Cardiovascular disease remains a leading cause of death worldwide, yet the diagnosis and treatment of heart disease in women continue to be under-recognized, under-diagnosed, and under-treated. This disparity was first highlighted in 1991 by Bernadine Healy, who noted a significant sex bias in the management of coronary artery disease. Healy famously pointed out that women with heart disease needed to present “just like a man” to receive similar care.
Despite concerted efforts over the past three decades to improve the recognition and treatment of coronary artery disease in women, sex-based differences in management and outcomes persist both in Australia and globally. These differences are attributed to complex factors, including sex-specific biological mechanisms and gender-related health disparities.
Current Research Findings
A 2018 study published in the Medical Journal of Australia (MJA) revealed that female patients with ST-elevation myocardial infarction (STEMI) received less invasive management and preventive therapy compared to their male counterparts. Their outcomes during follow-up were also poorer. In the current issue of the MJA, Kazi and colleagues provide further evidence of these disparities, while offering some hope that the gender gap in heart disease treatment may be slowly closing.
Kazi and colleagues conducted a retrospective review of treatment and outcomes for adults presenting with their first episode of STEMI at New South Wales hospitals between 2011 and 2020. Their study focused on rates of revascularization within seven days of presentation and major adverse cardiovascular events and mortality during the twelve months following admission. The researchers aimed to assess whether sex differences in treatment and outcomes had changed over time.
Key Findings and Trends
The study confirmed that female STEMI patients were generally older at presentation and had higher levels of comorbidity than male patients. They were also more likely to live in areas of socio-economic disadvantage. Female patients were less likely to undergo timely angiography, percutaneous coronary intervention, and coronary artery bypass grafting, resulting in higher adverse event and mortality rates during the 12-month follow-up period.
Angiography and percutaneous coronary intervention rates increased for both male and female patients during 2011–2020, but the increase was more rapid for female patients.
Furthermore, the decline in both cardiovascular death and all-cause mortality was slightly more pronounced for female patients, suggesting some progress in narrowing the treatment gap.
Understanding the Disparities
The reasons behind these sex differences in treatment and prognosis are multifaceted and warrant further investigation. The retrospective nature of Kazi and colleagues’ analysis limited their ability to fully explain the persistent disparities in invasive procedure rates and mortality between male and female patients. However, they speculate that the higher mean age and greater comorbidity at presentation for female patients may be contributory factors. Additionally, conditions like myocardial infarction with non-obstructed coronary arteries and spontaneous coronary artery dissection are more prevalent in women, potentially influencing treatment outcomes.
The narrowing of the treatment gap over the past decade is encouraging and may be attributed to increased awareness of the prevalence and unique presentation of cardiac disease in women, as well as a better understanding of sex-specific risk factors for cardiovascular disease.
Looking Ahead
While the progress is notable, the pace of change remains slow. As Kazi and colleagues acknowledge, it could take decades to completely close the gender gap in heart disease treatment at the current rate of improvement. Efforts to rectify these discrepancies more rapidly are crucial, particularly to reduce the nearly six percentage point difference in 12-month mortality reported by the authors.
Fully understanding the reasons for the different treatment of female patients is the first step, and should be of utmost interest to clinicians, policy makers, and, most importantly, to the women themselves.
Addressing these disparities requires a comprehensive approach involving clinicians, policymakers, and the healthcare community at large. By prioritizing research and awareness, stakeholders can work towards ensuring equitable treatment for all patients, regardless of gender.
