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Women scorned: CV disease undertreated and underdiagnosedAug 27, 2012 04:56 EDT
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.