Racial/ethnic and gender inequities in door-to-needle time among patients with STEMI: results from the EQUITY-MI cohort
E C Almeida, E Ferreira, F N Albuquerque, P P D M Spineti, R Esporcatte, D C AlbuquerqueAbstract
Background
Limitations persist in the literature regarding disparities in the management of patients with ST-segment elevation myocardial infarction (STEMI), particularly when comparisons are made according to race/ethnicity and gender.
Objective
To compare clinical characteristics and to assess door-to-needle time (DNT) within 30 minutes and evaluate 180-day survival according to race/ethnicity (White, Brown [mixed race], and Black) and gender.
Methods
EQUITY-MI is a single-centre, prospective cohort study of patients diagnosed with STEMI in the state of Rio de Janeiro, Brazil, who were referred to a single reperfusion centre. Continuous variables were analysed using the Kruskal–Wallis test and categorical variables using the chi-squared test. To estimate the effect of DNT within 30 minutes, logistic regression models were applied and odds ratios (ORs) were calculated. Survival analysis was performed using the Kaplan–Meier method with comparisons by the log-rank test. Cox proportional hazards models were used to estimate crude and adjusted hazard ratios (HRs) for 180-day mortality, adjusting for age, race/ethnicity, education level and household income. A significance level of 0.05 was adopted.
Results
Among 504 patients with STEMI, 27.2% were women and 67.8% self-identified as Black or Brown (mixed race). DNT within 30 minutes occurred in 27.2% of White patients compared with 12.5% of Black patients (p = 0.07). Race/ethnicity was an independent predictor, with Black patients having 2.86-fold lower odds of achieving DNT within 30 minutes compared with White patients (OR = 0.349, p = 0.023). Female gender was associated with 2.40-fold lower odds of DNT within 30 minutes compared with male gender (OR = 0.416, p = 0.015). Considering the interaction between race/ethnicity and gender, Black women had 5.49-fold lower odds of DNT within 30 minutes (OR = 0.182, p = 0.028). Kaplan–Meier analysis demonstrated significantly lower cumulative survival among women compared with men (log-rank p = 0.001), whereas no significant differences were observed across racial/ethnic groups (p = 0.304). In Cox regression, female gender was independently associated with higher 180-day mortality in both unadjusted (HR 4.63; 95% CI 1.68–12.75; p = 0.003) and adjusted models (HR 3.98; 95% CI 1.36–11.66; p = 0.012).
Conclusion
The EQUITY-MI study demonstrated inequities in both efficiency of care and clinical outcomes related to gender and race/ethnicity. Door-to-needle time frequently exceeded the recommended 30-minute target. Black patients and women had lower odds of timely thrombolysis, and female gender was independently associated with higher 180-day mortality. The interaction between race/ethnicity and gender revealed a pattern of intersectionality, with Black women experiencing the most unfavourable scenario compared with White men.Door-to-needle times stratifiedCox regression for survival at 180 days