1. Gender Disparity in Treatment of Coronary Artery Disease?
Alexandra Lansky,
M.D, FACC, FESC, FSCAI

2. Alexandra J. Lansky, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. Overview
Gender based statistics for cardiovascular mortality and morbidity
Gender gaps in management and outcomes of stable coronary artery disease (CAD)
Gender gaps in management and outcomes of ACS
Gender gaps in management and outcomes of STEMI
Conclusions

4. Gender-based Statistics for Cardiovascular Mortality and Morbidity
Gender Gap in Management and Outcomes of Women with Coronary Artery Disease
©2009 Abbott Laboratories 4

5. Why Should We Care About Women’s Cardiovascular Health?
CAD is not just a “man’s disease” 1
52% of US population is female 2
Life expectancy of US females expected to be 81 years by
Post menopausal women are at greater risk of CAD and today 33 M women are over 55 years of age 2
More difficult to diagnose coronary artery disease (CAD) in women 1
Most women don’t realize that cardiovascular disease is the single largest killer of American women. Healthcare professionals can improve female cardiovascular outcomes through education on risk factors, symptoms, and necessary lifestyle changes.
Women are living longer and research suggests that as women age, they are at greater risk for heart disease.
1/3rd of all women are over the age of 55
Lifetime risk of CVD in women is about 32% in other words 1 in every 3 women is likely to suffer from CVD
It is more difficult to diagnose the disease in women. When it is diagnosed, research indicates that women receive less aggressive treatment than men.
Healthcare professionals can reduce the number of CVD deaths in women by making them aware of lifestyle modifications and medical interventions that can reduce their risk.
The Nurse’s Health Study revealed that adherence to lifestyle guidelines involving diet, exercise, and abstinence from smoking is associated with a very low risk of coronary heart disease in women. In addition, women are often the decision makers for healthcare utilization in their families, so enhancing a woman’s education regarding risk factors for cardiovascular disease, providing a mechanism to identify her personal risk factors, and improving access to intervention and treatment will not only influence her own health status, but that of her family and friends.
References:
American Heart Association
Gallup Poll. Coronary Heart Disease: Women's Heart Health Initiative. American Medical Women's Association. Available at:
Brieger D et al, for the GRACE Investigators. Acute Coronary Syndromes Without Chest Pain: An Under Diagnosed and Under Treated High-Risk Group. Insights From The Global Registry of Acute Coronary Events (GRACE); Chest 2004.
Noel Bairey Merz, MD: Gender Differences in Atherosclerosis and Coronary Heart Disease:
A perspective from the WISE Study; ACC; March 6, 2004.
AHA Heart and stroke Statistical Update 2008
Adapted from American Heart Association, the Nurse’s Health Study. WISE and Acute Coronary Syndromes Without Chest Pain: Insights from GRACE
AHA Heart and stroke Stas update 2009

6. Heart Disease is the No.1 Killer of American Women
CVD : the #1 killer in women
One third of all deaths in women due to CVD
One woman dies of heart disease every minute
CVD kills more women than men every year (since 1984)
More women die of heart disease each year than all types of cancer plus other diseases combined
Heart disease deaths are 11 times higher than breast cancer deaths
Poorer outcomes in women following a myocardial Infarction
Women are more likely to die within a year of myocardial infarction than their male counterparts
Of women who survive myocardial infarction nearly half will be disabled by heart failure within six years
Older age at onset and lack of awareness may contribute to poorer outcomes than men
CVD #1 killer in women1
1/3rd of all deaths in women due to CVD1
CVD kills more women than men every year2
CVD occurs differently in women
More women die of heart disease each year than all types of cancer plus other diseases combined, more than 11 times that of breast cancer.
For comparision:
In the year 2000 ½ a million women died of CVD while 65,000 from lung cancer and 40,000 than breast cancer.
Heart disease also claims more women following a heart attack, fewer women are expected to survive a heart attack than men. Women tend to have poorer outcomes and more disability due to chronic heart failure than men.
In the US, 34% women – over 40 million are living with CVD2
AHA Heart and Stroke statistical 2009 update

7. CVD Disease Mortality Trends For Males And Females (United States: 1979-2005)
550
500
Deaths (x 1000)
450
400
Males
Females
1979 80 85 90 95 00 05
Source: AHA Heart Disease and Stroke Updates 2009
1Heart Disease and Stroke Statistics 2004_ update
CDC/NCHS

8. Heart Disease Mortality Rates Have Substantially Declined in the US
U.S deaths from Heart Disease  25% ; five years ahead of goals set by AHA
Translated into 160,000 fewer deaths in 2005
Factors contributing to substantial national progress:
Improved treatment of established disease
Widespread use of cholesterol-lowering statins
Aggressive management of high blood pressure
Anti-smoking legislation and tobacco excise taxes
Gains lag behind national averages for following subgroups:
Women
African-American
People living in the south
People with lower income levels
Source: downloaded on October 31st 2009

9. Gender Gaps in Management of Coronary Artery Disease (CAD)

10. Gender Gap in Diagnosis and Treatment of CAD
Prevalence of coronary Artery Disease (CAD)
M 52%: W 48%
Diagnostic Procedures (Diag. Catheterizations & Non-invasive Tests)
M 55%: W 45%
Although we would like to think that women are treated at parity to men from an interventional standpoint, recent data from AHA shows otherwise. Some of this may be clinically appropriate decision making, but what percentage is that?
CABG
M 73%: W 27%
PCI
M 61%: W 39%
Medical Management Only
M 47%: W 53%
Sources: HCUP, 2007 (National Inpatient Sample database). National Ambulatory Medical Care Survey (NHAMCS), National Hospital Discharge Survey (NHDS), ACC-NCDR CathPCI Registery, Aug 2009. 10

11. Gender Gap in Management of Stable Angina
Women less likely to:
Undergo an exercise ECG
Be referred for coronary angiography
EuroHeart Survey: N=3779; 42% women
Women with confirmed disease less likely to:
Receive anti-platelet and statin therapies
Less Likely to Have Test
More Likely to Have Test
Angiography 0.59
Exercise ECG 0.81
Stress Imaging 1.08
Adjusted Odds Ratio for Women
Medication
Overall (n-3779)
Male (n-2197)
Female (n-1582)
P1 Male v. Female
Antiplatelet
3058
1851 (84%)
1207 (76%)
<0.001
Aspirin
2942
1784 (81%)
1158 (73%)
Lipid-lowering drug
1892
1156 (53%)
736 (46%)
Statin
1830
1117 (51%)
713 (45%)
-Blocker
2513
1479 (67%)
1034 (65%)
0.21
No. of antienginal drugs, mean (SD)
1.6 (0.9)
1.7 (0.9)
0.06
Daly et al Euro Heart Survey. Circulation :113:

12. Gender Gap in Mortality Outcomes Following Stable Angina
.15
N = 994
Log rank: p = 0.02
.10
Cumulative Event Probability
.05
Males
Females 3 6 9 12 15 18
Time Since Entry (Months)
Cumulative probability of death or MI in patients with confirmed coronary disease and stable angina according to gender
Daly et al Euro Heart Survey. Circulation.2006:113:

13. Gender Gap in Management of ACS
“Get with the Guidelines” registry database: N=78,254 ACS pts b/w
Higher in-hospital mortality for women with STEMI (10.2% vs 5.5%, p<0.0001)
Higher adjusted in-hospital mortality for women with STEMI (OR 1.12 [ ])
Underutilization of evidence-based treatments for women
Delayed reperfusion among women (STEMI)
Measure/Treatment
Men (n=47 556), % (n)
Women (n=30 698), % (n)
Adjusted OR P
Early medical therapy
Aspirin within <24 h
-Blockers within <24 h
93.3 (40 332)
87.2 (34 653)
91.0 (24 686)
84.7 (21 124)
0.86 ( )
0.90 ( )
<0.0001
Invasive procedures
Cardiac catheterization
PCI
CABG
Revascularization
Reperfusion Therapy
56.2 (26 733)
52.3 (22 253)
9.2 (3893)
60.2 (25 614)
73.0 (12 184)
45.6 (14 012)
36.1 (10 070)
5.4 (1501)
40.9 (11 409)
56.3 (4874)
0.91 ( )
0.78 ( )
0.60 ( )
0.68 ( )
0.75 ( )
Timeliness of reperfusion
DTN time, median (25th-75th), min
DTB time, median (25th-75th), min
39.0 ( )
95.0 ( )
47.0 ( )
103.0 ( )
0.78 ( )
0.87 ( )
Hani Jneid et al Circulation 2008;118; ;

14. Gender Gap in Management of NSTEMI ACS-I
CRUSADE ACS Registry: N=35 875; 41% women; Hospital mortality higher (5.6% vs 4.3%, p<0.001)
Despite high risk characteristics, women less likely to receive optimal medical therapy:
Acute medications
Acute heparin and acute angiotensin-converting enzyme inhibitors
Acute treatment with glycoprotein (GP) IIb/IIIa inhibitors
Discharge medications
Aspirin, beta blockers, Statins, ACE inhibitors and Clopidogrel
Variable
Male (n=21,323)
Female (n=14,552)
Unadjusted OR
Treatment within 24 h
Aspirin
Heparin, any
Glycoprotein IIb/IIIa inhibitor, any
Troponin-positive
Troponin-negative
Beta-blocker
Angiotensin-converting enzyme inhibitor
Clopidogrel
91.6%
84.0%
38.6%
39.9%
29.0%
77.7%
42.2%
41.0%
89.6%
80.0%
28.7%
30.5%
19.4%
75.8%
42.4%
35.6%
0.83
0.80
0.68
0.69
0.94
1.03
0.82
Discharge medications
-Blocker
Statin
90.4%
82.7%
55.5%
63.4%
53.2%
87.5%
80.5%
55.3%
55.9%
48.0%
0.79
0.89
1.01
0.77
0.84
Blomkalns et al Large Scale Observations from Crusade (J Am Coll Cardiol 2005;45:832–7)

15. Gender Gap in Management of NSTEMI ACS-II
Despite high risk characteristics:
Women less likely to receive invasive procedures such as:
Cardiac Catheterization, PCI and CABG
Women experience greater delays in receiving diagnostic catheterization and PCI
Variable
Male (n=21,323)
Female (n=14,552)
Unadjusted OR
Non-invasive stress testing
11.7%
13.2%
1.10
Diagnostic catheterization
71.1%
60.1%
0.70
Catheterization 24 h of arrival
48.7%
42.1%
0.69
Percutaneous coronary intervention (PCI)
PCI 24 h of arrival
40.4%
51.9%
31.4%
44.3%
0.73
0.64
Coronary artery bypass grafting
14.0%
9.0%
0.62
Women also were less likely to receive invasive procedures, such as cardiac catheterization,
percutaneous coronary intervention, and coronary artery bypass grafting,
Blomkalns et al Large Scale Observations from Crusade (J Am Coll Cardiol 2005;45:832–7)

16. Gender Gap in Management of ACS Utilizing PCI (ACC-NCDR:2004-2006)
Women had
Higher rates of UA/NSTEMI (82% vs. 77%, P<0.0001)
Greater co morbidities (DM, hypertension, PVD, CVA)
Less high risk angiographic features
Higher rates of cardiogenic shock, congestive heart failure, bleeding, and vascular complications
Less likelihood of receiving aspirin or glycoprotein IIb/IIIa inhibitors or a statin prescription
Similar odds ratio for in-hospital mortality (OR 0.97, P=0.5)
N = 199,690
ACS Patients
N = 131,664
Male
N = 68,026
Female
American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) is a LARGE national cardiac catheterization laboratory registry WHERE WOMEN WERE REPRESENTED AT 35% OF THE POPULATION. THIS REGISTRY showed THAT women:
Have statistically significant higher rates of unstable angina and STEMI AT PRESENTATION, GREATER COMORBIDITIES, and higher rates of cardiogenic shock, congestive heart failure, bleeding, and vascular complications, Have similar odds ratio for in-hospital mortality
Less likely to receive aspirin, IIb/IIa inhibitors, or statin prescription
Have lower rates of subacute stent thrombosis.
THIS DATA SUGGESTS THAT WOMEN REACH FOR INTERVENTION WITH HIGHER RISK FACTORS PERHAPS LEADING TO MORE POST PROCEDURE COMPLICATIONS. THEY ALSO ARE LESS LIKELY TO RECEIVE MEDICATIONS DUE PERHAPS DUE TO FEAR OF THESE COMPLICATIONS
N = 12,335 (18%)
STEMI
N = 55,691 (82%)
UA/NSTEMI
Akhter et al. Am Heart J Jan;157(1):141-8 16

17. Gender Differences in Outcomes Following Myocardial Infarction
Male (n = 21,323)
Female (n = 14,552)
Unadjusted OR
Death
4.3%
5.6%
1.27
Death or myocardial infarction
7.1%
8.6%
1.17
Postadmission myocardial infarction
3.5%
4.0%
1.12
Cardiogenic shock
2.7%
3.1%
1.10
Congestive heart failure
8.8%
12.1%
1.35
Stroke
0.8%
1.1%
1.37
Red blood cell transfusion
13.2%
17.2%
Women have higher rates of Death, MI, Cardiogenic shock, CHF and Bleeding complications 1
Study N
Unadjusted Mortality Rate
% Women
Women vs. Men (%)
P-Value
Watanabe20
82783 35
1.1
0.5
<0.0001
Alfonso19
981 16
6.0
2.0
0.01
WHC15
7372 28
1.39
0.66
<0.002
Malenka24
12232 NA
1.64
0.7
<0.001
Bell34
3557 27
4.2
2.7
0.005
NHLBI22
2136 26
2.6
0.3
NCN*21
150918 33
1.8
1.0 --
Mehilli**23,42
4264 24
3.1
1.9
0.02
Welty33
5989
1.2
0.1
Malenka16
33666
NHLBI13
2524
2.2
1.3
NCN32
109708
Arnold31
5000 25
0.001
NACI30
2855 34
1.4 NS
Weintraub29
10785
Unadjusted Mortality rates higher in women across various studies of outcomes of MI 2
Blomkalns et al J Am Coll Cardiol 2005;45: 832–7
20,18,16,24,34,22,21,23,42,33,16,18,32,31,30,28 Lansky et al Circulation. 2005;111:

18. Conclusion Heart Disease remains the number 1 Killer of US women
Despite an overall 25% reduction in mortality from CVD in the US
Women lag in national average
Prevalence of CAD is similar in men and women
Women undergo fewer diagnostic procedures
Fewer Revascularization and more medical therapy
Less evidence based medical therapy
Consistent across the continuum of CAD, including Stable CAD, NSTEMI and STEMI
Women have higher mortality and morbidity
Women have less evidence based medical and revascularization therapy
Concerning in light of worse outcomes 18

19. THANK YOU