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4. Disparities Among Women in Acute Cardiac Care • Frances Canet, MD • Cath Conference • Thursday, May 26, 2011 4

5. Gender Disparities Across the Spectrum of Acute Cardiac Care 5 • Epidemiology • Diagnosis • Evaluation • Treatment • Medications • Interventions • Outpatient Follow-up • Outcomes

6. Epidemiology 6 Leading Causes of Death for American Women (2005)

7. Heart Disease Death Rates 1999-2003 Adults Ages 35 Years and Older by County 7

8. Among women ages 18 and older: 8 • 17.3 % are smokers • 51.6% are overweight (BMI greater than 25) • 27% have hypertension • 35% have high cholesterol • 53% do not meet physical activity recommendations.

9. Age Difference 9 • Heart disease mortality increases for both women and men with age. • For men, mortality is increased at all ages. • In women, the heart disease manifestation is delayed 10 years.

10. Symptomatic Presentation of MI 10 • For both genders, the predominant symptoms is chest pain. • Women are more likely to have atypical symptoms • -Abdominal pain • -Neck and shoulder pain • -Painless dyspnea and extreme fatigue in older women and in women with diabetes

11. Diagnosis 11 • The pretest probability of coronary heart disease is lower in women with chest pain presenting for diagnostic evaluation compared to men.

12. Evaluation 12 • Gender Disparities in the Diagnosis and Treatment of Non-ST Segment Elevation Acute Coronary Syndromes • 2005 –CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines)

13. Study Highlights 13 • Involved about 35,000 patients of which 41% were women. • Women were older (73 vs. 65) and more often had diabetes and hypertension. • Women were less likely to receive acute heparin, angiotensin converting enzyme inhibitors (ACEi), and glycoprotein IIb/IIIa inhibitors. • Women were also less likely to receive aspirin, ACEi and statins at discharge. • Cardiac catheterization and revascularization was higher in men.

14. Study Highlights (continued) 14 • Among patient with significant CAD, percutaneous revascularization was performed in a similar proportion of women and men. • Higher in hospital death for women (5.6% vs. 4.3%) • Higher risk for re-infarction (4.0% vs. 3.5%) • Higher risk for heart failure (12.1% vs. 8.8%) • Higher risk of stroke (1.1% vs. 0.8%) • Higher risk of red blood cell transfusion (17.2% vs. 13.2%)

15. Treatment 15 • Women were: • -less likely to have an ECG performed with 10 minutes of hospital presentation (25.2% vs. 29.3% for men) • -less likely to be cared for by a cardiologist (53.4% vs. 63.4% for men)

16. Interventions 16 • Men were: • -more likely to undergo diagnostic catheterization • -more likely to have revascularization procedures • Women were: • -more likely to undergo stress testing • -less likely to receive coronary thrombolysis, and more likely to have major bleeding if they did

17. Race and Gender Disparities in Rates of Cardiac Revascularization 17 • -Do disparities reflect appropriate use of procedures or problems in quality of care? • -Randomized 5026 Medicare beneficiaries aged 65-75 • -Compared underuse or the failure to receive a clinically indicated revascularization procedure vs. receipt of a revascularization that was not clinically indicated.

18. Race and Gender Disparities in Rates of Cardiac Revascularization 18 • Results: • -Revascularization was more clinically indicated among whites than black and among men than women. • -Failure to receive vascularization was more common among blacks than whites (40% vs. 23-24%), but similar among men and women (25% vs. 22-24%)

19. Race and Gender Disparities in Rates of Cardiac Revascularization 19 • Results: • -Among patients who received inappropriate revascularization , use was greater for whites than blacks using RAND criteria (10.5% vs.5.8%) • -Greater for men than for women (14.2% vs. 5.3% by RAND criteria)

20. Disparities in the Outcome of Cardiac Interventions 20 • -204 women compared to 577 men who had undergone direct angiography/primary PTCA for acute STEMI • -PTCA was equally successful (95% in women, 94% in men) • -No difference in 30 day mortality • -Higher post-discharge mortality after 3 years, significant after 4 years.

21. Reasons for improvement in peri-procedural complication rates and long-term outcome after PCI in women. 21 • -Improvement of interventional techniques • -Increase in number of implanted stents • -Improvement of antithrombotic medications • -Statins • -Intensive control of cardiovascular risk factors (diabetes)

22. Coronary Artery Bypass Graft Surgery 22 • -Women are usually older with more frequent comorbidity (DM, HTN). • -Perioperative mortality rate of 4.5% for women compared with 1.9% for men. • -Post-operatively women had a comparable 15-year survival to men.

23. Do gender disparities exist if access to medical care is controlled? 23 • -”Sex and Racial/Ethnic Disparities in Outcomes After Acute Myocardial Infarction” • -Relative to white men, black men: Hazard ratio for increase risk of acute MI recurrence was 1.44. • -Black women: 1.47 • -Asian women :1.37

24. More gender disparities 24 • Women were less likely then men to receive Aspirin and Nitroglycerin in the out-of- hospital management of chest pain.

25. Why the disparity? 25 • Driven by patient preferences. • The manner in which chest pain is recognized or diagnosed by out-of-hospital personnel. • The gender of the provider, influences the delivery of cardiac care. • Poor adherence to out-of-hospital chest pain protocols.

26. Disparities in Outpatient Care 26 • -Women were less likely than men to have low-density lipoprotein cholesterol controlled at <100mg/dL in those who have diabetes. • -Among participants with diabetes, 44.3% of men and 38.5% of women met LDL control measures. • -In patients with a history of cardiovascular disease, 55.6% of men and 46.6% of women met LDL control measures. • -Women achieved higher performance than men in controlling blood pressure, 70.8% for women an 68.9% for men.

27. Disparities in Cardiovascular Disease Extend Into: 27 • Congestive heart failure • Advanced heart failure therapies • Arrhythmia Management and EP devices • Cerebrovascular accidents

28. Summary 28 • -Cardiovascular disease is the number one cause of death among women, but awareness in the public is still growing. • -Awareness for heart disease in women has become a topic of interest because of the vast disparities compared to men : presentation, diagnosis, treatment, outcome .

29. Conclusions 29 • -Despite protocols for management and treatment of heart disease, the gender disparity exists, except in coronary revascularization. • -Data collection has been ongoing and yet mechanisms of disparities have yet to be delineated.

30. Conclusions 30 • -One would expect that with increased awareness of women’s heart disease and its risk factors among the general public coupled with care provider awareness about the disparities between men and women, the disparity gap will close. • -Perhaps, the risk factors for cardiovascular disease need their own campaigns individually.

31. The End 31