Providing a 'Red Alert' for Women's Hearts -- MEDICA - World Forum for Medicine

Providing a 'Red Alert' for Women's Hearts

Photo: Female patient and doctor

Data from the World Health Orga-
nisation (WHO) show that CVD in
Europe accounts for 55 percent of
deaths in women compared to just
43 percent of deaths in men;
© Nyulaszi

Today on International Women's Day, the European Society of Cardiology (ESC) is calling for action to reduce the gender disparities that are currently resulting in women receiving second rate cardiovascular (CV) care.

Studies published show a persistent under-utilisation of guideline recommended treatments for heart disease in women compared to men.

"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," says 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 cardiovascular disease (CVD) isn't as serious in women as men."

Data from the World Health Organisation (WHO) show that CVD in Europe accounts for 55 percent of deaths in women compared to just 43 percent of deaths in men. While breast cancer - perhaps the most feared illnesses among women - is responsible for only 3 percent of female deaths. Moreover, recent data from the National Health and Nutrition Examination Surveys (NHANES) looking at tends in midlife coronary heart disease risk show over the past two decades the prevalence of myocardial infarction (MI) has increased in women aged 35 to 54 years, while declining in men of the same age.

"It's very important that physicians are aware that coronary artery disease (CAD) is a frequent disease among women, that gets more common as they get older," says Thomas Lüscher, editor of the EHJ, who has brought together a special issue exploring CV issues facing women.

The studies published in the themed issue raise particular concerns that women are being prescribed fewer drugs than men. "We were shocked to find that even after infarction - the most dramatic cardiac situation we envisage - there's still a dramatic under-utilisation of drugs in women," says Professor Thomas F. Lüscher, from University Hospital Zurich (Switzerland). "These issues need to be urgently corrected to ensure that women get equal access to state of the art treatments as men."

In the first EHJ study cardiologists from the University of Bologna (Bologna, Italy), and the University of Toronto (Toronto, Ontario, Canada), analysed the medical details of 4471 men and 2087 women who had experienced an acute coronary syndrome (heart attack) between 1999 and 2003. The details (which included 23 clinical variables) were recorded on the Canadian Registry of ACS I and I. Results show that women were less likely to:

• Receive beta-blocker: 75.76 percent of women received beta blockers in comparison to 79.24 percent of men (P<0.01).
• Receive lipid-modifying agents: 56.37 percent of women received lipid-modifying agents compared to 65.44 percent of men (P<0.0001).
• Receive angiotensin-converting enzyme (ACE) inhibitors – 55.52 percent of women received ACE inhibitors compared to 59.99 percent of men (P<0.01).

The authors led by Raffaele Bugiardini, from the University of Bologna (Bologna, Italy) say that the disparity appears to depend upon multiple factors related to patient age - women are more likely to be older with concerns about prescribing drugs in the elderly - , congestive heart failure - women are more likely to develop heart failure during ACS and physicians are reluctant to initiate beta blockers in patients with congestive heart failure -, and the physician's decision to undertake catheterization - women are less frequently referred for cardiac catheterization than men.

However, after adjusting for age, the presence of congestive heart failure, and whether or not the patient underwent catheterization, women still received fewer ACE-inhibitors and lipid lowering drugs than men. "We've known for years that women are treated differently from men, but now this study shifts the philosophy and starts to explain why," says Bugiardini.

In the second study between 2006 and 2008, Nina Johnston and colleagues from Uppsala University Hospital and Center for Gender Medicine, Karolinska Institutet, (Stockholm, Sweden) analysed use of cardiovascular medications and diagnostic coronary angiography in 7195 men and 5005 women with suspected coronary artery disease (CAD) after experiencing chest pain.

Results showed that prior to undergoing angiography 83 percent of women had been prescribed aspirin in comparison to 86.1 percent of men (P=0.001).

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

In the print version of the EHJ the two papers will be accompanied by an editorial by Noel Bairey Merz, from Cedar-Sinai Heart Institute (California, USA). The condition, Merz believes, affects women far more frequently than men and may explain why it is more difficult to make a diagnosis in women."We estimate that microvascular coronary dysfunction accounts for a third to one half of heart disease in mid-life women, but unlike obstructive CAD, it doesn't show up on an angiogram making it more difficult to diagnose," explains Merz.

"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," says Stramba-Badiale.; Source: European Society of Cardiology