Sex disparities remain in CHD risk factor management

Martha Gulati, MD, MS, FACC, FAHA, FASPC

The findings confirm what we’ve all been talking about for the last decade or so, not unique to the United States or the Western world: Women are being treated differently when it comes to CVD. Although we’re seeing a narrowing in the gap between men and women, that doesn’t really come through in these data, and we’re still seeing this persistence of women being undertreated.

This study looked at eight countries in Europe, Asia and the Middle East. Asia was just represented by China and Taiwan, and the Middle East was represented by Saudi Arabia, but the study covered countries that have so many different issues related to them. Some are more Western and some have less advanced therapies, but no matter what you look at, women get treated less aggressively after having a diagnosis of heart disease.

We’ve shown that there’s a similar disparity in the United States. This study was from the SURF study: the Survey of Risk Factors. We know from the Get With the Guidelines data in the United States, after people are diagnosed with MI, there’s a difference between what women go home on and what men go home on after they have a diagnosis of heart disease.

After an MI, the one thing we can do easily in the hospital is get control of BP, and yet, we have data saying that women go home with less controlled BP than men. There is really no reason for that. There is evidence that they’re less likely to get the lifesaving therapy that we recommend after a MI. We know that compared with men, women are less likely to be aggressively treated and less likely to get guideline-recommended therapies.

Since this is a problem that we’ve seen in the United States and now looking at the SURF data, the issue with women being treated differently than men once a diagnosis of CVD is made, it seems to be a worldwide issue that isn’t unique to any specific country. The SURF data show that this gap in treatment and lifestyle recommendations is seen in many countries. It’s just a persistent problem. Somehow, we still think of heart disease as a male disease.

Hopefully the findings will increase awareness by showing that all over the world, people need to think about heart disease. These are people with a diagnosis of heart disease. There shouldn’t be a difference in these treatments or differences in lifestyle recommendations. We should be as aggressive in women as in men.

It was interesting in this study that the Asian population was probably the outlier in terms of lifestyle targets in Asia, so in China and Taiwan, that women were more physically active after diagnosis of heart disease than men, but that could have been self-directed too. It’s not clear that physical activity was more likely to be recommended by anyone, just a survey of what activities were being done after a diagnosis of CVD. In the other two regions, women were less physically active. In general, most of the treatment targets were less aggressive in women compared to men. What cannot be teased out of these data is availability of medications and education, and how much follow-up they get based on this.

The only thing that women had better in all geographic areas was getting their BP on target after a diagnosis of heart disease. But in everything else, including getting cholesterol and glucose on target, was less likely in women compared with men.

We need an interventional trial to see how can we narrow these gaps. How can we start treating women equally? Is it a public health campaign? Is it an educational campaign that targets patients, or an educational campaign that targets physicians, or both? We need to figure out what will make women be treated as well as we treat men. Of course, there are gaps in both and we need to do a better job in both, but we need to be as aggressive in terms of secondary prevention in women as we are with men.

It’s hard for patients to know that they need to improve their cholesterol levels unless their physician tells them that or prescribes them the right medication or gets them to the goals that they need to be at. The same goes for glucose or diabetes control. Without education from their health care team, a patient won’t necessarily be empowered to know what lifestyle changes will help, what their goals should be or what medications are needed. Maybe empowering the patients to ask the questions is one approach. Across countries, some component of the health care team —whether it’s the physicians, the nurse practitioners, the health care workers — needs to make sure that they understand that you don’t treat women differently than men once they have a diagnosis of heart disease.

Additionally, there needs to be more research done on implementation of lifestyle changes to patients and how we get this information to men and women. Referrals, particularly in Europe, seem to be a lot like the United States, where women get referred much less often to cardiac rehabilitation. The only risk factor where women did better was that they were less likely to be smokers, which is a good thing. I won’t minimize that because it is the most reversible cause of CVD, but we still have a long way to go with the other lifestyle changes.

We need some sort of an interventional trial to target the best ways to make these lifestyle changes.

In the United States, we have the Go Red campaign and the Red Dress campaign to heighten awareness of heart disease as the No. 1 killer of women. People recognize the pink ribbon as a symbol of breast cancer. It’s not clear that the red dress has conveyed the same thing to everyone about heart disease. But it was at least the beginning of increasing awareness for women to help them recognize heart disease is the No. 1 killer and to help them be empowered and to ask the right questions. Nonetheless, we still have persistent gaps, and this campaign has not reached all women. Specifically, we have far more work to do in racial minorities in terms of educating them on their risk of heart disease.

What we want to do for both men and women is to empower them to know what puts you at risk for heart disease and work to prevent it. Spreading a public health awareness message like the “Go Red” campaign will help any of these counties.

The Go Red campaign has been effective, but maybe our message has to be change or be refined. We all need to reconsider how we convey our messaging because we haven’t been able to be as quick to spread awareness or be as effective as the pink ribbon campaign. Women know they are at risk for breast cancer, yet heart disease is far more common in women. How do we get women to think of their heart, protect their heart and get screening for CVD at least as often as they think of protecting their breasts? We need to challenge our medical community and public health messaging to ensure women’s hearts are as important as men’s.