Persistent Sex Disparities in Pre-hospital Delay Among STEMI Patients Despite Overall Improvements: Findings from the Chinese Cardiovascular Association Chest Pain Center Registry

BACKGROUND Women with ST-elevation myocardial infarction (STEMI) historically experience longer pre-hospital delays than men. Whether this disparity has narrowed in China following nationwide quality initiatives remains unknown.

We analyzed 1,104,812 STEMI patients from the Chinese Cardiovascular Association Database-Chest Pain Center (2016–2023). Pre-hospital delay (symptom-to-door time) and its components (symptom-to-call [EMS call delay], call-to-door [transport delay]) were analyzed. Sex differences were assessed using multivariable quantile regression (adjusting for age, comorbidities, cardiovascular risk factors), examining trends over time (2016–2019, 2020–2022, 2023).

Women consistently experienced longer pre-hospital delays than men (median: 170 vs. 124 minutes; adjusted median difference: 24.44 min, 95%CI:22.71– 26.16, P60 min wider at 90th percentile by 2023). Decomposition revealed the disparity was primarily driven by EMS call delay (adjusted difference: 13.42 min, 95%CI:10.76–16.08, P<0.001), not transport delay (1.49 min, P<0.001). Younger women (<60 years) exhibited the largest relative disparity. The 2020–2022 pandemic period disrupted improvement trends, especially for EMS call delay.

Despite overall reductions in pre-hospital delay for STEMI in China, sex disparities persisted, especially younger women. Targeted interventions addressing symptom recognition and help-seeking behavior in women are urgently needed. Competing Interest Statement The authors have declared no competing interest. Clinical Trial This study is a retrospective analysis of registry data (CCA Database-Chest Pain Center, 2016-2023) without prospective intervention. As a non-interventional observational study, it is exempt from clinical trial registration per ICMJE guidelines. Funding Statement This research was supported by the National Natural Science Foundation of China (82273733; 82170342; T2288101) and the Foundation of Shanghai Hospital Development Center (SHDC2023CRS034). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All data utilized in this study have undergone anonymization procedures and adhere to a privacy and confidentiality agreement. The anonymized data will be accessed upon formal request and subsequent review by the data management committee of the CCA Database - Chest Pain Center. The study was approved by the Ethical Committee of Zhongshan hospital, Fudan University (approval no. B2024-045). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Nonstandard Abbreviations and Acronyms - CCA - Chinese Cardiovascular Association - EMS - Emergency medical service - NCPCP - National Cardiovascular Patient Care Program - MICE - Multiple Imputation by Chained Equations