"The results of our study showed that women, especially high-risk women, aren't receiving the recommended treatment for patients with acute coronary syndromes," said Sonia S. Anand, MD, PhD, FRCPc, associate professor of medicine at McMaster University in Hamilton, Ontario, Canada, and lead author of the paper. "All women should be considered for these types of procedures, as are men, when they come to the hospital with these conditions."
Dr. Anand, who holds the May Cohen Eli Lilly Chair in Women's Health Research at McMaster, spoke today at the American Medical Association's 24th annual Science Reporters Conference in Washington, D.C. She and her coauthors analyzed data from the Clopidogrel in Unstable Angina Evaluation (CURE) trial, a study of 4,836 women and 7,726 men with ACS, a group of conditions that includes angina, or chest pain, and certain types of heart attacks.
The patients, from 28 countries, were recruited between December 1998 and September 2000. Dr. Anand and her research team assessed their status when they were discharged, one month later, and then one to three more times at three-month intervals.
The problem started, Dr. Anand said, when women with ACS weren't sent for diagnostic tests, such as coronary angiography, during which physicians use a catheter to inject dye into the arteries to identify blockages. Overall, 15 percent fewer women underwent angiography, and 20 percent fewer high-risk women than high-risk men had the test. "It wasn't that once the disease was documented, physicians ignored women and didn't send them to have operations--they did," Dr. Anand said. "But the initial trigger to send them for the catheterization was much lower for women compared to men."
Therefore, the rates of invasive procedures that generally follow angiography were also lower among women than men. Women were 35 percent less likely to undergo angioplasty or coronary artery bypass graft surgery, treatments that reopen blocked blood vessels or reroute blood through newly created arteries. "Even high-risk women received fewer procedures," Dr. Anand said. "Although there wasn't a difference in their death, heart attack or stroke rates, we certainly found that women returned more often to the hospital complaining of chest discomfort over the nine months of follow-up. It may be that because they received fewer procedures and therefore interventions, they still have ongoing coronary disease."
The paper raises more questions than it answers about the causes of these gender differences, Dr. Anand said. "Maybe women refuse procedures more than men, maybe there is a bias that causes physicians to feel that men are high-risk so they should have procedures and not women, or maybe women have different chest pain symptoms than men," she said. "There are a lot of potential explanations as to why women wouldn't get the same number of procedures."
Dr. Anand is working to find the root of the problem through several new studies, including an online survey of physicians who are presented with patient scenarios and asked to respond with a treatment plan. By observing whether physicians would treat identical patients differently depending on gender, she hopes to shed light on the issue of physician bias.
But women don't have to wait for definitive answers to put this knowledge to use. Those who are at risk for or who already have cardiovascular disease--the number-one killer of women--should educate themselves about their treatment options, Dr. Anand said. "Women who develop acute coronary syndromes can ask their physicians if they are candidates for such procedures, as opposed to staying silent and leaving it up to the doctor to decide," she said.