Secondary Prevention Lagging Behind in Women With Established Coronary Disease

In general, control of cardiovascular risk factors is far from optimal in patients with established coronary heart disease (CHD), but women seem to be getting the short end of the stick, a survey conducted in Europe, Asia, and the Middle East affirms.

Women were less likely to meet goals for most of the risk factors examined, a finding consistent with prior studies in predominantly Western populations, researchers led by Min Zhao, PhD (University Medical Center Utrecht, the Netherlands), report in a study published online September 20, 2017, ahead of print in Heart.

“Greater knowledge and awareness of CHD in women, better understanding of regional differences, as well as more widespread use of women-specific clinical guidelines appropriate to local settings, could help to decrease the sex disparities in CHD risk factor management and could improve CHD outcomes in both men and women,” they write.

Indeed, there appears to be a tendency to downplay the risk of heart disease in women, according to C. Noel Bairey Merz, MD (Cedars-Sinai Heart Institute, Los Angeles, CA), who co-authored an editorial accompanying the study.

“We’ve documented in community and physician surveys that heart disease . . . is perceived both by community women and treating physicians as less important—much less important—than breast health or weight issues,” Bairey Merz told TCTMD. “This is a paradox because more women die of heart disease than anything else. Many more women die of heart disease than breast cancer every year at all ages.”

“This is not okay. Women are not second-class citizens.” C. Noel Bairey Merz

If doctors use all of their time with a female patient discussing weight loss at the expense of focusing on a variety of cardiovascular risk factors, for example, “that’s a gender bias, and then women end up being undertreated,” she said.

The study should serve as a wake-up call, Bairey Merz said: “This is not okay. Women are not second-class citizens.”

Regional Variation Exists

Zhao and colleagues examined data from the phase I audit of the Survey of Risk Factors (SURF), which enrolled adult patients with established CHD—defined as a history of CABG, PCI, ACS, or stable angina—from outpatient cardiology clinics in 11 countries across Europe, Asia, and the Middle East.

The analysis included 10,112 patients (29% women). On average, women were 4 years older than men, were more likely to have stable angina and a history of hypertension or diabetes, and were less likely to have a history of CABG or to have received prescriptions for antiplatelet or lipid-lowering therapy.

Based on recommendations by Joint European Societies guidelines, both men and women had less-than-ideal control of risk factors. Women, however, were less likely than men to achieve treatment targets for total cholesterol (OR 0.50; 95% CI 0.43-0.59), LDL cholesterol (OR 0.57; 95% CI 0.51-0.64), and glucose (OR 0.78; 95% CI 0.70-0.87) after adjustment for age. They were also less likely to be physically active (OR 0.74; 95% CI 0.68-0.81) and nonobese (OR 0.82; 95% CI 0.74-0.90) and to attend cardiac rehabilitation (OR 0.60; 95% CI 0.54-0.66).

On the other hand, women had the advantage over men in terms of controlling blood pressure (OR 1.31; 95% CI 1.20-1.44) and being nonsmokers (OR 1.93; 95% CI 1.67-2.22). There was no sex difference in terms of HbA1c control among patients with diabetes.

Index scores also tended to favor men. Women were less likely to have an adequate Cardiovascular Health Index Score (OR 0.81; 95% CI 0.73-0.91), which incorporates three treatment targets and three lifestyle goals, or to meet all treatment targets (OR 0.75; 95% CI 0.60-0.93). The likelihood of meeting all lifestyle goals showed a similar trend but the difference between women and men did not reach statistical significance.

Some regional variation was found, and sex differences in the likelihood of reaching treatment targets were smaller in Europe than in Asia and the Middle East. When looking at lifestyle goals, however, women were more likely than men to achieve them in Asia, with men maintaining an advantage in Europe and the Middle East.

The likelihood of having an adequate Cardiovascular Health Index Score was higher for women in Asia, but lower for women in Europe and the Middle East.

Replicating the Breast Cancer Effort

Bairey Merz said studies like this one that quantify disparities in care are an important step toward eliminating differences: “In a data-driven society, something that you can’t count ends up not counting.”

She noted that in a survey by the Women’s Heart Alliance, she and her colleagues assessed knowledge, attitudes, and beliefs in order to identify areas that were not consistent with the best evidence and could be addressed. “The attitudes and beliefs can sometimes be barriers,” Bairey Merz said.

She pointed to the efforts in the breast cancer field as an example of how a big medical problem can be tackled.

“If you look at overall mortality for women, it’s down to 3% for breast cancer,” Bairey Merz said. “And we didn’t get there just coincidentally. We got there because of a 50-year campaign to understand, detect, treat, and cure breast cancer. So, we have to do the same thing for heart disease.”