Women’s troubles: why women still come second in heart disease

I love a bit of Barbra Streisand. The woman spells her name without an ‘a’ just to be different. One of Barbra’s finest films is Yentl, based on a short play about a young Jewish woman who upon her father’s death, pretends to be a man to be allowed to study at a Jewish religious school. Barbra won the Best Director Golden Globe for this film, the first woman to do so.

So why are we talking about early 1980’s films? Well, Yentl syndrome was first described by Dr Bernadine Healy to describe a phenomenon where women are more likely to be underdiagnosed, under-treated and die from the heart disease from their male counterparts. Women who present with typical or atypical symptoms of coronary disease are much less likely to undergo diagnostic coronary angiography (where dye looks at the blood vessels of the heart to see where they are narrowed) or be started on medications we would normally deem necessary for a patient with heart disease. Now this is not a gender-based discrimination problem, but rather a problem in biology. Men who have coronary artery disease tend to present with fairly typical symptoms like central chest pain, have big or obvious blockages of big coronary arteries and then therefore go on to get the appropriate treatment. Women, on the other hand, have atypical symptoms like tiredness, atypical chest pain or shortness of breath that may not trigger an angiogram. If they do have one, it is more likely to demonstrate what we term ‘microvascular disease’ where tiny blood vessels are blocked and may fall outside of the abilities of diagnostic tests or treatment.

Currently, the Annals of Thoracic Surgery has an article in press entitled ‘Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter?’. This study, by Hannan et al seems to show that we do have a gender difference that is a little concerning.

The study looked at a group of men and women who had had either coronary artery bypass surgery or a stent for their coronary disease. As with most studies, there was more than double the number of male patients in the study. But each gender was then divided into two equal groups; those who had surgery and those who had a stent. The group then looked at how many people survived, had another heart attack, a stroke or another procedure to unblock the coronary arteries. The idea was to see whether men or women did better with heart surgery versus stents.

There is a noticeable difference between the men and women patients. For patients undergoing heart surgery, the mortality rate for women was 11.8% and 8.0% for women. A similar trend was seen in those getting stents. The women who had stents had a 13.7% rate of death, the men 9.1%. Similar trends were seen for strokes, heart attacks and needing another procedure.

While this study was not set up soley to look at how women performed to men in treatment, there is quite a noticeable gender difference. This is supported by a growing body of evidence that suggests all of the things I mentioned earlier. Women present later, get diagnosed less, get undertreated and do poorly when the have heart disease. For a condition that is killing women more frequently than cancer or any other disease, we seemed to have underperformed in both studying why and translating this to better care for women. Again, this not a discrimination thing, this is a biology thing. But one thing is abundantly clear, we desperately need more work and much more attention into women’s heart disease.

References:

Hannan et al. Comparison of 3-Year Outcomes for Coronary Artery Bypass Graft Surgery and Drug-Eluting Stents: Does Sex Matter? Annals of Thoracic Surgery 2015. Article in Press

, , , , , , . Factors influencing underutilization of evidence-based therapies in women. European Heart Journal. http://dx.doi.org/10.1093/eurheartj/ehr027

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