Sex Disparities in MI Care Are Narrowing, but There’s Still a Long Way to Go
PARIS, France—Across Europe, efforts to end sex disparities in MI care are paying off for women. However, there’s still much room for improvement, experts said in a special session devoted to the topic at EuroPCR 2016.
Sharing data from France, Sweden, the United Kingdom, Spain, and the Netherlands, they showed marked differences in how well various countries have addressed these issues.
“It’s still not perfect, but many people have been working for years with perseverance on the topic. And progressively, the message has been conveyed. Again, it’s still not perfect and there’s still a lot to do, but we are going in the right direction,” session co-chair Marie-Claude Morice, MD (Institut Cardiovasculaire Paris, France), told TCTMD.
There are many reasons for these gains, including increased awareness among women of “the fact that they have to take care of themselves and [realize] breast cancer will not be their killer but [rather] cardiovascular disease,” she said. Doctors are also becoming more cognizant that women too can suffer from acute MI.
Why the Difference?
Anecdotal evidence suggests women tend to put their families’ needs ahead of their own and may dismiss the warning signs of MI until those needs are taken care of. It may be that “they wait to finish at home and think about [their] children and husband” before seeking medical attention, one audience member observed.
This is not to say that, even if they behaved similarly when experiencing an MI, women and men would be exactly the same in terms of their disease, Morice noted. While baseline differences are often adjusted for in studies, that does not detract from their importance in real life. “The risk factors are there,” she said in the session. “You can’t take them off.”
Panelist Fina Mauri, MD (Hospital Germans Trias I Pujol, Barcelona, Spain), agreed that there are some inherent differences. “It’s not that the system doesn’t treat women well,” she said. “The problem is that we are different when we present.”
Women themselves may be less diligent about post-MI care. “Men after a heart attack go to a rehabilitation clinic [and] they participate in coronary groups for exercise. But for women, the majority of them just want to go home,” said panelist Julinda Mehilli, MD (Deutsches Herzzentrum, Munich, Germany), noting that this carries implications for recovery. A member of the audience also spoke up, noting that doctors—even female doctors—may need to shoulder some of the blame. “I myself send men more frequently than women to rehab,” she admitted.
What Cardiologists Can Do
Physicians must do their part to encourage women to take advantage of cardiac education programs, including rehabilitation, Morice told TCTMD. Though they are now learning, “cardiologists used to underestimate women’s symptoms, because they are less typical and so on.” That a female cardiologist publicly admitted to being less aggressive with cardiac rehab for women is telling, she said.
“Our objective is to increase the life expectancy of people—to save lives and improve their quality of life. There is more to do for women than for men,” Morice commented, adding that this means cardiologists need to pay extra attention when treating female patients.
Importantly, female cardiologists cannot be the only ones worrying about sex disparities, she stressed. “Male cardiologists are also treating women, so this gender issue should be considered by every single doctor.”
Among approximately 20 attendees at the session, held on the final morning of EuroPCR as the meeting drew to a close, only one was male.
Focusing on the trajectories of patients who were younger than 50 years when they experienced an MI in France, Stéphane Manzo-Silberman, MD (Hôpital Lariboisière, Fernand-Widal, Paris, France), showed that diabetes and previous CAD were each on the upswing from 2005-2009 to 2010-2012, while the rates of smoking and high blood pressure were decreasing. Still, the rate of smoking remained “incredible,” she said, with three-quarters of women being current smokers.
Yet there were no differences in the time it took for women versus men to call emergency services, she said. “Fortunately, system delays do not differ either, and that’s quite satisfactory that we are following the [European Society of Cardiology] guidelines. Both genders have to be treated equally.”
Nor were there any differences in choice of reperfusion therapy. However, she said, there was a “worrying trend” seen in the years 2010-2012, during which women had begun to show signs of having higher in-hospital mortality than men (P = 0.23). Mortality at 30 days has decreased sharply since the mid-1990s, Manzo-Silberman added, but again there are signs of worsening survival for women in recent years.
Sweden and the United Kingdom
Vijay Kunadian, MBBS, MD (Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England), meanwhile, shared data from the BCIS and SCAAR registries on approximately 370,000 British and 90,000 Swedish patients, respectively, treated between 2007 and 2011.
By and large, women in the registries tended to be older and have more risk factors than did men. They were also more likely to present with NSTEMI/unstable angina compared with men and more apt to have cardiogenic shock. Women experienced more in-hospital complications, including a greater need for blood transfusions.
Women in Sweden and the United Kingdom had higher mortality rates than men at 30 days and 1 year. The gap was particularly large for STEMI patients undergoing primary PCI, she reported.
After primary PCI, female sex independently predicted higher mortality in the United Kingdom at 30 days (OR 1.18; 95% CI 1.07-1.30) and 1 year (OR 1.15; 95% CI 1.06-1.24) and in Sweden at 1 year (OR 1.11; 95% CI 1.00-1.23). Older age at the time of PCI also was strongly predictive.
Presenting findings for 2010 to 2014 from a Catalonian registry called Codi IAM, Neus Salvatella, MD (Hospital del Mar, Barcelona, Spain), said women in that region had delayed treatment compared with men.
“It took women 21 more minutes to ask for help when they had chest pain,” she pointed out, noting that the time between symptom onset and first medical contact was a median of 90 minutes for women and 69 minutes for men (P < 0.001). Of those undergoing primary PCI, a lower proportion of women versus men had reperfusion within 120 minutes of first medical contact (44.5% vs 51.4%; P < 0.001).
Despite women having a worse clinical profile, patient sex had no impact on mortality after adjustment for confounding factors.
Finally, a presentation on the Netherlands outlined sex differences in secondary prevention among STEMI patients. Monique ten Haaf, MD (VU University Medical Center, Amsterdam, the Netherlands), said that 30 centers in the country provide PCI and approximately 12,000 STEMI patients receive primary PCI there each year. There are regional but no national registries, she added.
According to ten Haaf, there are “no gender-specific recommendations regarding treatment and secondary prevention after STEMI” in the Netherlands or in the European Union as a whole. During triage, there is no apparent sex bias, but as has been seen elsewhere, women delayed seeking care. In addition, she said, “gender bias in secondary prevention still exists.”
Manzo-Silberman S. Higher mortality among young women with ACS: still true in France? Presented at: EuroPCR 2016. May 20, 2016. Paris, France.
Kunadian V. Impact of gender gap in time-to-treatment on mortality: lessons from United Kingdom and Sweden registries. Presented at: EuroPCR 2016. May 20, 2016. Paris, France.
Salvatella N. Impact of treatment strategy on gender differences in STEMI outcomes: lessons from Catalonia registry. Presented at: EuroPCR 2016. May 20, 2016. Paris, France.
ten Haaf M. Gender differences in secondary prevention among STEMI patients in the Netherlands. Presented at: EuroPCR 2016. May 20, 2016. Paris, France.
- Manzo-Silberman, Kunadian, Salvatella, and ten Haaf report no relevant conflicts of interest.