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AUSTRALIAN women with acute coronary syndromes (ACS) are less likely than men to receive evidence-based treatment, according to findings described by one leading international expert as “a huge, huge issue for women”.
Professor Roxana Mehran, Director of the Center for Interventional Cardiovascular Research and Clinical Trials at the Cardiovascular Research Institute at Mount Sinai School of Medicine in New York, told InSight+ in an exclusive podcast that the undertreatment of women in this area was largely down to a lack of data and female participation in clinical trials.
“The disparities continue to remain there, despite all of our education,” she said.
“We’re seeing that the prevalence of acute myocardial infarction is actually increasing instead of decreasing, especially among women over the age of 45. We are seeing that recurrent myocardial infarction and recurrent events are higher for women compared with men.
“We’re seeing increasing myocardial infarction in young women, or admissions for younger women presenting with an acute coronary syndromes, and we know that women present differently, they have different triggers, their lesion and their vessels look very different than men.”
Professor Mehran has coauthored an editorial, published in the MJA, in response to research from Bachelet and colleagues, detailing sex disparities in the management of non-ST-elevation ACS between men and women in Australian hospitals.
Professor Clara Chow, a cardiologist at Westmead Hospital and a co-author of the research, told InSight+ that these sex disparities were “no small thing” with no “single simple solution”.
Professor Chow and her colleagues analysed Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events (CONCORDANCE) registry data for patients diagnosed with non-ST-elevation ACS (NSTEACS) in 43 Australian hospitals during 23 February 2009 – 16 October 2018. They looked for receipt of guideline-based medications and invasive therapies, including cardiac catheterisation and revascularisation, with procedures and outcomes at the 6-month follow-up assessed by telephone interview.
“The proportion of women who underwent cardiac catheterisation was smaller (1710, 71% v 4134, 77%), and the median time to catheterisation was longer (53 h v 47 h); non-obstructive coronary artery disease was detected in a larger proportion of women than men during catheterisation (602, 35% v 566, 14%),” Bachelet and colleagues reported.
“At discharge, fewer women were prescribed aspirin (85% v 91%), a second antiplatelet medication (59% v 68%), β-blockers (71% v 75%), or statins (86% v 92%), or referred to cardiac rehabilitation (54% v 63%).
“Smaller proportions of women with coronary artery disease (CAD) than of men underwent coronary artery bypass grafting (110, 10% v 563, 16%) or were prescribed statins at discharge (94% v 96%). Fewer women than men were referred to cardiac rehabilitation (750, 69% v 2652, 75%), including among those who had been revascularised.”
Professor Chow told InSight+ that in women, non-obstructive coronary artery disease underlying their NSTEACS presentation was more common than in men.
“It might be because there are mechanisms that are more common in women that haven’t really been picked up and differentiated as clearly when we are doing the diagnostic studies.
“Of course, if you do less diagnostic studies in women, compared with men, that’s a big part of the problem as well.”
Professor Chow said the proportion of clinical trial participants who were women (20–30%) was “even more unbalanced than the actual presentation of that disease”.
Professor Chow told InSight+ that communication and recognising differences in the way women and men communicate their symptoms were part of the answer.
“I wonder sometimes if it’s in the way of taking the clinical history, that we don’t account for that properly, in how we communicate with patients,” she said.
“It often comes right back down to that communication.
“I’m not saying that that’s an excuse. But I am saying that we do need to see that people of all diverse backgrounds do communicate differently, and it does probably affect how we make a diagnosis quickly or not.
“One of the things that is occurring here is there is more delay with women [getting treated] compared with men, and maybe we need to somehow more quickly get through all of that complexity of that communication to get to the answer.
“I often tell my residents that you’ve got to base your decisions on objective markers.
“If [the patient has] a raised troponin, and an electrocardiogram abnormality, you’ve got enough [to make a decision]. Whether they tell you their chest pain is exactly typical, or atypical is not going to make the big jump – you need to move on.”
Is there unconscious sexism going on if women are being diagnosed with coronary artery CAD, but still going home undertreated and under-referred?
“I hope not,” said Professor Mehran.
“Why would you not want to refer women to angiography or refer women to coronary revascularisation, when we know that in ACS revascularisations are life-saving for these patients?
“Why aren’t they going home on guideline-directed medical therapies?
“Why are they getting less statins? Less antiplatelet regimens? We’ll never know the answer to these questions.
“We just have to keep drilling that this needs to stop. Hopefully, we can equalise it and bring [the numbers] up.”
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Sue Ieraci is correct to say that the US styled acute hospital / interventional cardiology / algorithms based churn is sub-optimal. We have failed to appreciate how the move to super sensitivity troponin assays has distorted our ‘look’ at acute ischaemia & distinguish genuine acute plaque rupture etc. from other causes of myocardial stress +/- symptoms.
The use of current ultra sensitive (Rule Out if negative) tests is very different from earlier CK-MB based (Rule In) strategies, where significant elevation had a high specificity for acute plaque rupture / coronary obstruction.
A fundamental point of Any test is that higher sensitivity moves hand in glove with loss of specificity.
So if many of the cases classified as ACS based on troponins are then clinically thought to be MINOCA = Myocardial infarction with non-obstructive coronary arteries, then of course there should be lower rates of anti-platelet & statin therapy & cardiac rehab referral…, as there is zero evidence these are needed. I expect this largely explains the apparent gender ‘disparity’ and suggests to me we need a better understanding of MINOCA & its best management.
The effort to make investigation and treatment more evidence-based needs to consider over-treatment and mis-treatment as well as under-treatment. Too much of acute hospital-based cardiology is about churning people through algorithms to interventional cardiology. Interventional cardiology was initially based on the model of the critical stenosis causing AMI – for which stenting is evidence-based.
Let’s remember the pathophysiology. Now that there are many more preventive strategies and less smoking, the massive “widow-maker” AMI is less common. Women with coronary disease tend to be older, with more diffuse disease. Just rushing through a couple of troponins and onto the lab is not the right strategy for these patients. There are many stents inserted for non-STEMIs – which is not evidence-based, but leaves the recipients requiring anticoagulants for life, with a risk of stent clotting.
So, let’s stop over-diagnosing and mis-diagnosing as well as under-diagnosing. Not every chest pain pathway should have a stent at the end.
Fully agree. I would even go so far as saying there is evidence to suggest a need for gendered primary health clinics. It is a serious equity issue from all bio-psycho-social aspects.
This is not new. Many articles have shown that women are diagnosed and treated less aggressively than men in this situation. It’s not credible that this difference is due to women’s “lack of participation in clinical trials”. Until we admit to the underlying causes then how will progress be made – we need to demand that female patients receive effective treatment.