Introduction: The Mortality Gap in Cardiovascular Care
It is a well-documented but poorly addressed paradox in modern medicine: patients with mental health conditions (MHCs) die significantly earlier than the general population, often due to cardiovascular disease rather than their psychiatric illness. While lifestyle factors and medication side effects contribute to this disparity, growing evidence suggests that the healthcare system itself may provide different levels of care to those labeled with psychiatric diagnoses. A recent study published in the European Heart Journal: Quality of Care and Clinical Outcomes, titled Disparities in ST-elevation myocardial infarction diagnosis and management among patients with mental health conditions, provides a sobering look at how these disparities manifest in the highest-stakes environment of clinical cardiology: the management of ST-elevation myocardial infarction (STEMI).
STEMI care is governed by the mantra time is muscle. Every minute of delay in restoring coronary blood flow correlates directly with myocardial necrosis, heart failure, and death. Despite the implementation of standardized fast-track protocols designed to minimize human error and bias, this new research indicates that a history of mental health conditions remains a significant barrier to timely intervention and survival.
Study Design: The EVALFAST Registry
To investigate these disparities, researchers analyzed data from the EVALFAST prospective registry. This registry tracks confirmed STEMI patients admitted directly to the catheterization laboratory at Fribourg Hospital, a high-volume center, since June 2008. By focusing on a single, well-organized center with established protocols, the study aimed to determine if MHC-related delays persist even when the clinical pathway is optimized.
The study population included 1,208 patients, excluding those who presented with cardiac arrest to avoid confounding by the severity of initial presentation. Patients were classified into the MHC cohort if their electronic health records documented any psychiatric condition—ranging from mood disorders to psychotic disorders—at the time of their STEMI diagnosis. Approximately 12.1% (147 patients) met this criteria.
The primary endpoint was the time from first medical contact (FMC) to diagnosis. Secondary endpoints included FMC-to-balloon time (total ischemic time from a system perspective), infarct size measured by peak CK-MB levels, and major adverse cardiac and cerebrovascular events (MACCE) at 30 days and five years. Researchers used generalized linear models and Cox regression to adjust for demographic differences, cardiovascular risk factors, and the mode of presentation.
Key Findings: The Diagnostic Delay
The demographic analysis revealed that the MHC cohort was significantly different from the control group. Patients with MHCs were more likely to be women (36.7% vs. 23.3%) and had a higher prevalence of hypertension. This baseline difference suggests that MHC patients may present with more complex clinical profiles even before the acute event.
However, the most striking findings were related to treatment timelines. After adjusting for all relevant variables, patients with MHCs experienced a significantly longer time from first medical contact to diagnosis, with an average delay of +16.43 minutes (95% CI +4.19 to +28.68; P = 0.009). This initial diagnostic lag cascaded into a prolonged FMC-to-balloon time, which was +18.63 minutes longer in the MHC group (95% CI +4.86 to +32.39; P = 0.008).
Crucially, the study found no significant difference in the diagnosis-to-balloon time (P = 0.420). This indicates that once the STEMI was officially recognized, the catheterization laboratory team treated MHC patients with the same efficiency as anyone else. The failure occurred earlier in the process—at the point of initial clinical suspicion and diagnostic confirmation.
Impact on Myocardial Health and Survival
These minutes were not clinically silent. The delay in diagnosis and subsequent reperfusion translated into objective evidence of greater myocardial damage. Patients in the MHC cohort had significantly larger infarct sizes, with peak CK-MB levels averaging +71.3 U/L higher than their peers (95% CI +18.0 to +124.6; P = 0.009).
The long-term consequences were even more pronounced. The MHC group faced a higher risk of 30-day MACCE (adjusted Hazard Ratio [HR] 1.82; 95% CI 1.05-3.17; P = 0.034). Most alarmingly, the risk of cardiovascular death at five years was more than doubled for patients with a mental health history (adjusted HR 2.04; 95% CI 1.18-3.55; P = 0.011).
The Phenomenon of Diagnostic Overshadowing
The researchers noted that delays were particularly pronounced among patients who self-presented to the emergency department rather than arriving via ambulance. This suggests that the interaction between the patient and the initial triage staff is a critical point of failure.
This phenomenon is often referred to as diagnostic overshadowing, where a patient’s physical symptoms are attributed to their psychiatric history rather than an underlying medical condition. For instance, chest pain or shortness of breath in a patient with a known anxiety disorder might be prematurely labeled as a panic attack, leading to a delay in ordering an electrocardiogram (ECG).
Furthermore, communication barriers may play a role. Patients with certain mental health conditions may describe their symptoms in non-traditional ways, or their affect may not match the severity of their physiological distress, potentially misleading clinicians who rely on typical clinical presentations to trigger rapid action.
Expert Commentary and Clinical Implications
The findings from the EVALFAST registry suggest that institutional protocols alone are insufficient to overcome the implicit biases associated with mental health diagnoses. Even in a fast-track system, the gatekeeping phase—the time between a patient appearing before a clinician and the clinician deciding to act—is vulnerable to subjectivity.
For clinicians and hospital administrators, these data suggest several areas for improvement:
1. Standardized Triage Triggers: Emergency departments should implement strict, symptom-based triggers for ECGs (e.g., any chest pain or unexplained shortness of breath) that bypass the need for a physician’s initial psychiatric assessment.
2. Implicit Bias Training: Medical staff should be educated on the risks of diagnostic overshadowing and the high cardiovascular burden in the psychiatric population.
3. Integrated Care Pathways: Closer collaboration between psychiatry and cardiology is needed to ensure that patients with chronic mental illness receive aggressive primary and secondary cardiovascular prevention.
Conclusion: A Call for Equitable Urgency
The study by Garin et al. serves as a powerful reminder that clinical outcomes are not just a product of technical skill in the catheterization lab, but of the equitable application of diagnostic urgency. A history of mental illness should not be a prognostic factor for heart disease, yet this data shows it currently is. To close the mortality gap, health systems must ensure that the label of a mental health condition does not slow the clock when every second counts.
References
Garin D, Mendola E, Faucherre Y, et al. Disparities in ST-elevation myocardial infarction diagnosis and management among patients with mental health conditions. Eur Heart J Qual Care Clin Outcomes. 2025;11(8):1431-1439. doi:10.1093/ehjqcco/qcaf088.
