What is…
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Disparities Among Women
in Acute Cardiac Care
Frances Canet, MD
Cath Conference
Thursday, May 26, 2011
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Gender Disparities Across the
Spectrum of Acute Cardiac Care
Epidemiology
Diagnosis
Evaluation
Treatment
Medications
Interventions
Outpatient Follow-up
Outcomes
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Epidemiology
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Leading
Causes of
Death for
American
Women
(2005)
Heart Disease Death Rates 1999-2003
Adults Ages 35 Years and Older by County
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Among women ages 18 and
older:
17.3 % are smokers
51.6% are overweight (BMI greater
than 25)
27% have hypertension
35% have high cholesterol
53% do not meet physical activity
recommendations.
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Age Difference
Heart disease mortality increases
for both women and men with
age.
- For men, mortality is increased
at all ages.
- In women, the heart disease
manifestation is delayed 10
years.
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Symptomatic Presentation of MI
For both genders, the
predominant symptoms is
chest pain.
Women are more likely to
have atypical symptoms
-Abdominal pain
-Neck and shoulder pain
-Painless dyspnea and
extreme fatigue in older
women and in women with
diabetes
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Diagnosis
The pretest
probability of
coronary heart
disease is lower in
women with chest
pain presenting for
diagnostic
evaluation
compared to men.
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Evaluation
Gender Disparities in the Diagnosis and
Treatment of Non-ST Segment Elevation Acute
Coronary Syndromes
2005 –CRUSADE (Can Rapid Risk Stratification
of Unstable Angina Patients Suppress Adverse
Outcomes With Early Implementation of the
American College of Cardiology/American
Heart Association Guidelines)
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Study Highlights
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Involved about 35,000 patients of which 41% were
women.
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Women were older (73 vs. 65) and more often had
diabetes and hypertension.
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Women were less likely to receive acute heparin,
angiotensin converting enzyme inhibitors (ACEi), and
glycoprotein IIb/IIIa inhibitors.
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Women were also less likely to receive aspirin, ACEi
and statins at discharge.
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Cardiac catheterization and revascularization was
higher in men.
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Study Highlights (continued)
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Among patient with significant CAD, percutaneous
revascularization was performed in a similar proportion
of women and men.
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Higher in hospital death for women (5.6% vs. 4.3%)
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Higher risk for re-infarction (4.0% vs. 3.5%)
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Higher risk for heart failure (12.1% vs. 8.8%)
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Higher risk of stroke (1.1% vs. 0.8%)
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Higher risk of red blood cell transfusion (17.2% vs.
13.2%)
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Treatment
Women were:
-less likely to have an ECG performed
with 10 minutes of hospital presentation
(25.2% vs. 29.3% for men)
-less likely to be cared for by a
cardiologist (53.4% vs. 63.4% for men)
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Interventions
Men were:
-more likely to undergo diagnostic
catheterization
-more likely to have revascularization
procedures
Women were:
-more likely to undergo stress testing
-less likely to receive coronary thrombolysis,
and more likely to have major bleeding if
they did
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Race and Gender Disparities in
Rates of Cardiac Revascularization
-Do disparities reflect appropriate use of
procedures or problems in quality of
care?
-Randomized 5026 Medicare
beneficiaries aged 65-75
-Compared underuse or the failure to
receive a clinically indicated
revascularization procedure vs. receipt
of a revascularization that was not
clinically indicated.
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Race and Gender Disparities in
Rates of Cardiac Revascularization
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Results:
-Revascularization was more clinically
indicated among whites than black and
among men than women.
-Failure to receive vascularization was
more common among blacks than whites
(40% vs. 23-24%), but similar among men
and women (25% vs. 22-24%)
Race and Gender Disparities in
Rates of Cardiac Revascularization
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Results:
-Among patients who received
inappropriate revascularization , use was
greater for whites than blacks using RAND
criteria (10.5% vs.5.8%)
-Greater for men than for women (14.2%
vs. 5.3% by RAND criteria)
Disparities in the Outcome of
Cardiac Interventions
-204 women compared to 577 men who
had undergone direct
angiography/primary PTCA for acute
STEMI
-PTCA was equally successful (95% in
women, 94% in men)
-No difference in 30 day mortality
-Higher post-discharge mortality after 3
years, significant after 4 years.
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Reasons for improvement in periprocedural complication rates and
long-term outcome after PCI in
women.
-Improvement of interventional
techniques
-Increase in number of implanted stents
-Improvement of antithrombotic
medications
-Statins
-Intensive control of cardiovascular risk
factors (diabetes)
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Coronary Artery Bypass Graft
Surgery
-Women are usually older with more
frequent comorbidity (DM, HTN).
-Perioperative mortality rate of 4.5% for
women compared with 1.9% for men.
-Post-operatively women had a
comparable 15-year survival to men.
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Do gender disparities exist if access
to medical care is controlled?
-”Sex and Racial/Ethnic Disparities in Outcomes
After Acute Myocardial Infarction”
-Relative to white men, black men: Hazard
ratio for increase risk of acute MI recurrence
was 1.44.
-Black women: 1.47
-Asian women :1.37
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More gender disparities
Women were less likely then men to
receive Aspirin and Nitroglycerin in the
out-of- hospital management of chest
pain.
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Why the disparity?
Driven by patient preferences.
The manner in which chest pain is recognized or
diagnosed by out-of-hospital personnel.
The gender of the provider, influences the delivery
of cardiac care.
Poor adherence to out-of-hospital chest pain
protocols.
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Disparities in Outpatient Care
-Women were less likely than men to
have low-density lipoprotein cholesterol
controlled at <100mg/dL in those who
have diabetes.
-Among participants with diabetes,
44.3% of men and 38.5% of women met
LDL control measures.
-In patients with a history of
cardiovascular disease, 55.6% of men
and 46.6% of women met LDL control
measures.
-Women achieved higher performance
than men in controlling blood pressure,
70.8% for women an 68.9% for men.
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Disparities in Cardiovascular
Disease Extend Into:
Congestive heart failure
Advanced heart failure therapies
Arrhythmia Management and EP
devices
Cerebrovascular accidents
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Summary
-Cardiovascular disease is the number
one cause of death among women, but
awareness in the public is still growing.
-Awareness for heart disease in women
has become a topic of interest because
of the vast disparities compared to men :
presentation, diagnosis, treatment,
outcome .
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Conclusions
-Despite protocols for management and
treatment of heart disease, the gender
disparity exists, except in coronary
revascularization.
-Data collection has been ongoing and
yet mechanisms of disparities have yet to
be delineated.
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Conclusions
-One would expect that with increased
awareness of women’s heart disease and its
risk factors among the general public coupled
with care provider awareness about the
disparities between men and women, the
disparity gap will close.
-Perhaps, the risk factors for cardiovascular
disease need their own campaigns
individually.
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The End