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FOR some time, it has been known that men and women present differently with acute coronary syndromes (ACS). Observational studies have shown women are more likely to have atypical symptoms and that they present at an older age on average, with more comorbidities – all of which could logically lead to worse outcomes. But once you account for these and other differences, do women with ACS still do worse and do they get poorer treatment than men?
The answer on both counts, according to a new study published in the MJA, is yes – at least when the diagnosis is ST-elevation myocardial infarction (STEMI).
The study authors, from a number of hospitals across the country, found that revascularisation rates for women with STEMI are lower than for men, even after adjusting for risk category. Women are also less frequently referred for cardiac rehabilitation and less likely to get preventive medications such as b-blockers or statins. At 6 months, women were more likely to have another serious cardiovascular event, and were more likely to have died.
The cohort study involved almost 3000 patients with STEMI, around two-thirds of whom were men, identified prospectively from data collected from 41 Australian hospitals between 2009 and 2016.
Senior author, Professor Clara Chow of the University of Sydney and Westmead Hospital, says that going into the study, her hypothesis was that there would be no differences in treatment between the genders because STEMI had a clear diagnostic path and very well defined treatment protocols.
“Something is going wrong after diagnosis,” she told MJA InSight in an exclusive podcast. “Part of the previous literature was saying STEMI is diagnosed later in women, and potentially that could be the case, but once the diagnosis is made, men and women should get the same treatment and get revascularised. But it’s not occurring.”
Does the poorer treatment mean that some women presenting with STEMI may be dying unnecessarily?
“You have to raise that possibility,” Professor Chow says. “They are doing worse, this is a hard fact.”
Dr Jenny Deague, a Perth-based cardiologist who sits on the boards of both the Cardiac Society of Australia and New Zealand and the National Heart Foundation, says that the study findings are worrying but not necessarily surprising.
“STEMI treatment is very guideline-driven, so it’s disappointing to see the difference between men and women. But even at my own hospital, we did a study of door-to-balloon times and women had longer times, so we’re not identifying STEMI in women as easily as in men. We do see these differences at the coalface, but the good news is that we’re aware of the issue and we’re trying to reverse the biases, and things are getting better.”
Dr Deague, who was not involved in the MJA study, points to the finding that treatment did improve for women over the time period of the study.
“You’ve got to remember that the original coronary care units in Australia didn’t even let women into them. You were only allowed in if you were a bread-winning man. So, we’ve come a long way in women’s health. But coronary heart disease is the commonest killer of women, and treatment of STEMI is one area that we really should be able to nail down.”
She says that there’s been an upsurge of interest in women and heart disease among cardiologists.
“At the last European Society of Cardiology meeting I was at, they had a whole stream on women’s cardiology. And next year at the Cardiac Society meeting in Adelaide there will be a spotlight on heart disease in women. So, the cardiology community is focusing on all of this.”
Dr Deague says the most worrying aspect of the study for her is the worse mortality for women at 6 months.
“That’s my main concern. If the women were getting less medication but the mortality was the same, then that would be a difference that didn’t necessarily matter. But that’s not the case. Some people may not be able to tolerate b-blockers, but not to be given statins after STEMI is simply unacceptable.”
She says that one thing GPs can take away from this study is to ensure that when their patients come out of hospital with a STEMI that they are on statin medication.
“That’s something our GP colleagues can double-check on. They can ensure patients are in a cardiac [rehabilitation] program, have been considered for b-blockers and are on statin medication, in case the cardiologist missed it.”
In other STEMI news, the MJA is also publishing a research letter that shows that Victorian hospitals are struggling to meet the demands of new guideline requirements for door-to-balloon times in patients with STEMI. The recently updated guidelines tighten the recommended time from 90 to 60 minutes.
The research authors found that median door-to-balloon times in 16 Victorian hospitals where percutaneous coronary intervention was performed was 69 minutes – within the old guideline requirements, but outside the new ones.
Results were no better for patients presenting at hospital within the so-called golden first hour after symptom onset, when there is the greatest potential for myocardial salvage.
Reducing delays after hours and increasing rates of in-hospital notification of receiving hospitals could reduce door-to-balloon times, the authors say.
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I had complained to GP about intermittent chest pain. Question always was “what were you doing at the time” Nothing in particular. One stress test – “run till you have a heart attack” Really? Whos is going to do tha?
2012 had a STEMI at age 53. I was turned away from hospital, not believed.
Temporary correction followed by intermittent chest pain for a week. Returned to hospital with extreme chest pain one week later, woken from sleep by the pain. I had no other known health issues other than a serious asthma attack in 2009 suspected of having swine flu. but no subsequent issues. No dementia, no diabetes, no hypertension etc
10 hours later doctor organised a hospital transfer but not before repeatedly making derrogatory remarks about my physical appearance. Shipped out to 2nd hospital, arrived there 14 hours after onset. Approximately 27 hours after onset stents in place to clear 95% blockage and 70% blockage in same artery..
So much for 60-90 minute door-balloon guideline.
Very grateful for nursing care and final cardio specialist.
Was told by nursing staff I was lucky this specailist accepted the case as all other cardio specialists in that hospital refused to accept smokers. As if being a smoker was a childhood dream and I had not tried many times to quit. Managed to quit while in hospital.
Maintained all meds ever since including statins. I was referred for ‘rehabilitation’ but could not attend due to family pressures/committments at the time. No-one discussed with me importance of this follow up rehab, GP did not mention rehab.
Despite considerable heart damage as a result I have had no subsequent cardio events.
A few years later diagnosed with Hashimotos disease which would have most likely have been present at time of cardio event. Also stuggled to get a diagnosis because I was repeatedly not believed.
Why do doctors NOT believe women?
The MJA paper reports that “The mean age of women with STEMI at presentation was higher (66.6 years; standard deviation [SD], 14.5 years; men, 60.5 years; SD, 12.5 years), as was their mean GRACE score (123.5; SD, 33.3; men, 111.4; SD 30.0). Further, a larger proportion of women than of men had hypertension, diabetes, a history of prior stroke, chronic kidney disease, chronic heart failure, or dementia”. What is not clear from the paper, and possibly not extractable from the data, is whether there were sex differences when cases were matched for age and co-morbidities.
I agree with Guy; I cannot remember ever seeing that criterion for care. STEMIs are STEMIs. Women have more complications from stenting; has this been factored in? Are more women excluded from stenting for this reason? And women tend to be older; is the difference in treatment a factor of age or gender? Seems to have been overlooked in the article.
Can we have a reference to the assertion that ” you were only allowed in if you were a bread winning man”. I certainly don’t recall this restriction.