Lingering Gaps in CVD Care for Women Spotlighted in British Consensus Statement

Continued efforts are needed to ensure that women receive adequate care for a variety of cardiovascular diseases, according to a new consensus statement from societies affiliated with the British Cardiovascular Society (BCS).

Senior author Vijay Kunadian, MBBS, MD (Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, England), was a member of the Lancet commission on women and CVD, which called for a reduction in the global burden of heart disease in women of one-third by 2030. That was 4 years ago, and there hasn’t been much change since then.

“If you look at the statistics, ischemic heart disease is still the number one killer for women, and women continue to receive underprescription of medications and undertreatment” compared with the care men receive, Kunadian told TCTMD, noting that females remain underrepresented in clinical research as well.

The purpose of the new statement was “essentially to continue highlighting the problem and address the sex differences in healthcare” by bringing together the 21 BCS-affiliated societies to provide suggested actions that can be taken across specific diseases and care settings,” she said.

“We should all come together as a whole and deal with the problem of cardiovascular disease in women as an entirety,” said Kunadian, who is the research and development group lead for the British Cardiovascular Intervention Society. Efforts are needed, she added, to ensure that women have equitable access to specialist care and screening and receive appropriate care for female-specific conditions.

Sex-Based Approach

The consensus statement, published online this week in Heart with first authors Upasana Tayal, BMBCh, PhD (National Heart and Lung Institute, Imperial College London, England), and Graziella Pompei, MD (Newcastle University Translational and Clinical Research Institute), begins by reviewing traditional risk factors in the female population, including those specific to women alone, such as hormonal fluctuations associated with menopause.

The authors delve into specific disease areas (CAD, valvular heart disease, heart failure, inherited cardiac conditions, adult congenital heart defects, and heart rhythm disorders) and service types (cardio-oncology, cardiac rehabilitation, noninvasive CV testing, and primary care). There are “action points” covering ways to address shortcomings in women’s care in each of these areas and from patient and nursing perspectives.

We've been talking about it for decades, but we haven't seen the progress that we really want to see. Vijay Kunadian

Making a distinction between sex and gender, the authors say their advice is “mostly referring to a sex-based approach since the pathophysiological differences in CVD are driven by biological sex and the associated reproductive organs/hormones.

“However,” they continue, “we recognize that a gender-based perspective would be helpful to explore and call attention to acquired risk factors secondary to personal choices, hormonal fluctuation, and social/physical relationships. Gender is a wider concept which can vary across different cultures and over time.”

Though the suboptimal care of women with cardiovascular disease has been known for a long time, there hasn’t been much change over the years. “We've been talking about it for decades, but we haven't seen the progress that we really want to see,” Kunadian said.

Survey findings show that “women continue to be underprescribed and less likely to undergo invasive coronary angiography following a myocardial infarction, for example,” she pointed out. “We really need to continue discussing this as well as make proactive measures to address the challenges and the female-specific conditions in order to close the gap in the mortality difference between men and women following myocardial infarction.”

Guideline committees have been giving increasing attention to the issue in recent years, with Kunadian noting that European guidance documents on ACS and chronic coronary syndrome—for which she was on the task forces—include women-specific recommendations.

“All of these people are beginning to buy into the idea [that] we need to make sure that women are treated with the latest guideline-recommended pharmacotherapy and interventional strategies,” she said.

Clinicians also need to get better about following up with women who develop pregnancy-related conditions like preeclampsia and gestational diabetes, which signal greater risks of cardiovascular issues in the future, Kunadian indicated. “It's taking proactive measures to make sure that these risk factors are addressed and treated to make sure that the woman does not come back 10 years later with a full-blown heart attack when it's quite late in the disease progression phase.”

It's important, too, to listen carefully to women who are seeking care for a potential cardiovascular issue because their concerns have too often been dismissed in the past, she stressed. “Sometimes talking to a female patient takes a lot longer,” she said. “But if we did that as a first consultation, taking the time to talk to the patient, then we are able to get to the bottom of the problem to ensure they receive the appropriate treatment.”

Getting women more involved in cardiovascular research is another key step in eliminating sex-based disparities in care, Kunadian suggested. She cited two trials reported this year—the SMART trial of TAVI in patients with small aortic annuli (about 87% women) and the RHEIA trial of TAVI versus SAVR (100% women)—as signs of positive movement in this area.

“It is acceptable to do women-only research because we are tailoring, individualizing, the therapy to the need of the patient rather than sort of a blanketed approach,” Kunadian said.