In veterans with premature ASCVD, women treated less intensively vs. men
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Among veterans with premature atherosclerotic CVD, women received less aggressive secondary prevention treatments compared with men and demonstrated lower levels of statin adherence in ischemic heart disease, researchers reported.
According to data published in JAMA Cardiology, additional disparities were observed for race, in which women with ASCVD were more often Black than white or Asian.
“It may be that clinicians who are taking care of patients who have premature CVD, may think that this was an isolated event,” Salim S. Virani, MD, PhD, FAHA, professor of medicine and cardiology at Baylor College of Medicine, staff cardiologist at the Michael E. DeBakey VA Medical Center in Houston, told Healio. “If I have a 45-year-old man or 40-year-old woman who had a heart attack, stroke or peripheral artery disease, we may think this was a one-time event and that they’re going to be fine; whereas we know that may not be the case. A lot of these patients continue to have recurrent events. Perhaps it is a bias that when we see a young patient sitting in front of us in the office, they look much better compared to an older adult who had a stroke or MI. That may lead to what we call therapeutic inertia.
“We see gaps from the patient side as well. A young patient who has a CV event also has what we call an optimism bias,” Virani told Healio. “They think, ‘I am young, nothing is going to happen to me.’ We have all gone through that phase in our life, where we think that nothing can happen to us because age is on our side. That could be another reason why we are seeing some of these issues with statin adherence.”
For this cross-sectional, nationwide analysis, researchers used VITAL registry to identify 10,413 women and 137,187 men with premature ASCVD (age 55 years) and 1,340 women and 8,145 men with extremely premature ASCVD (age 40 years). Participants had at least one primary care visit in the Veterans Affairs health care system from October 2014 to September 2015. ASCVD encompassed ischemic heart disease, ischemic cerebrovascular disease and PAD. The primary outcomes were antiplatelet use, any statin use, high-intensity statin use and statin adherence.
Women represented 7.1% of total patients with premature ASCVD and 14.1% patients with extremely premature ASCVD.
Women with premature ASCVD were more often Black (36.1% vs. 23.8%) and less often Asian (0.5% vs. 0.7%) or white (56.1% vs. 68.1%) compared with men.
Similarly, women who experienced extremely premature ASCVD were also more often Black (36.8% vs. 23.2%) and less often Asian (1.3% vs 1.5%) or white (55% vs 67.8%), compared with men.
Women received less intensive treatment
Researchers reported that among patients with premature ischemic heart disease, women were less often prescribed antiplatelet therapy (adjusted OR = 0.47; 95% CI, 0.45-0.5), any statin therapy (aOR = 0.62; 95% CI, 0.59-0.66) and high-intensity statin therapy (aOR = 0.63; 95% CI, 0.59-0.66) compared with men; however, women who did receive statin therapy were less adherent compared with men (mean proportion of days covered, 0.68 vs. 0.73; beta coefficient = 0.02; 95% CI, 0.03 to 0.01).
These findings were consistent for patients with ischemic cerebrovascular disease and PAD.
In extremely premature ASCVD, women were less often prescribed antiplatelet therapy (aOR = 0.61; 95% CI, 0.53-0.7), any statin therapy (aOR = 0.51; 95% CI, 0.44-0.58) and high-intensity statin therapy (aOR = 0.45; 95% CI, 0.37-0.54) compared with men.
“What we’re showing now is that now for women with premature ASCVD, there’s a double whammy; even among this group with premature CVD, women aren’t receiving class I therapies like antiplatelets and statins. But even for these, we see very wide disparities,” Virani told Healio.
In other findings, researchers observed no sex-related differences in statin adherence among patients with premature ischemic cerebrovascular disease, premature PAD or extremely premature ASCVD.
Saving life-years in premature ASCVD
“The important thing to remember here is that we are talking about secondary prevention,” Virani told Healio. “The number of life-years that we can lose are much greater in this group compared with a patient who may be 70 or 75 years old and experiences their first event. In terms of disability and the opportunity cost, it is higher for a young patient compared to an older patient.
“I would highlight that there are gender disparities, but even among men who have premature ASCVD, we still need to do a lot of work,” Virani told Healio. “Our results highlight the need that interventions should be directed toward both clinicians and patients to make sure that those interventions are effective when we start addressing these at a health care system level.”
Perspective
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Martha Gulati, MD, MS, FACC, FAHA, FASPC
Women veterans with premature ASCVD are woefully inadequately treated, specifically with antiplatelet agents or any statin at all. But very few of them get high-intensity statin therapy. Anyone with ASCVD should have received high-intensity statin therapy based on all our guidelines. It is shocking to see those numbers of just how poorly we do. But I am equally shocked at how poorly we treat veteran men.
We see similar persisting gaps based on sex in the general population, although it's quite accentuated in this veteran population. There is expected to be around 2 million women in the VA health system by 2025. This is a significant and important portion of our population. We're not giving them adequate care, and they deserve the best health care.
This study shows inadequate secondary prevention for our veteran population, but the gaps are greatest for these young women in the VA system. If I know the patient I'm seeing is a veteran woman, I consider that a risk enhancer — this is a high-risk group to develop ASCVD.
Veteran women have higher rates of traditional cardiac risk factors. About 40% of them have hypertension overall; it was also very high in this population. Also, 44% of them are obese and 27% have hyperlipidemia, which is much higher than the population at large, particularly for a younger age group. Veteran women also have nontraditional risk factors for CVD. Post-traumatic stress disorder is very common, as is depression. If you put those two things together, a third of veteran women have those risk factors.
According to a paper that came out in Circulation in 2019, about 40% of veteran women have sexual trauma that they suffered during their military service and 10% of them are homeless as well, and this puts them at greater risk for CVD.
The sexual trauma that these women experience may impact whether veterans would trust the VA health system. This study mentioned that women were not necessarily being compliant with medication, and part of that may be related to some distrust and a poor relationship with the VA system at large. Another potential contributor is that younger people are not being viewed as high risk. That seems to be a barrier that we aren't looking at. They already have had a CV event. Young women and men who have had ischemic heart disease, PAD or an ischemic stroke should be viewed as at highest risk because they have the most to lose in their future. Even from disability life years lost, it could be catastrophic. We need to focus educational efforts to our health care community. It's obvious providers are not understanding that these patients are at high risk and we need to do something about this if we hope to improve outcomes in both men and women.
I would have liked to see data on whether patients were referred to cardiac rehabilitation, because that's always a good guide to how seriously we took their event. Going to cardiac rehab is as powerful as our medical therapies, and should be given to patients after a cardiac event as a prescription. It's something that saves lives. But we do know that women are far less likely to be referred to cardiac rehabilitation and, if they get referred, are less likely to complete it. Especially young women, who do not feel like they belong there.
The future focus for the veteran population with ASCVD is to start creating patient-centered interventions to reduce the disparities in care among veterans at large, and then of course, addressing the disparities in care based by sex. We should be pushing to get our veterans the best health care that they need. CVD is the leading cause of death in men and women in general and certainly in veterans, and they deserve better than this
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