for continuous variables and frequencies with percentages are described for categorical variables. Student's t-tests are applied to see a significant difference between males and females for continuous variables and Chi-square tests for categorical variables. Gender distribution according to years is presented in the form of figures. Multivariate logistics regression analysis is applied to see associated factors to gender using enter method with significant factors at univariate analysis. Adjusted odds ratios are presented in the forest graph. P = 0.05 (two-tailed) is considered a statistically significant level. IBM Corp. Released 2019. IBM SPSS Statistics for Windows, version 26.0. Armonk, NY: IBM Corp. is used for the statistical analysis.
Adults successfully resuscitated (return of spontaneous circulation) from “Cardiac Arrest” occurring outside the hospital, which was presumed cardiac in origin, who were admitted to the department of cardiology of Hamad Medical Corporation HMC between 1991 and 2010.
Excluded: OHCA who died on the scene/in ambulance/brought in dead, OHCA secondary to noncardiac causes (metabolic and drug overdose).
| Results|| |
A total of 41,453 patients were admitted to the cardiology department from January 1991 to June 2010; of these, 987 (2.4%) were admitted after sustaining OHCA. Among them, 269 (27.3%) were women and 718 (72.7%) were men.
Twenty percent of the total OHCA patients survived to hospital admission. About 40.2% of these patients survived to discharge. Hence, the survival rate is around 8%.
The temporal trend in patients with OHCA according to gender is shown in [Figure 1]. The number of OHCA male patients steadily increased over time (59%), whereas the number of OHCA female patients showed a plateau (P = 0.03).
|Figure 1: The temporal trend in patients with OHCA according to gender. OHCA, out-of-hospital cardiac arrest. OHCA: Out-of-Hospital Cardiac Arrest|
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Baseline clinical characteristics
Women9 were older (61 ± 14 years vs. 55 ± 15 years, P = 0.001), more likely to be Middle Eastern Arabs (77.7% vs. 48.6%, P = 0.001).
Women were more likely to have diabetes mellitus (DM) (62.1% vs. 35.5%, P = 0.001), hypertension (HTN) (63.9% vs. 34.7%, P = 0.001), and chronic renal failure (12.3% vs. 5.6%, P = 0.001) and more obese (body mass index ≥30) (41.2% vs. 23.9%, P = 0.02) but less likely to be smokers (1.9% vs. 26.6%, P = 0.001) [Table 1].
According to clinical profiles, dyspnea was a more common presenting symptom in female patients (36.4% vs. 20.5%, P = 0.001), whereas chest pain was more common in males (30.6% vs. 17.8%, P = 0.001) [Table 2].
ST-segment elevation myocardial infarction
Of note, there was a significant difference in events of myocardial infarction in females versus males (13.8% vs. 36.1%, P = 0.001).
It was noted that antithrombotic therapy was used less in a group of females (4.8% vs. 17.3%, P = 0.001). However, there was no significant difference in the use of evidence-based medications among patients [Table 3]. Furthermore, males were undergoing PCI and implantation of intra-aortic balloon pump more than females (13% vs. 5.2%, P = 0.001 and 4.7% vs. 0.7%, P = 0.003, respectively) [Table 4].
|Table 4: Percutaneous procedures done for out-of-hospital cardiac arrest patients|
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Although the mortality rate was higher in females than in males (65.4% vs. 57.7%, P = 0.03), the multivariate logistic regression analysis did not show gender as an independent predictor of death in this clinical setting.
| Discussion|| |
Survival outcomes from OHCA are generally poor with survival-to-discharge rates ranging from 3.0% to 16.3%. In our analysis, the survival rate was 8% within the same range. Several studies have reported varying gender-specific survival results, and the findings have been somewhat contradictory.,,,,,,,
We found substantial male predominance among OHCA patients, consistent with previous studies., Female patients with OHCA were older, and more likely to have comorbid conditions (HTN, DM, and case report forms), which is also consistent with previous reports.,,
While the total number of OHCA patients increased overtime over the 20-year study period, the incidence per 100,000 population decreased [Figure 2]. The reason for this is due to the special nature of the Qatari population, which tripled since 2001 (600,000 population in 2001 and 1.6 million in 2010), in fact, the main cause of this increase is the influx of a young healthy workforce into the state of Qatar; this age group is not only significantly lower than the average age of patients with OHCA at presentation, however, this is a preselected group of healthy individuals who had undergone preemployment health screening before arrival in the country [Figure 3]. Another potential reason for the decline in the in-hospital mortality rate in the last quarter (2006–2010) as compared with the period prior (1996–2005) is the increased use of the PCI in the latter group (more specifically in those with ST-segment elevation myocardial infarction [STEMI]), as this is the only treatment that has been shown to have a beneficial impact on survival. Improvements in multidisciplinary and intensive medical care are also likely contributors to this favorable trend.
|Figure 2: The incidence of OHCA per 100,000 population. OHCA: Out-of-Hospital Cardiac Arrest|
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Preceding symptoms and treatment
Data from the retrospective analysis of a prospective registry of all cardiac patients hospitalized post successfully resuscitated post-OHCA suggests that women who suffer an OHCA have fewer specific symptoms. The most common presenting symptom in male patients with OHCA was chest pain where female patients were more likely to have shortness of breath (not chest pain), and more male patients had STEMI on presentation and that is explained why female patients were less likely to be treated with antithrombotic therapy/PCI and were less likely to have Intra-Aortic Balloon Pump (IABP) insertion. However, among those with definite STEMI, both genders were treated the same. The ejection fraction was similar in males and females.
Like previous studies, survival outcomes also differed across genders in our study but when survival is adjusted for this imbalance in predictors of outcome, the gender difference in survival to discharge disappears [Figure 4].
The study is a 20-year registry during which treatments had changed. The quality of postarrest care includes the implementation of a comprehensive, multidisciplinary system of care with structured interventions including extracorporeal membrane oxygenation and hypothermia management has been shown to affect the outcome;, which was not available at the time of the registry, however, it is conceivable that differences in-hospital care may lead to differences in long-term survival rates,,, after cardiac arrest. Hence, in future studies, it is important to assess the impact of postarrest care on OHCA outcomes. Another study limitation inherent in all studies of observational design is the accuracy of the findings of the study depends on the accuracy of the collected data, which are difficult to verify in a retrospective manner.
| Conclusion|| |
In this sample of the state population, women who have OHCA had a lower rate of survival, but gender was not an independent predictor of mortality following OHCA.
We appreciate all staff who are involved in data collection and data supervision. We also convey thanks to the participants of the cardiology inpatient data (CCUx) registry, Heart Hospital, Doha, Qatar.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al
. Heart disease and stroke statistics-2013 update: A report from the American Heart Association. Circulation 2013;127:e6-245.
Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al
. Heart disease and stroke statistics-2008 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-146.
EUGenMed Cardiovascular Clinical Study Group, Regitz-Zagrosek V, Oertelt-Prigione S, Prescott E, Franconi F, Gerdts E, et al
. Gender in cardiovascular diseases: Impact on clinical manifestations, management, and outcomes. Eur Heart J 2016;37:24-34.
Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, et al
. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the Global Registry of Acute Coronary Events. Chest 2004;126:461-9.
Kaul P, Armstrong PW, Sookram S, Leung BK, Brass N, Welsh RC. Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction. Am Heart J 2011;161:91-7.
Kytö V, Sipilä J, Rautava P. Gender and in-hospital mortality of ST-segment elevation myocardial infarction (from a multihospital nationwide registry study of 31,689 patients). Am J Cardiol 2015;115:303-6.
Kang SH, Suh JW, Yoon CH, Cho MC, Kim YJ, Chae SC, et al
. Sex differences in management and mortality of patients with ST-elevation myocardial infarction (from the Korean Acute Myocardial Infarction National Registry). Am J Cardiol 2012;109:787-93.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al
. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.
Kannel WB, McGee DL. Epidemiology of sudden death: Insights from the Framingham Study. Cardiovasc Clin 1985;15:93-105.
Arrich J, Sterz F, Fleischhackl R, Uray T, Losert H, Kliegel A, et al.
Gender modifies the influence of age on outcome after successfully resuscitated cardiac arrest: A retrospective cohort study. Medicine (Baltimore) 2006;85:288-94.
Herlitz J, Engdahl J, Svensson L, Young M, Angquist KA, Holmberg S. Is female sex associated with increased survival after out-of-hospital cardiac arrest? Resuscitation 2004;60:197-203.
Vukmir RB. Prehospital cardiac arrest and the adverse effect of male gender, but not age, on outcome. J Womens Health (Larchmt) 2003;12:667-73.
Kim C, Fahrenbruch CE, Cobb LA, Eisenberg MS. Out-of-hospital cardiac arrest in men and women. Circulation 2001;104:2699-703.
Perers E, Abrahamsson P, Bång A, Engdahl J, Karlson BW, Lindqvist J, et al.
Outcomes of patients hospitalized after out-of-hospital cardiac arrest in relation to sex. Coron Artery Dis 1999;10:509-14.
Perers E, Abrahamsson P, Bång A, Engdahl J, Lindqvist J, Karlson BW, et al.
There is a difference in characteristics and outcome between women and men who suffer out of hospital cardiac arrest. Resuscitation 1999;40:133-40.
Kannel WB, Schatzkin A. Sudden death: Lessons from subsets in population studies. J Am Coll Cardiol 1985;5:141B-9B.
Castrén M, Silfvast T, Rubertsson S, Niskanen M, Valsson F, Wanscher M, et al
. Scandinavian clinical practice guidelines for therapeutic hypothermia and post-resuscitation care after cardiac arrest. Acta Anaesthesiol Scand 2009;53:280-8.
Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, et al
. Part 9: Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S768-86.
Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, et al.
Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 2007;73:29-39.
Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: Insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv 2010;3:200-7.
Martinell L, Larsson M, Bång A, Karlsson T, Lindqvist J, Thorén AB, et al
. Survival in out-of-hospital cardiac arrest before and after use of advanced postresuscitation care: A survey focusing on incidence, patient characteristics, survival, and estimated cerebral function after postresuscitation care. Am J Emerg Med 2010;28:543-51.
Sunde K, Søreide E. Therapeutic hypothermia after cardiac arrest: Where are we now? Curr Opin Crit Care 2011;17:247-53.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]