Consider differences between men, women in CVD, care

Issue: November 2011

WASHINGTON, D.C. - To achieve successful outcomes, physicians must consider the differences between men and women in presentation of cardiovascular disease and be mindful of potential disparities in care, a speaker said at the 22nd Annual Meeting of the North American Menopause Society.

Classic prevention efforts, such as improving diet and physical activity, may be even more crucial for women because although cardiac risk factors are identical between sexes women may still be at higher risk for CVD, according to Martha Gulati, MD, MS, of The Ohio State University College of Medicine. For instance, women with diabetes are three to seven times more likely than men with diabetes to develop CVD. Likewise, women with hypertension and poor cholesterol levels also have a higher risk for disease than men, she said.

"More than 90% of heart disease is preventable," Gulati said. "The problem is we don't use [prevention strategies] enough in women and minorities."

Disparities in care

An inability to recognize CVD in women is also a barrier to effective treatment. Often, pictures depict men with CVD grabbing their chests in pain, Gulati pointed out, but this is not the norm for about 30% of women. Instead, they may experience milder pain or no pain at all.

"If we always show this image with men, we will not always recognize the same thing happening in women," Gulati said. "Sometimes, it is difficult for the patient to appreciate and difficult for the physician to appreciate."

In addition, outcomes are different for women as well, Gulati said. Women with coronary disease are more likely than men to experience heart failure, she said. Even so, the European Heart Survey showed that women diagnosed with angina were less likely to exercise, undergo angiography, receive statin or antiplatelet therapy, and undergo coronary revascularization. Similarly, US data from 1994 to 2002 indicate that women were less likely to undergo perfusion therapy, coronary angiography and had higher rates of hospital mortality. Other research also suggests that certain variables, such as administration of aspirin or beta blockers within 24 hours of an event, door-to-needle time and door-to-balloon time, are worse for women, according to Gulati.

"We are not doing as well treating our women." Gulati said. "The reason that interventions are not helping women as much as they do men is because women are not getting them."

Differences in disease

Gulati said one very important factor to also bear in mind is that CVD presents differently in women than in men. For example, compared with 7% to 10% of men, approximately one-third of women have normal coronary arteries after MI. Further, information from the WISE study indicates that, among women with symptoms of ischemia, 60% were likely to have coronary artery disease. This condition is known as cardiac syndrome X, according to Gulati. In the past it was considered a benign diagnosis, but data now show that women in this state have worse outcomes.

According to Gulati, recognizing this condition can be difficult. For instance, if the disease process is diffuse, physicians may only be able to discover cardiac syndrome X when using intravascular ultrasound. Nevertheless, the disease may be microvascular. In this case, physicians may need a different strategy for evaluation, such as cardiac MRI or stress testing under MRI, according to Gulati. Moreover, another hypothesis implicates endothelial dysfunction in the worsening of outcomes among women with this condition, which further complicates treatment.

"I suggest guidelines for prevention and intervention of CVD go further. If women have normal arteries after MI, look for another type of disease or other causes of their symptoms," Gulati said. "I suggest doing another study, sending these patients to a specialized site that might do some of these tests and then, if they do have an abnormal response, treat them more aggressively." - by Melissa Foster

For more information:

Gulati M. Coronary disease & stroke in women: Strategies for intervention. Presented at: the 22nd Annual Meeting of the North American Menopause Society; Sept. 21-24, 2011; Washington, D.C.

Disclosure: Dr. Gulati reports no relevant financial disclosures.

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