SLIDE 1 We’ve Come a Long Way Baby… Or Have We? Gender Equity in Cardiac Care
Beth L. Abramson MD MSc FRCP FACC
Paul Albrechtsen Professor in Cardiac Prevention & Women’s Health Associate Professor of Medicine, U. of Toronto Director: Cardiac Prevention Centre & Women ’s CV Health, Division of Cardiology, St. Michael ’s Hospital
SLIDE 2 Objectives
- To understand quality indicators in CV
care for the postmenopausal woman
- To review care gaps in this area
- To discuss strategies to reduce disparity
in care for the woman at CV risk
SLIDE 3
Beth L. Abramson MD MSc FRCP FACC- Disclosure
Speaker for various companies including: Amgen, Astra Zeneca, Boehringer Ingelheim, Bristol Myer Squibb, Dupont, Eli Lilly, Norvartis, Fournier, Merck Frosst, Pfizer, Servier, Sanofi- Aventis Ongoing research with funds from: Astra Zeneca, Eli Lilly, Sanofi, Roche, Merck National Advisory Board – Amgen, Astra Zeneca, Boehringer-Ingelheim, Novartis, Sanofi-Aventis Author: Heart Health for Canadians
SLIDE 4 What is Women’s health?
- More than gynecological needs
- More than breast cancer evaluation
- More than obstetrical needs
SLIDE 5
Atherothrombosis…KILLS
It’s an equal opportunity killer!
SLIDE 6 Cardiovascular Diseases: Leading Cause of Death in Canada
Diabetes 2% Cancer 28% Accidents/ Poisoning/ Violence 6% Infectious Diseases 2% Other 15% Cardiovascular 38% Respiratory 9%
Source: Laboratory Centre for Disease Control, 1996- Using Statistics Canada
SLIDE 7 Risk Increases in Women after the Menopause
SLIDE 8 An Equal Opportunity Killer!
Abramson et al HSF 2007 report
SLIDE 9 Courtesy Dr. N. Wegner
SLIDE 10 Courtesy S. Hayes MD
SLIDE 11
www.nih.gov
WWW.NIH.GOV
SLIDE 12
Cardiac Care and Women What We Know…
SLIDE 13
May lead to wrong conclusions…
- Should not be used to deny therapy
- apples Vs. oranges..
- 2% Vs. 4% risk
- Individual Risk/Benefit for the particular
patient ♀or ♂
Outcomes Different by Gender: Biology or Bias?
SLIDE 14 Major Bleeding and Gender GPIIb/IIIa Inhibitors; NSTMI / ACS Appropriate vs Excess Dose
Alexander KP. Circulation ,2006;114:1380-87
46% treated women v. 17% treated men received excess dose
p=0.0001
SLIDE 15 Historically, women have been treated differently than men in the CV field
- Access
- Diagnosis
- Treatment
SLIDE 16
- N. C. Chandra,et al,. Arch Intern Med 158 (9):981-988, 1998.
Treatment of women in the USA with MI s: The National Registry of Myocardial Infarction-I N= 354 435
SLIDE 17 No Change Over Time?
- Sex and Racial Differences in the
Management of AMI 1994-2001:
– NRMI database n= 598,911
- Rates of Therapy vary according to race and
sex, with no evidence that the differences have narrowed in recent years
- “Probably, persistent differences in treatments
and procedures reflect some unmeasured characteristic of patients or health care factor that has not changed over time.”
Vaccarino, NEJM 2005
SLIDE 18
The Project for an Ontario Women’s Health Evidence-Based Report (POWER):
SLIDE 19 Crude angiography rates* within 3 mos of AMI discharge, by sex in Ontario, 2005/06
Women 44 56 Men 61 39
* Angiography rates were determined by identifying patients who were on the CCN list for angiography within 3mos of discharge. Data source(s): CIHI-DAD, 2005/06; CCN 2005/06
www.powerstudy.ca
SLIDE 20 Crude angiography rates* within 3 mos of AMI discharge, by sex and income, in Ontario, 2005/06
41 45 46 44 48 56 58 62 65 66 20 40 60 80 100 Q1 (Low est) Q2 Q3 Q4 Q5 (Highest) Neighbourhood income quintile Percentage (%) Women Men
* Angiography rates were determined by identifying patients who were on the CCN list for angiography within 3mos of discharge. Data source(s): CIHI-DAD, 2005/06; CCN 2005/06; Statistics Canada Census 2001
www.powerstudy.ca
SLIDE 21 76 53 21 80 60 25 20 40 60 80 100 45-64 65-79 80+ Age group (years) Percentage (%) Women Men
Fig 3. Angiography rates within 3 months of AMI discharge, by sex and age group, in Ontario
www.powerstudy.ca
SLIDE 22 Angiography rates within 3 months of discharge for AMI, by sex, income and region in Ontario
SLIDE 23 69 73 72 69 74 78 20 40 60 80 100 Beta blocker ACEi and/or ARB Statin Medication Percentage (%) Women Men
Fig 2: Medication management one year post AMI discharge: beta blockers, ACEi and/or ARB and statin use by sex, in Ontario www.powerstudy.ca
- 9,882 patients were hospitalized with AMI 2005/06
- 7,961 were alive one year post D/C, med use assessed
SLIDE 24
- M. & F. had similar rates of beta blocker & ACE/ARB
- Women were significantly less likely to use statins,
undergo angiography post-MI, and receive care from a
- cardiologist. (Differences persisted after age-adjustment).
- There was significant regional variation in care,
- Angiography rates post AMI ranged from 40%-68%.
Sex and age differences varied across regions
Good News – Bad News story….
SLIDE 25 Women and ICDs
- Data to suggest women are less likely
to be referred for ICD insertion
- Large gender gap that needs
exploring!
SLIDE 26 Post ACS Management
- A- Anti-platelets, ACE-Is, ARBs
- B - Beta Blockers and BP
- C - Cholesterol, Cigarettes, Cease HRT
- D - Diabetes and Diet
- E - Exercise and Education = rehab +
- ALL PROVEN EFFECTIVE IN WOMEN!
SLIDE 27 HOPE 3 TRIAL: Primary Prevention
- Moderate risk individuals
- 46% women.
- BP lowering effective
- Statins lower event rates
NEJM 2016
SLIDE 28
Why women are different…
https://youtu.be/t7wmPWTnDbE
SLIDE 29
Quality of Life is Important
SLIDE 30 Gender Issues In CV care summary:
- CVD is a leading cause of female mortality
- Women are still under-treated
- All CV interventions and medication are proven
effective in women
- female patients are older, sicker, and require
aggressive intervention
- focus on QOL more as the female population ages
