Sian Claire Owen, medical journalist for Cardio Debate, UK

Results from a study funded by the British Heart Foundation and published in Journal of the American Heart Association have hit the headlines claiming that women who suffer heart attacks are not being offered the same treatment as men. [1]

The report from the SWEDEHEART study analysed data from 48,118 patients, 35.4% of whom were women, and all who were diagnosed with acute myocardial infarction. The primary endpoint of this analysis was all-cause mortality, however researchers also looked at the likelihood of patients receiving the recommended evidence-based pharmacological drugs.

This study revealed that, on the surface women had a better adjusted prognosis than men after an acute MI. However, scratch beneath the surface and a different picture emerges.

Younger women (aged under 60 years) and women with ST-elevation Myocardial Infarction (STEMI) had a worse prognosis, and were less likely to be prescribed evidence-based treatment than their male counterparts. Furthermore, this discrepancy in gender did not decrease over two decades. [1]

Women in the study were more likely to have previously been diagnosed with hypertension or type II diabetes, and were also more likely to develop prehospital cardiogenic shock or in-hospital heart failure.

Sub-group analyses showed that the estimated risk for developing prehospital cardiogenic shock was higher for women compared to men (OR 1.67, 95% Cl 1.30 to 2.16, P<0.001), and the risk in women with STEMI was also higher compared to the risk in men (OR 1.31, 95%Cl 1.16 to 1.48). [1]

Other findings show that women with STEMI were less likely to undergo coronary angiography than men, and after adjustment of traditional CV risk factors women were less likely to receive evidence-based treatments including beta-blockers, ACE inhibitors, statins and P2Y12 inhibitors.

The reasons for this are unclear and certainly warrant further investigation. It is common for women to present at a later stage in the disease than men for a variety of reasons. For example, as Professor Angela Maas, Professor Women’s Cardiac Health, Cardiology Department, Radboud University Medical Center, Nijmegen, The Netherlands told Cardio Debate: “We often think hypertension is asymptomatic, but it can actually give a lot of symptoms, especially in women who are middle aged,” adding that: “It is easy to discriminate between stress-related elevated blood pressure and severe developmental hypertension. Just ask questions about pregnancy [e.g., the presence of gestational diabetes] or the family history.” [2]

However the study authors suggest the presence of ‘systemic undertreatment’ in women. [1] Professor Juan Tamargo, Professor of Pharmacology, Universidad Complutense, Madrid, Spain has previously addressed this issue with Cardio Debate, saying: “We need to clarify to people that there is a problem and that there are some ways to improve it.” [3]

“There is the feeling that male physicians usually consider that women need less strict treatments; we don’t give the same advice to women as we do to men. There are lots of things (regarding gender differences and gender treatment bias) that should be included in position papers and clinical guidelines [to avoid undertreatment in women].” [3]

Patients should be prescribed evidence-based medicines regardless of their gender, and this should be a given. Hopefully this study will steer the conversation in the right direction, and encourage the medical community to address this serious issue.

References

  1. Redfors B, Angeras O, Ramunddal T, et al. Trends in gender differences in cardiac care and outcome after acute myocardial infarction in Western Sweden: A report from the Swedish Web System for Enhancement of Evidence-Baed Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). J Am Heart Assoc DOI: 10.1161/JAHA.115.001995
  2. https://www.cardio-debate.com/2017/11/12/hypertension-in-post-menopausal-women-is-a-major-health-issue-prof-angela-maas/
  3. https://www.cardio-debate.com/2017/10/15/gender-differences-in-cardiovascular-disease/