Women with atherosclerotic CVD aren’t taking statins as often as men. Why?
Click Here to Manage Email Alerts
Key takeaways:
- Women with atherosclerotic heart disease are less likely than men to receive a statin prescription.
- Data show women were more likely to be considered statin-intolerant than men in clinical notes.
Editor's Note: This is part 2 of a three-part Healio Exclusive series on navigating statin intolerance. Part 1 can be viewed here.
Decades of data demonstrate the benefits of statin therapy for people at high CV risk, yet many patients — particularly women — are not treated with statins.
Women with atherosclerotic CVD are less likely than men to be prescribed any statin, less likely to be prescribed a high-intensity statin and more likely to be deemed statin-intolerant, data show.
Experts say the reasons for the persistent sex disparity are not fully understood and are likely multifactorial.
“Women are more likely to report statin intolerance, and that is a concern,” Fatima Rodriguez, MD, MPH, FACC, FAHA, FASPC, associate professor in cardiovascular medicine at Stanford University, told Healio. “Gender disparities in statin prescriptions and adherence are pervasive and persistent. There are patient-, clinician- and system-level factors that contribute to this problem, and a multiprong approach is needed to narrow this care gap.”
Assessing sex disparities, nonacceptance of statin therapy
In an analysis of electronic health records prescription data, Rodriguez and colleagues used a deep-learning natural language processing (NLP) approach to identify and interpret discussions of statin prescriptions documented in clinical notes.
Women with ASCVD were less likely to be prescribed statins compared with men with ASCVD (56.6% vs. 67.6%; P < .002). When statins were prescribed, women were less likely to receive high-intensity dosing (41.4% vs. 49.8%; P < .001). Statin disparities were more pronounced among women who were younger, had private insurance and did not speak English as a primary language.
Among patients who were not prescribed statins, women were less likely than men to have statin use reported in their clinical notes despite the absence of a recorded prescription (32.8% vs. 42.6%; P < .001). Women were also more likely to be deemed statin intolerant in structured data or clinical notes compared with men (6% vs. 5.3%; P = .003).
“Some of it is clinician therapeutic inertia,” Rodriguez said in an interview. “When people think of heart attacks, they do not think of women. People think women are at lower CV risk [than men]. We know that is simply not true.”
In a retrospective study published in February in JAMA Network Open, Alexander Turchin, MD, MS, director of Quality in Diabetes at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, and colleagues evaluated sex disparities in nonacceptance of statin therapy among 24,212 statin-naive patients with ASCVD, including 50.8% women, and assessed the association with LDL control. Researchers found that nonacceptance of statins was higher in women compared with men (24.1% vs. 19.7%; P < .001) and was similarly greater among women across every subgroup in analyses stratified by comorbidities. Nonacceptance of statin therapy was associated with a longer time to achieve an LDL level of less than 100 mg/dL.
“Women were more than 20% more likely than men not to accept their clinician’s initial statin therapy recommendation,” the researchers wrote. “This disparity increased as time went on; over the entire course of the study, women were 50% more likely to never initiate statins. Multiple previous studies have reported lower rates of cholesterol control among women compared with men. These differences have been explained in part by sex disparities in the rates of adherence and adverse effects to statins. The present study suggests that disparities in nonacceptance of a statin therapy recommendation are another important factor.”
Often, clinicians and patients do not feel the sense of urgency that they should with regard to managing risk with statins, according to Kevin C. Maki, PhD, CLS, FNLA, president and chief scientist of Midwest Biomedical Research, adjunct professor at Indiana University School of Public Health and immediate past president of the National Lipid Association.
“ASCVD risk is underestimated among women generally, so women feel much more susceptible to, say, breast cancer than they do to CVD, even though the risk of dying from CVD over a lifetime is about 10 times the risk of dying from breast cancer,” Maki told Healio.
Concerns surrounding statins during pregnancy
There are also concerns related to statins and pregnancy, according to Healio | Cardiology Today Editorial Board Member Erin D. Michos, MD, MHS, FACC, FAHA, FASE, FASPC, associate professor of medicine and director of women’s cardiovascular health at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, who noted that the FDA has removed its most stringent warnings related to statins and pregnancy.
“Women are not treated with statins because of this theoretical concern that they may get pregnant, but women could have reproductive potential for 4 decades,” Michos said. “To not treat high-risk women because they might possibly get pregnant is doing these women a disservice, especially in the setting of familial hypercholesterolemia, and can doom these women to early-onset CVD.”
In a commentary published in Circulation in 2022, Rina Mauricio, MD, assistant professor in the department of internal medicine at UT Southwestern Medical Center, and Amit Khera, MD, MSc, FACC, FAHA, professor of internal medicine and director of the UT Southwestern Preventive Cardiology Program, wrote that the intent of the recent FDA recommendation on statins was not to approve statin use in all pregnant patients.
“Rather, the goal was to revise the language to reassure clinicians that in certain individuals, especially very high-risk patients, continuing statin therapy through pregnancy may be beneficial,” Mauricio and Khera wrote. “Ultimately, the continuation of statins in these patients rests on shared decision-making between patient and clinician and should consider the nuances of the patient’s history and risk factor profile. In our view, using shared decision-making, those with ASCVD events, especially recent ones, should be encouraged to continue statins during pregnancy or resume them as soon as possible if they are withheld.”
Michos said clinicians should first counsel all reproductive-capable women about conception, pregnancy and breastfeeding, and ideal times to stop and start statin therapy.
“It is much better to have short interruptions of a year or 2 than to go decades untreated,” Michos said. “It is really about cumulative burden — not only how high cholesterol is, but the years of exposure. It is also likely that statins are not teratogenic.”
Rodriguez said there is a critical need for implementation science research that tests patient, clinician and system interventions to eliminate the persistent sex disparity in statin prescription for patients with ASCVD.
“NLP and increasingly popular large language models may be used to analyze large volumes of clinical data to generate greater insights into factors that contribute to sex-based care gaps in CVD management,” Rodriguez said. “Identifying drivers of disparities can allow targeted interventions that promote health equity.”
Editor’s Note: Part 3 of this Healio Exclusive series will explore nonstatin options for patients unable or unwilling to take a statin.
We want to hear from you:
Healio wants to hear from you: What needs to be done to ensure equity in statin prescribing? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or tweeting @CardiologyToday. We will contact you if we wish to publish any part of your story.
References:
- Brown CJ et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.1047.
- Mauricio R, et al. Circulation. 2022;doi:10.1161/CIRCULATOINAHA.121.058983.
- Witting C, et al. Am J Prev Cardiol. 2023;doi:10.1016/j.ajpc.2023.100496.
For more information:
Kevin C. Maki, PhD, CLD, FNLA, can be reached at kmaki@mbclinicalresearch.com.
Erin D. Michos, MD, MHS, FACC, FAHA, FASPC, can be reached at edonnell@jhmi.edu; X (Twitter): @erinmichos.
Fatima Rodriguez, MD, MPH, FACC, FAHA, FASPC, can be reached at frodrigu@stanford.edu; X (Twitter): @farodriguezmd.
Collapse
Healio Interviews
Click Here to Manage Email Alerts