Women scorned: CV disease undertreated and underdiagnosed

How much would the panel who chaired the "What about Women?" session at the 2012 ESC meeting disagree with the Oscar Wilde quote, "Women are meant to be loved, not to be understood"? Some would suggest that about the only place in the medical arena where women are fairly represented or studied is on the gynecology exam table. Strong evidence supporting that opinion is that nearly all major clinical studies are underpowered for the female gender, which represents approximately 25% of cohorts. "At least registries do better. They represent about 40% of the study population. That is real life," lamented Dr Julinda Mehill of Germany, cochairperson of the "What About Women" presentation. The notion that women are undertreated and underdiagnosed is not new news, but the presenters in today's session meant to change all that with interesting new information regarding the female gender.

Taking issue at least one category of the CHA₂DS₂-VASC scoring system for embolic stroke, Anders Mikkelsen of Copenhagen University Hospital Gentofte presented the study entitled, "Female gender increases stroke risk in AF patients aged >75 years by 20%." When scored by the CHA₂DS₂-VASC system, an extra point is given to the patient in atrial fibrillation if she is female, affirming the long held theory that women are somehow at higher risk of forming a clot in the left atrial appendage and subsequently embolizing it to the brain. He presented the results from 44 744 female patients from the Danish register with nonvalvular atrial fibrillation. Women less than 65 years of age and aged 65 to 74 demonstrated a 0.89 and a 0.91 relative risk ratio, respectively, but patients older than 74 years demonstrated a 1.2 increase in relative risk. He agreed that stroke risks are increased in women with atrial fibrillation but qualified the statement that this risk includes only women of a certain age. "The impact could be far reaching," he inferred, suggesting many women might be able to avoid anticoagulation but was careful to state that "more study is needed prior to coming to a definitive conclusion."

Dr Deniz Karasoy from Copenhagen reported on "young" women age 20 to 50 years who gave birth between 2004 and 2009 and compared their risk of new-onset atrial fibrillation. Of 271 203 women, there were 110 cases of atrial fibrillation over a 4.6-year follow-up period. He teased out the risk factor of obesity with a body-mass index (BMI) of 30 to 35 kg/m², demonstrating a twofold increase in atrial fib. The very obese (BMI >35 kg/m²) demonstrated a threefold higher risk. He then discussed the need for emphasis on dietary discretion and exercise as a potential for a substantial impact on the future burden of atrial fibrillation. It is interesting that certain young fertile women are now known to be harbingers of risk for this common arrhythmia usually relegated to the stereotypical elderly patient.

To add insult to injury, a study presented on behalf of the ALARM-HF group by assistant professor Dr John Parissis from the University of Athens, Greece, looked at female patients who did not receive optimal medical therapy readily prescribed for their male cohorts. Women represented 37% of around 5000 patients studied. The female patients presenting in acute heart failure were older and had higher systolic blood pressures and higher heart rates than their male counterparts. They had less coronary heart disease, less hemodynamic shock, and more right heart failure. Women faired equally well from a mortality standpoint in this study, but fewer women than men received adequate heart-failure therapies such as ACE inhibitors or beta blockers. The presenter emphasized the important implication of gender-tailored management, specifically targeting diastolic heart failure in women.

Finally, Dr Martin Russ suggested interventionalists might stay their hand when they reach for a bare-metal stent during a PCI in female patients. Citing several studies in which the drug-eluting-stent (DES) class outperformed bare-metal stents in general, he postulated the practice of bare-metal-stent implants in women might suggest a long-held gender bias rooted in anemia (among other things), which hints at bleeding complications to come. The findings from the countrywide German Registry revealed that out of nearly 101 000 stent implants between 2005 and 2009, "women received a lower percentage of DES for every quarter of each year." These findings were even more remarkable when one considers the small size of a female coronary artery would favor DES utilization. The choice of stent was particularly striking in the "over-80-year--old" population, in which males were 4.6% more likely to receive a DES. Dr Russ pointed out that the difference in stent selection may impact outcomes negatively and that no randomized controlled trial supports the preference of a DES in men only.

This series of presentations were a welcome respite from the usual unspoken and often multifactorial neglect of women in clinical studies. We can be faulted to some degree for our lack of participation, and we present late and our outcomes are impacted negatively because some of us ignore symptoms for days or months. With the type of information presented at today's conference, women and the physicians treating them can become more proactive in their conversations and their therapies.

Marcelene Cox , a 20th century American writer and satirist, once said, "The quickest way to know a woman is to go shopping with her." Perhaps a better way is to just enroll her in a clinical trial.

Your comments

	Women scorned: CV disease undertreated and underdiagnosed
	# 1 of 2	September 10, 2012 08:03 (EDT)
	Jean-Pierre Usdin	dear Melissa probably you had also noticed that women were less taken in consideration during the Olympic Games. some news-papers reported a kind of discrimination concerning the lower numbers of female athlets, the number of female'scompetions with some  canceled because the board of Olympic Games did not want more the 20 000 participants and decided to make some cuts in female participation. only one woman seats in the executive Olympic Games Board!  of course subventions are less important for women's competition and training this is well known in soccer, specially in Europe. at last (not the least) the way most of the women traveled to London was odious: first class for male; economy for women (Japane female soccer and Australian female Baskett in spite of their long legs! as an exemple among others) but, finally the japaneses' soccer team had a kind of consolation: they played the final (woned by US-congratulations-) in the mythic Wembley stadium were many male soccers have the dream to play one day. with all my thanks for your Heartfelt papers  always on line with actuality and usefull Jean-Pierre
	# 2 of 2	September 10, 2012 08:08 (EDT)
	Joyce Schaan	I needed a total knee replacement last year and because of high blood pressure with no disease upon studies I was placed on atenalor and b enezipril.  I had fallsi in 5 days and hte internist I went to would not listen when I told him shat had happened.  His comment was takie the medicaine or I'll see you never get a total knee replacement.   I fired him and went to a cardiology group and had my surgery.  By the time this happened I needed 4, yes count them, blood transfusions since my hgb went to 6.  I had MRSA twice and 2 surgeries in one month because a  physician did not want his word questiobned.  Gentlemen start pushing drug companies to make medications for women.  Number one I am a woman and number 2 don't ever presume to treat me like a lesser person.  I was the one who found the drug-drug interaction which was confirmed by a pharmacist-my how could a pharmacist kinow more than a male doctor!  It's easy, some of us study about wier thngs like P450 cytochromes and drug handbooks.  More women then men have cardiac problems so why do we still have drugs made for men and not women?  What an untapped market but then again what does a woman know??  You wouild be surprised.  Oh and by the way thasnks to all those falls with a bad back I soon will not walk.  I am 71 years old and an instructor of nursing, look out doctors because not only will I not be silenced but I will teach others to stand up for themself.  Thank you.  Now you can have your say!

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