Under-treatment of ACS in women: “it must stop”

AUSTRALIAN women with acute coronary syndromes (ACS) are less likely than men to receive evidence-based treatment, according to findings described by a leading international expert as “a huge problem for women”.

Professor Roxana Mehran, director of the Center for Interventional Cardiovascular Research and Clinical Trials at the Cardiovascular Research Institute at the Mount Sinai School of Medicine in New York, said Overview+ in an exclusive podcast that the under-treatment of women in this area was largely due to a lack of data and the participation of women in clinical trials.

“The disparities continue to exist, despite all of our education,” she said.

“We are finding that the prevalence of acute myocardial infarction is increasing rather than decreasing, especially in women over 45 years old. We find that recurrent myocardial infarctions and recurrent events are higher in women than in men.

“We are seeing an increase in myocardial infarctions in young women, or admissions in younger women with acute coronary syndrome, and we know that women present differently, that they have different triggers, that their lesions and their vessels are very different from those of men. “

Professor Mehran co-authored an editorial, published in the MJA, in response to research of Bachelet and his colleagues, detailing the gender disparities in the management of non-ST segment elevation ACS between men and women in Australian hospitals.

Professor Clara Chow, cardiologist at Westmead Hospital and co-author of the research, said InSight + that these gender disparities were “no small thing” without “one simple solution”.

Professor Chow and colleagues analyzed data from the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) for patients diagnosed with non-ST segment elevation ACS (NSTEACS) in 43 Australian hospitals as of 23 February 2009 to October 16, 2018. They sought to receive guideline-based medications and invasive therapies, including cardiac catheterization and revascularization, with procedures and results at 6-month follow-up assessed by telephone interview.

“The proportion of women who underwent cardiac catheterization was lower (1710, 71% v 4134, 77%), and the median time to catheterization was longer (53 h v 47h); non-obstructive coronary artery disease was detected in a greater proportion of women than men during catheterization (602, 35% v 566, 14%) ”, reported Bachelet and colleagues.

“At discharge, fewer women were prescribed aspirin (85% v 91%), a second antiplatelet drug (59% v 68%), -blockers (71% v 75%) or statins (86% v 92%), or referred for cardiac rehabilitation (54% v 63%).

“Lower proportions of women with coronary artery disease than men have undergone coronary artery bypass grafting (110, 10% v 563, 16%) or were prescribed statins on discharge (94% v 96%). Fewer women than men were referred for cardiac rehabilitation (750, 69% v 2652, 75%), including among those who had been revascularized.

Professor Chow said InSight + than in women, the non-obstructive coronary artery disease underlying their NSTEACS presentation was more common than in men.

“Maybe that’s because there are more common mechanisms in women that haven’t really been detected and differentiated as clearly when we do the diagnostic studies.

“Of course, if you do fewer diagnostic studies in women than in men, that’s a big part of the problem too.”

Professor Chow said the proportion of women participating in clinical trials (20-30%) was “even more out of balance than the actual presentation of this disease.”

Professor Chow said InSight + that communicating and recognizing the differences in how women and men communicate their symptoms was part of the answer.

“I sometimes wonder if it’s in the way of taking clinical history that we don’t account for it properly, in the way we communicate with patients,” she said.

“It often comes down to this communication.

“I’m not saying it’s an excuse. But I’m saying we have to see that people from all walks of life communicate differently, and that probably affects how we diagnose quickly or not.

“One of the things happening here is that there is more delay with the women [getting treated] compared to men, and maybe we have to get through all this complexity of this communication faster to get the answer.

“I often tell my residents that you have to base your decisions on objective benchmarks.

“Yes [the patient has] have high troponin and an abnormal EKG machine, you have had enough [to make a decision]. Whether they tell you that their chest pain is very typical or atypical won’t take the plunge, you have to move on.

Is there unconscious sexism if women are diagnosed with coronary artery disease, but still come home under-treated and under-oriented?

“I hope not,” said Prof Mehran.

“Why wouldn’t you want to refer women to angiography or refer women to coronary revascularization, when we know that in ACS revascularizations save the lives of these patients?

“Why don’t they go home with medical therapy that meets the guidelines?

“Why are they getting fewer statins? Less antiplatelet diets? We will never know the answer to these questions.

“We just have to keep drilling for this to stop. Hope we can equalize it and bring [the numbers] up.”

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