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
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
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
What is Women’s health? • More than gynecological needs • More than breast cancer evaluation • More than obstetrical needs
Atherothrombosis…KILLS It’s an equal opportunity killer!
Cardiovascular Diseases: Leading Cause of Death in Canada Infectious Other Diseases 15% 2% Cardiovascular 38% Accidents/ Poisoning/ Violence 6% Respiratory Cancer Diabetes 9% 28% 2% Source: Laboratory Centre for Disease Control, 1996- Using Statistics Canada
Risk Increases in Women after the Menopause
An Equal Opportunity Killer! Abramson et al HSF 2007 report
Courtesy Dr. N. Wegner
Courtesy S. Hayes MD
WWW.NIH.GOV www.nih.gov
Cardiac Care and Women What We Know…
Outcomes Different by Gender: Biology or Bias? • Gender Lens important… 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 ♂
Major Bleeding and Gender GPIIb/IIIa Inhibitors; NSTMI / ACS Appropriate vs Excess Dose 46% treated women v. 17% treated men received excess dose p=0.0001 Alexander KP. Circulation ,2006;114:1380-87
Historically, women have been treated differently than men in the CV field • Access • Diagnosis • Treatment
Treatment of women in the USA with MI s: The National Registry of Myocardial Infarction-I N= 354 435 N. C. Chandra,et al,. Arch Intern Med 158 (9):981-988, 1998.
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
The P roject for an O ntario W omen’s Health E vidence-Based R eport (POWER):
Crude angiography rates* within 3 mos of AMI discharge, by sex in Ontario, 2005/06 Men Women 39 44 56 61 * Angiography rates were determined by identifying patients who were on the CCN list for angiography within 3mos of discharge. www.powerstudy.ca Data source(s): CIHI-DAD, 2005/06; CCN 2005/06
Crude angiography rates* within 3 mos of AMI discharge, by sex and income, in Ontario, 2005/06 100 Percentage (%) 80 66 65 62 58 56 48 60 46 45 44 41 40 20 0 Q1 (Low est) Q2 Q3 Q4 Q5 (Highest) Neighbourhood income quintile 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 www.powerstudy.ca Census 2001
Fig 3. Angiography rates within 3 months of AMI discharge, by sex and age group, in Ontario 100 Women 80 76 Percentage (%) 80 Men 60 53 60 40 25 21 20 0 45-64 65-79 80+ Age group (years) www.powerstudy.ca
Angiography rates within 3 months of discharge for AMI, by sex, income and region in Ontario
Fig 2: Medication management one year post AMI discharge: beta blockers, ACEi and/or ARB and statin use by sex, in Ontario 100 78 74 73 72 69 69 Percentage (%) 80 60 40 20 0 Beta blocker ACEi and/or ARB Statin Medication Women Men • 9,882 patients were hospitalized with AMI 2005/06 • 7,961 were alive one year post D/C, med use assessed www.powerstudy.ca
Good News – Bad News story…. • 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
Women and ICDs • Data to suggest women are less likely to be referred for ICD insertion • Large gender gap that needs exploring!
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!
HOPE 3 TRIAL: Primary Prevention • Moderate risk individuals • 46% women. • BP lowering effective • Statins lower event rates NEJM 2016
Why women are different… https://youtu.be/t7wmPWTnDbE
Quality of Life is Important
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
Recommend
More recommend
