The Main Artery

Despite increased attention, efforts to highlight the differences between men and women’s heart care may not be working as well as we’d like to think.

Here’s the lead from a story I recently read:

“The risk factor profile in women presenting with acute coronary syndrome (ACS) and acute MI is distinctive compared to men, and cardiologists need to tailor their management of women with these differences in mind,” noted Kimberly A. Skelding, MD, during a presentation at the 33rd annual scientific sessions for the Society for Cardiovascular Angiography and Interventions (SCAI).

Really? This is still big news?

I don’t mean to diss Dr. Skelding’s findings in any way. In fact, thank God, she’s out there talking about them.

I’m just discouraged. I remember working on an ad more than 20 years ago for one of our clients that stressed the need to recognize differences in women’s CV symptoms and care.

Despite more than two decades of marketing and education, many problems are still rampant in women’s heart care. Dr. Skelding highlighted the following:

- later referrals, which equates to more advanced coronary artery disease

- more urgent or emergency procedures and longer door-to-balloon times

- lower rates of internal mammary artery grafts with bypass surgery, even after adjustment for age, extent of disease and urgent surgery

“Although we’re improving mortality overall in both groups, we’re not doing it as well in women,” said Skelding, who encouraged practitioners to examine these potential treatment disparities at their own institutions.

Only 33 percent of PCI procedures are performed in women annually, and delayed treatment for women is common—often more than 24 hours after presentation.

“It’s hard to say if this delay is a result of the disease state not being as well recognized or due to a lack of aggressive treatment,” she said.

Skelding offered several additional insights:

• Women continue to be underrepresented in clinical trials for PCI, as they don’t meet the inclusionary criteria.

• Women are 61 percent more likely to present with in-stent restenosis following drug-eluting stent implantation, particularly diffuse in-stent restenosis.

• Almost two-times more women will return to the ER within 30 days of their intervention, even after successful      interventions.

• For anticoagulants, among drug applications submitted to the FDA between 1994 and 2000, 20 percent had gender differences in pharmacokinetics, including more hepatic cytochrome CYP3A in women; more dietary supplements taken by women; more accumulation in fat; and less renal excretion.

• Women with acute coronary syndrome are less likely to have an ECG done within 10 minutes of presentation; less likely to be cared for by a cardiologist during their inpatient admission; and less likely to acutely be given appropriate pharmacotherapy.

• Following PCI, women with ACS have a 37 percent higher risk of death, MI or rehospitalization than men with ACS.

• Women who are less than 65 years old have a 46 percent higher risk of death, MI or rehospitalization.

There also are gender differences in atherosclerosis, including plaque erosion.

And for the treatment of acute MI in clinical practice, women have longer door-to-balloon times and are still less likely to undergo invasive evaluation on the index admission regardless of age.

Based on all the clinical data, Skelding encouraged cardiologists to “treat with parity. Examine your local data to see how your female patients are being diagnosed and treated in order to improve outcomes, improve practice and improve enrollment in clinical trials.”

We can only hope that physicians and patients alike listen to this advice. I think we all have a lot of work to do.