In the beginning of the 21 st century, studies have continued to look into additional factors influencing the treatment and diagnosis of women such as race and others have found that physicians may not be following guidelines properly in both preventive and responsive treatment.
398,801 patients enrolled in cardiovascular trials funded by the National Heart, Lung, and Blood Institute between 1965 and 1998 were studied according to gender and their prevalence of CVD. Although the enrollment of women increased significantly during this time, after excluding single-sex trials from the data, it was found that there was no significant increase in the enrollment of women. In conclusion, there has been no change in the sex composition of cohorts in the majority of cardiovascular studies.
Graph: Percentage of women among enrollees in cardiovascular trials involving men and women, according to the year the trial was started. Single-sex trials are not included.
This study involved more than 100,000 patients who suffered an acute myocardial infarction and looked at hospital admissions in Medicare patients between January 1994 and February 1995. Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs. 50.8%) or female physicians (34.8% vs. 45.8%). Women were less likely to undergo cardiac catheterization, regardless of the treating physician’s sex. The authors concluded that “sexual discrimination, principally by male physicians towards women, does not explain sex-associated disparities in cardiac catheterization use after an acute myocardial infarction. However, other attitudes common to both male and female physicians may contribute to lower rates of cardiac procedure use in women.”
The American College of Cardiology and the American Heart Association joint electrocardiography guidelines state that all patients presenting to the emergency department (ED) with chest pain should undergo electrocardiography (ECG) to rule out acute ischemia or infarction, regardless of sex or age. To examine whether this basic guideline is being implemented uniformly, Arnold et al looked at a national sample from the National Hospital Ambulatory Medical Care Survey of 3,356 patients presenting to the ED with chest pain between 1995 and 1998. They found that men (86%) were significantly more likely to undergo ECG than women (82%) but these differences were only found among patients under the age of 55. In addition, blacks (80%) were significantly less likely to undergo ECG in comparison to whites (85%). The study concluded: “These management differences may delay diagnosis of acute coronary ischemia and potentially explain, at least in part, sex and race referral differences in cardiovascular therapies.”
Studies into the application of the newest treatments for curing certain abnormal heart rhythms, specifically the use of radiofrequency ablation, also showed gender bias. In 2003, an article in the Journal of the American College of Cardiology found that women were referred for catheter ablation, a treatment of choice for certain specific arrhythmias called supraventricular tachycardias, much later than men. In this study, 894 consecutive patients were referred for catheter ablation: 418 men and 476 women. The women had more severe symptoms than men and were referred for treatment an average of 28 months later than men after the onset of their symptoms. They were also given significantly more antiarrhythmic drugs before referral. The authors concluded that physicians and/or patients tend toward a more conservative approach in female patients and concerns about female patients in particular are unwarranted because ablation procedures in women had equally high success, low complication, and low recurrence rates as those procedures in male patients. The authors note that the delay in diagnosis of tachycardia might be due to the preference to attribute symptoms to panic, anxiety or stress in women.
In 2003, researchers wanted to evaluate the differences in medical care and clinical outcomes among black and white women with established coronary artery disease. They studied the 2699 women enrolled in the Heart and Estrogen/progestin Replacement Study (HERS) and found that during an average of 4.1 years of follow-up, cardiac events were twice as likely in black women compared with white women. Despite the fact that black women had higher rates of hypertension, diabetes, and hypercholesterolemia, they were less likely than white women to receive aspirin or statins. The study came to the conclusion that black women less often received appropriate preventive therapy and adequate risk factor control despite a greater coronary heart disease event risk.
A review of all cardiovascular advertisements portraying people from 1996 to 1998 in 34 U.S. edition journals found that 20% depicted a female patient while 80% depicted a male patient. While advertisements featuring male patient appeared 1618 times, female patient advertisements were found 249 times. In addition, the study found that advertisements depicting female patient had significantly fewer mean appearances than male patient advertisements in journals’ premium positions. The majority of these female patients depicted were between the ages of 35 and 55 while the male patients were between the ages of 35 and 70, in contrast with the reality that cardiovascular disease affects older women greater than older men. Despite the increasing emphasis on cardiovascular disease in women, there is significant under-representation of female patients in cardiovascular advertisements and this is cause for concern, given that these pharmaceutical advertisements are an important source of medical information for physicians.
Using a standardized online questionnaire, 500 randomly selected physicians were assessed for their awareness and adherence to national CVD prevention guidelines by specialty. Intermediate-risk women, as assessed by the Framingham risk score, were significantly more likely to be assigned to a lower-risk category by primary care physicians than men with identical risk profiles. Fewer than 1 in 5 physicians knew the fact that more women than men die each year from CVD. The study concluded that, “Gender disparities in recommendations for preventive therapy were explained largely by the lower perceived risk despite similar calculated risk for women versus men.” It suggested that educational interventions are necessary to improve the quality of CVD preventive care and decrease the mortality from CVD for all.
As we progress into the 21st century, in addition to an increase in the number and diversity of gender-specific studies, we have seen promising improvement in the generation of awareness about cardiovascular disease in women. In April 2003, TIME magazine’s cover story reported on “Women and Heart Disease.” There has been a growing popular interest in creating awareness and many campaigns, such as the American Heart Association’s Go Red for Women, have emerged. They bring the issue of the gender discrepancy in treatment and diagnosis of CVD to mainstream society’s attention. High profile women such as singer Toni Braxton and actress Mira Sorvino are some of the notable supporters and spokeswomen for Go Red for Women. Even First Lady Barbara Bush serves as ambassador for the Heart Truth campaign, which is working to spread the word about heart disease in women. The more awareness that is spread on the issue of women and CVD, the sooner and the more thoroughly the gender gap will be addressed.