DrSamGirgis.com has the pleasure of hosting the following post by guest blogger, Dr. Richard Andraws MD, who is a Board Certified Cardiologist
The heart of a woman falls back with the night,
And enters some alien cage in its plight,
And tries to forget it has dreamed of the stars,
While it breaks, breaks, breaks on the sheltering bars.
-Georgia Douglas Johnson
Men and women are different creatures. Works ranging from the Bible to Hesiod’s Theogeny to John Gray’s contemporary tome on the celestial origins of the sexes have told us as much. To an extent, we accept this as a fact of life. Indeed, it adds a certain intrigue and spice to things. But when it comes to healthcare, gender disparities are much less tolerable. But why do such disparities even exist? Why does cardiac care in women seem so fraught with them?
Historically, heart disease has been a man’s disease. Men appear to develop it and suffer its consequences earlier and more frequently. The classic descriptions of heart-related chest pain (angina) derive from male patients. And most of the science on the diagnosis and treatment of heart disease has disproportionately focused on male subjects. Despite this, cardiovascular disease is the leading cause of death among American women, and its prevalence is increasing.
Cardiologists have recognized that heart disease has been underdiagnosed in women, leading to faulty clinical reasoning and treatment. A major reason for this is that women tend to present “atypically,” meaning that their symptoms are often very different from those of men. For instance, they may not get classical chest pain (or chest pain at all) when having a heart attack. And a woman’s chest pain may not correlate to significant blockages in her coronary arteries (i.e. the blood vessels that feed the heart). Aware of these complexities, cardiologists should be treating women as aggressively as men if not more so.
But are we?
With that question in mind, Bugiardini and colleagues (in the latest issue of European Heart Journal) reviewed the Canadian Registry of ACS I and II. These were databases of patient information culled from thousands of individuals presenting with heart attacks or heart attack symptoms to hospitals across Canada. Information collected included basic demographics, clinical findings, procedures the patients’ underwent, and medications at discharge. The investigators examined the use of evidence-based medications at discharge in women versus men.
In general, women fared worse than men, a previously described finding. Except for agents like aspirin, women were significantly less likely to receive several beneficial medication classes. This primarily was because women were older, developed congestive heart failure more frequently, and were less likely to undergo a catheterization procedure. The investigators hypothesize that these factors may have caused physicians to be less aggressive for fear of worsening their outcomes. Additionally, they may have felt there was not enough evidence to support certain medications in older, sicker, or “lower risk” patients. Doctors appeared more aggressive with women undergoing (or having undergone) bypass surgery, but even then there was inconsistency.
The study was limited by the data available in the registries. The investigators could only analyze medications at discharge and not subsequent treatment. There were no data on which patients could not receive certain drugs due to other conditions or allergies. And patterns of treatment change as time goes on: the database covered the years 1999 to 2001, the beginning of a period of intense improvement in treating heart disease and women with heart disease. Thus, it may not be reflective of current trends. However, Bugiardini and colleagues remind us that while a woman’s heart may be unique, it should not be left to its plight without the very best care available.
Bugiardini R, Yan AT, Yan RT, et al. Factors influencing underutilization of evidence-based therapies in women. European Heart Journal. 2011; 32:1337-1344.
Cardiovascular Disease Prevalence and Mortality (http://cfpub.epa.gov/eroe/index.cfm?fuseaction=detail.viewInd&lv=list.listbyalpha&r=235292&subtop=381)
Heberden W. Some account of a disorder of the breast. Medical Transactions 2, 59-67 (1772) London: Royal College of Physicians.
Kim ESH, Menon V. Status of women in cardiovascular clinical trials. Arteriosclerosis, Thrombosis, and Vascular Biology. 2009; 29: 279-283
Johnson BD, Shaw LJ, Pepine CJ, et al. Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women’s Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 2006; 27: 1408-1415.