Cardiovascular Revascularization Medicine 12 (2011) 243–246

Is there a gender disparity in treatment of coronary artery disease?

Sara D. Collinsa,⁎, Alexander J. Lanskyb

aWashington Hospital Center, Washington, DC, USAbNew York-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA

Received 3 September 2010; accepted 3 September 2010

It is important to highlight why we should focus onwomen's cardiovascular health in particular. In contrast tohistorical thought, cardiovascular disease (CVD) is not justa “man's disease” as CVD is the no. 1 killer in women [1].One third of all deaths in women are due to CVD, onewoman dies of heart disease every minute, and CVD killsmore women than men every year (since 1984). Contrary topopular belief, heart disease deaths are 11 times higher thanbreast cancer deaths. More women die of heart disease eachyear than all types of cancer plus all other diseasescombined [2]. An emphasis must be placed on preventionof CVD as once women are diagnosed with a myocardialinfarction (MI), their outcomes are worse than those ofmen. Women are more likely to die within a year of MIthan their male counterparts. Of women who survive anMI, nearly half will be disabled by heart failure within 6years. The cause for this disparity in outcome is likelymultifactorial; however, older age at onset of CVD and lackof awareness may contribute to poorer outcomes than thoseof men [2].

Overall, heart disease mortality rates have substantiallydeclined in the US. From 1999 to 2005, US cardiac deathsdecreased by 25%, translating into 160,000 fewer deaths in2005 (Fig. 1) Several factors contributed to this progress,including improved treatment of established CVD, wide-spread statin use, aggressive antihypertensive management,antismoking legislation, and tobacco excise taxes. Unfortu-nately, despite this significant progress in the overallpopulation, women as well as other subgroups, such asAfrican Americans, people living in the southern United

⁎ Corresponding author. Washington Hospital Center, 110 Irving Street,NW, Suite 4B-1, Washington, DC 20010, USA.

E-mail address: saradcollins@gmail.com (S.D. Collins).

1553-8389/10/$ – see front matter © 2011 Published by Elsevier Inc.doi:10.1016/j.carrev.2010.09.003

States, and those with lower socioeconomic status, lagbehind [3].

One reason why these gender disparities exist may beginwith the diagnosis and treatment of coronary artery disease(CAD) in women. Women undergo fewer diagnosticprocedures for CAD than men. Once diagnosed, womenare more often managed medically and undergo lesscoronary artery bypass graft (CABG) and percutaneouscoronary intervention (PCI) than men [4,5] (Fig. 2). Thesegender differences were studied in a stable angina populationin the EuroHeart Survey. In this population of 3779 patients(42% women), women were less likely to undergo anexercise ECG or be referred for coronary angiography.Women with confirmed disease were less likely to receiveantiplatelet and statin therapies, although beta blocker usewas similar. When looking at outcomes, these women had ahigher probability of death or MI at 18-month follow-up aswell [6] (Fig. 3). This data highlights the fact that women aremore likely to receive medical vs. invasive therapies,although this medical treatment is not optimal.

An analysis of 78,254 patients with acute coronarysyndrome (ACS) as well as ST-elevation myocardialinfarction (STEMI) between 2001 and 2006 was recentlyconducted from the “Get with the Guidelines” registrydatabase. The STEMI subpopulation was particularlyinteresting in that it demonstrated higher adjusted in-hospitalmortality for women [odds ratio (OR) 1.12 (1.02–1.23)], aswell as lengthier door-to-needle [adjusted OR 0.78 (0.65–0.92), Pb.0001] and door-to-balloon times [adjusted OR0.87 (0.79–0.95), Pb.0001] in women. This study alsoconfirmed the fact that women are less likely to receive earlymedical therapy, as well as invasive procedures such as PCIor CABG [7].

Another study of the CRUSADE ACS Registry con-ducted in 35,875 patients (41% women) also demonstrated

Fig. 1. Cardiovascular disease mortality trends for males and females (United States: 1979–2005) [2].

244 S.D. Collins, A.J. Lansky / Cardiovascular Revascularization Medicine 12 (2011) 243–246

higher mortality in women (5.6% vs. 4.3%, Pb.001). Despitehigh-risk characteristics, women were less likely to receiveoptimal medical therapy, including peri-procedural anti-coagulants and anti-platelet agents. Women were alsodischarged less frequently on aspirin, beta-blockers, statins,and clopidogrel. This gender disparity in management ofpatients with ACS persisted in regard to invasive procedures.Women were less likely to receive cardiac catheterization,PCI, and CABG [8].

Gender disparities in ACS patients are highlighted in ananalysis of the ACC-NCDR Database from 2004 to 2006. Inthis population, women had higher rates of unstable angina/NSTEMI (82% vs. 77%, Pb.0001), greater baseline

Fig. 2. Gender gap in diagnosis a

comorbidities, but fewer high-risk angiographic features.Although women had higher rates of cardiogenic shock,congestive heart failure, bleeding, and vascular complica-tions, there was a similar OR for in-hospital mortality (OR0.97, P=.5) [9]. Most studies of outcomes after MIdemonstrate that women have higher rates of death, MI,cardiogenic shock, congestive heart failure, and bleedingcomplications. Unadjusted mortality rates are higher inwomen in most studies as well (Fig. 4).

In conclusion, despite an overall 25% reduction inmortality from CVD in the United States, women lagbehind the national average. Although the prevalence ofCAD is similar in men and women, women undergo fewer

nd treatment of CAD [4,5].

Fig. 4. Gender differences in outcomes following MI [8,10].

Fig. 3. Cumulative probability of death from MI in patients with confirmed coronary disease and stable angina according to gender [6].

245S.D. Collins, A.J. Lansky / Cardiovascular Revascularization Medicine 12 (2011) 243–246

diagnostic procedures, less revascularization, and lessevidence-based medical therapy. These disparities areconsistent across the continuum of CAD including stableand unstable coronary syndromes.

References

[1] Adapted from American Heart Association, the Nurse's Health Study.WISE and Acute Coronary Syndromes Without Chest Pain: Insightsfrom GRACE.

246 S.D. Collins, A.J. Lansky / Cardiovascular Revascularization Medicine 12 (2011) 243–246

[2] AHA Heart and Stroke statistical 2009 update.[3] Source: http://www.webmd.com/heart-disease/news/20080122/heart-

stroke-deaths-decline-in-us. Accessed October 31, 2009.[4] HCUP, 2007 (National Inpatient Sample database). National Ambu-

latory Medical Care Survey (NHAMCS), 2006.[5] National Hospital Discharge Survey (NHDS). ACC-NCDR CathPCI

Registry, Aug 2009, 2006.[6] Daly C, Clemens F, Lopez Sendon JL, Tavazzi L, Boersma E, Danchin

N, Delahaye F, Gitt A, Julian D, Mulcahy D, Ruzyllo W, Thygesen K,Verheugt F, Fox KM. EuroHeart Survey Investigators. Genderdifferences in the management and clinical outcome of stable angina.Circulation 2006;113:490–8.

[7] Jneid H, Fonarow GC, Cannon CP, Hernandez AF, Palacios IF, MareeAO, Wells Q, Bozkurt B, Labresh KA, Liang L, Hong Y, Newby LK,Fletcher G, Peterson E, Wexler L. Get With the Guidelines SteeringCommittee and Investigators. Sex differences in medical care and earlydeath after acute myocardial infarction. Circulation 2008;118:2803–10.

[8] Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K,Diercks DB, Brogan Jr GX, Boden WE, Roe MT, Ohman EM, Gibler

WB, Newby LK, CRUSADE Investigators. Gender disparities in thediagnosis and treatment of non-ST-segment elevation acute coronarysyndromes: large-scale observations from the CRUSADE (Can RapidRisk Stratification of Unstable Angina Patients Suppress AdverseOutcomes With Early Implementation of the American College ofCardiology/American Heart Association Guidelines) National QualityImprovement Initiative. J Am Coll Cardiol 2005;45:832–7.

[9] Akhter N, Milford-Beland S, Roe MT, Piana RN, Kao J, Shroff A.Gender differences among patients with acute coronary syndromesundergoing percutaneous coronary intervention in the AmericanCollege of Cardiology–National Cardiovascular Data Registry(ACC-NCDR). Am Heart J 2009;157:141–8.

[10] Lansky AJ, Hochman JS, Ward PA, Mintz GS, Fabunmi R, Berger PB,NewG, Grines CL, Pietras CG, KernMJ, Ferrell M, LeonMB,MehranR, White C, Mieres JH, Moses JW, Stone GW, Jacobs AK, AmericanCollege of Cardiology Foundation, American Heart Association.Percutaneous coronary intervention and adjunctive pharmacotherapyin women: a statement for healthcare professionals from the AmericanHeart Association. Circulation 2005;111:940–53.