Call to action on heart disease in women

Heart failure

By Michael Woodhead

19 Jun 2019

Leading cardiology clinicians and researchers have made a call to action to address widespread sex discrepancies in all aspects of heart disease.

The Heart Foundation Women in Heart Disease Forum 2019 held in Sydney heard that the scale of the problem went far beyond underdiagnosis and delayed treatment of heart disease in women. Sex differences in heart disease encompassed under-representation of women in clinical trials, lack of sex-specific clinical guidelines and risk calculators, under appreciation of the cardiovascular consequences of conditions such as pregnancy and pre-eclampsia, and under-representation of women in cardiology.

Professor Robyn Norton, Principal Director of the George Institute for Global Health said a fundamental problem was that sex and gender were often not considered as factors in research, with women accounting for only 20-30% of participants in studies. She explained that sex differences related to biological characteristics whereas gender differences related to factors such as socioeconomic and cultural differences.

For both there was a paucity of data in all aspects of heart disease in women, including differences in epidemiology, characteristics and symptoms, as well as risk factors, prognosis and outcomes of treatment.

“There’s a lot that we need to be doing in Australia if we are going to embed the concept of sex and gender in our research and practice,” she said.

Widespread implementation would require such changes to be adopted by bodies including medical schools, research funding bodies, medical journals, regulatory authorities, guideline authors and ethics committees as well as industry, Professor Norton suggested.

Professor Clara Chow, a cardiologist at the University of Sydney, presented data on the sex differences in the management of STEMI in Australian hospitals. Women had lower rates of revascularistion, were less likely to receive statins or referral to cardiac rehab at discharge and had higher mortality rates than men at six months.

Professor Norton noted that similar findings on undertreatment from the UK had translated into 8000 additional deaths among women from heart disease over a ten year period

“When I saw this I thought it was outrageous and we really need to do something, “ she said.

“We’ve now got to the point where we know these differences exist, the next big challenge is to move on to prevention and treatment practices.”

Cardiologist Dr Clare Arnott from the Royal Prince Alfred Hospital Sydney told the meeting of a real world example of a young woman with chest pain being given less attention in an emergency department than a middle aged man with similar symptoms.

Current approaches to cardiovascular disease also overlooked the fact that women had a higher risk of stroke than men and women have higher rates of heart failure with preserved ejection (HFpEF) fraction whereas men have higher rates of HF with reduced ejection fraction (HFrEF), she said.

Other examples of sex differences in heart disease management included a focus on obstructive coronary disease, which predominated in males, whereas women may have non-obstructive disease due to endothelial dysfunction, microvascular disease or spontaneous coronary artery dissection or vasospasm.

But Dr Arnott warned that nothing would change if the discrepancies were seen only as a “women’s health” issue.

“It’s a societal problem. We will never solve this issue or improve outcomes for women until we engage men,” she said.

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