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Arrhythmia Watch editorial team

Clinical Articles, Featured

Cardiovascular Disease – The gender gap not closing?

Women are receiving second-rate cardiovascular (CV) care compared to men, due to under-utilisation of guideline recommended treatments, according to research published recently in the European Heart Journal.

In a study1 by cardiologists from the Universities of Bologna and Toronto, the medical details of 4,471 men and 2,087 women who had experienced an acute coronary syndrome (ACS) between 1999 and 2003 were analysed. The details (which included 23 clinical variables) were recorded on the Canadian Registry of ACS I and I.

Gender Gap

Results show that women were less likely to:

– Receive beta-blocker: 75.76 % of women received beta blockers in comparison to 79.24% of men (p<0.01).

– Receive lipid-modifying agents: 56.37 % of women received lipid-modifying agents compared to 65.44% of men (p<0.0001).

– Receive angiotensin-converting enzyme (ACE) inhibitors – 55.52% of women received ACE inhibitors compared to 59.99% of men (p<0.01).

The authors, led by Dr Raffaele Bugiardini, University of Bologna, attribute the disparity to multiple factors. After adjusting for age, the presence of congestive heart failure, and whether or not the patient underwent catheterisation, women still received fewer ACE-inhibitors and lipid lowering drugs than men.

A second study2 led by Dr Nina Johnston of Uppsala University Hospital, examined the use of CV medications and diagnostic coronary angiography in 7,195 men and 5,005 women with suspected coronary artery disease (CAD), after experiencing chest pain,
between 2006 and 2008. Results showed that prior to undergoing angiography 83% of women had been prescribed aspirin in comparison to 86.1 % of men (p=0.001).

The study also showed that in the youngest age group (aged <59 years) 78.8% of women who underwent angiography were found to have normal/ non-significant CAD in comparison to 42.3% of men (p<0.001), and furthermore that 18.2% of men were diagnosed with left main or three vessel disease compared to 4.2% of women (p<0.001). This, say the authors, underlines the difficulty faced by clinicians in diagnosing CAD in women.

The studies accompany recent calls from the European Society of Cardiology (ESC) for action to reduce the gender disparities suggested by such results. “The ESC wants to raise awareness, among both cardiologists and the public, that women still are not receiving equal access to medical treatments and also are not being represented sufficiently in clinical trials,” said Marco Stramba Badiale, an ESC spokesman on women’s issues from IRCCS Istituto Auxologico Italiano, Milan.

“The problem is that despite female gender being associated with worse CV outcomes there are still major misconceptions among both health professionals and the public that CVD is not as serious in women as men…if physicians see women aged 55 to 60 years with atypical symptoms in the emergency room they don’t automatically think of heart attacks”.

Women must be included in RCTs

The ESC are calling upon the European Medicines Agency (EMA) to make the fair representation of women in clinical trials a requirement for the licensing of all pharmaceutical agents. This is supported by Work Package 6 of the EuroHeart project, a study that was undertaken by the ESC in conjunction with the European Heart Network. The study reviewed 62 randomised clinical trials published since 2006, finding that out of 389,891 participants, 33.5% were women, and that additionally only 50% of trials reported their analysis by gender.

“It’s very important that data concerning women is analysed separately because there are often differences in the pharmacodynamics, pharmacokinetics and physiology in comparison to men, making it possible that the efficacy of drugs might be completely different in women,” said Stramba-Badiale.

The American Heart Association (AHA) has taken action against gender inequality in a recent update to its Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.4 While a previous update in 2007 stipulated a >20% risk of coronary heart disease (CHD) in the next 10 years as criteria for ‘high risk’, the new guidelines lower the threshold to a >10% risk of dying from any CV event in the next 10 years.

The guidelines acknowledge that there is increasing concern amongst patients and clinicians over the management of CHD in women, and that there have been improvements in CVD risk factor awareness, treatment, and control. The authors state that future improvements will require “concerted efforts toward further research and the dissemination and implementation of lifestyle and treatment interventions,” as well as a “focus on incorporating multidimensional, interactive systems to increase accountability among payers, healthcare professionals, and patients for cardiovascular preventive care in women”

  1. R Bugiardini. AT Yan, RT Yan et al. Factors influencing underutilization of evidence-based therapies in women. European Heart Journal. Doi: 10.1093/eurheartj/ehr027.
  2. N Johnston, K Schenck-Gustafsson, B Lagerqvist et al. Are we using cardiovascular medications and coronary angiography appropriately in men and women with chest pain? European Heart Journal. Doi: 10.1093/eurheartj/ehr009
  3. Towfighi A, Zheng L, Ovbiagele B. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med. 2009;169:1762-6.
  4. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of CVD in women—2011 update. A guideline from the American Heart Association. Circulation 2011;123:1243-62.

Published on: April 6, 2011

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