Term Paper on "Female Gender Disparities in Cardiovascular Disease Women"

Term Paper 9 pages (2805 words) Sources: 20

[EXCERPT] . . . .

Female Gender Disparities in Cardiovascular Disease

Women and Cardiovascular Disease: A Synthesis of the Literature

One in three women in the United States suffers from cardiovascular disease, or also known as coronary artery disease (CAD). This fact has stimulated the lay and scientific communities to recognize coronary artery disease as a significant health issue for women. Progress has been made in defining the incidence of heart disease in women and describing gender-specific differences related to cardiac anatomy and physiology. In addition, both traditional and gender specific coronary risk factors have been studied, along with the reliability of conventional cardiac diagnostic tests in women. However, a great deal remains unknown because women largely have been excluded from past research on the diagnosis and treatment of heart disease. In particular, women's cardiac symptoms may differ from the classic cases seen in men.

Coronary artery disease (CAD) kills more women than all cancers combined, yet their diagnosis can be missed or delayed. Detection of CAD at an earlier stage in women may result in earlier recognition and treatment and subsequently lower associated morbidity and mortality rates. The purpose of this evidentiary review is to examine the effect of gender on the recognition, treatment, and outcomes of coronary artery disease in women. For example, women experience shortness of breath on exertion, abdominal pain, and back pain, while men often have classic midsternal chest pain. Clinical outcomes of women receiving standard medical and surgical treatments remain another area of uncertainty (Shirato & Swan, 2010).



The development of evidence-based medicine has led to daily clinical practice being increasingly based on the results of large, randomized, multi-centre studies that were aimed at improving the prevention and treatment of disease in both sexes. However, given the differences between the two sexes as concerns the incidence of cardiovascular disease, as well as the effectiveness of preventive and therapeutic measures, the lesser representation of women in large studies creates a problem. It is indicative that, in clinical studies of coronary artery disease or stroke that were published between 1997 and 2006, women made up only 27% of the population, while in many of those studies results were not given separately for each sex; thus, there is a significant lack of data concerning cardiovascular diseases in the female sex.

Additionally, numerous studies have shown suboptimal rates of CHD therapies among women. Once women enter the health care system, they are likely to receive fewer medical and interventional procedures such as thrombolytic therapy or rescue coronary angioplasty. Treating women and men differently may be explained, in part, by difficulties in diagnosis that may occur in women with CHD, particularly because chest pain in women may often be considered benign. However, treating women differently when there is no reason to do so, such as in the setting of acute myocardial infarction (MI), would seem to be an apparently unjustified sex dependent approach (Pyrgakis, 2010).

Synthesis of Literature Reviewed

Randomized trials have shown that low-dose aspirin decreases the risk of a first myocardial infarction in men, with little effect on the risk of ischemic stroke. A randomized controlled trial with low dose aspirin was conducted on women (Ridker et al., 2005), since there are few similar data in women. The methods involving randomly assigning 39,876 initially healthy women 45 years of age or older to receive 100 mg of aspirin on alternate days or placebo and then monitored them for 10 years for a first major cardiovascular event (i.e., nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes).

The results: During follow-up, 477 major cardiovascular events were confirmed in the aspirin group, as compared with 522 in the placebo group, for a nonsignificant reduction in risk with aspirin of 9%. There was a 17% reduction in the risk of stroke in the aspirin group, as compared with the placebo group, owing to a 24% reduction in the risk of ischemic stroke and a nonsignificant increase in the risk of hemorrhagic stroke. As compared with placebo, aspirin had no significant effect on the risk of fatal or nonfatal myocardial infarction or death from cardiovascular causes. In this large, primary-prevention trial among women, aspirin lowered the risk of stroke without affecting the risk of myocardial infarction or death from cardiovascular causes, leading to a nonsignificant finding with respect to the primary end point.

The Women's Ischemia Syndrome Evaluation (WISE) study provided an opportunity to determine possible relationships among hostility, angiographic CAD, and anginal symptoms in a large sample of women. A previous report from the WISE study showed that hostility and anger are positively related to CAD risk factors and that hostility was positively predictive of CAD events in this sample. To determine the relationship of psychological characteristics to initial CAD diagnosis, the study compared (1) anger and hostility in symptomatic women with and without angiographic CAD and (2) the relationship of measures of anger and hostility to anginal and cardiac-related symptom reports and functional status in the WISE sample. To determine the relationship of anger and hostility to angiographic coronary artery disease (CAD), symptoms, and functional status among women with suspected CAD.

Data were collected from 636 women with suspected CAD referred for diagnostic angiography in the Women's Ischemia Syndrome Evaluation (WISE) Study. CAD was assessed as angiographic presence/absence of disease (50% stenosis in any epicardial coronary artery). Hostility/anger, angina, symptoms, and functional status were assessed by the Cook- Medley Hostility Inventory, Spielberger Anger Expression Scale, cardiovascular symptom history, and the Duke Activity Status Index.

Logistic regression revealed that anger-out (i.e., aggressive behavior in response to angry feelings) was independently associated with the presence/absence of angiographic CAD.

Thus, among women with suspected CAD, anger-out scores were associated with the presence of angiographic CAD. Anger/hostility traits were associated with increased symptoms, particularly with nonanginal chest pain in women without angiographic CAD. Relationships among psychosocial factors, cardiac symptoms, and angiographic CAD are potentially important in the management of women with suspected CAD (Krantz, et al., 2006).

Whether the increased mortality after PCI (percutaneous coronary intervention) and MI (acute myocardial infarction) in women in comparison with men can be explained by factors inherent to the female sex is unclear. However, several vascular abnormalities more prevalent in women including vasospastic disorders, Raynaud phenomenon, various forms of vasculitis, and migraine headaches underlie the concept of sex differences in the pathophysiology of ischemic vascular disease. In addition, the macro- and microvasculature is smaller and stiffer, with more diffuse atherosclerosis and endothelial as well as smooth muscle dysfunction in women as compared with men. Of note, impairment of coronary flow reserve, as assessed by intracoronary response to adenosine, has served as a marker of microvascular smooth muscle cell dysfunction and has been shown to be an independent predictor of adverse cardiovascular outcomes in women. Many of these differences in the vasculature have been attributed to female sex steroid hormones and their fluctuations throughout the life cycle in women.

In its broadest sense, the term "health disparities" refers to preventable differences in the indicators of health of different population groups, usually defined by race, ethnicity, socioeconomic status, geographic location of residence, education level, and sex. Whether sex differences in the biological and pathophysiologic manifestation of cardiovascular disease translate into differences in access to and delivery of evidence-based therapies is not well defined.

During the past 2 decades, several reports have indicated that women experience greater delays to intervention and are referred for diagnostic catheterization less frequently than men. Although women's older age, differences in symptoms and pain perception, and a higher prevalence of co-morbidities, lower predictive accuracy of noninvasive testing, and an increased risk for an adverse procedural outcome in women have been proposed as explanations for these observations, there is some evidence to suggest a potential gender and racial bias. Yet increasingly it has been recognized

that socioeconomic and cultural factors and lack of awareness of the prevalence and implications of coronary heart disease in women have played an important role (Jacobs, 2009).

The reasons for gender disparities in stroke outcome remain unclear, and little is known about the value of acute neuroimaging characteristics in elucidating differential stroke outcomes between the sexes. In a study by Silva et al., patients with acute ischemic stroke were prospectively evaluated. CT angiography (CTA) was performed in all patients within 24 h of symptom onset. CTA source images were used to evaluate lesion volume. The primary outcome measure was a modified Rankin scale (mRS) score 6-3 at 6 months. 676 patients were evaluated (322 women). Women were older than men, more frequently had a prestroke mRS, and had higher admission National Institutes of Health Stroke scale score. More women had intracranial artery occlusions than men (46 vs. 33.1%), but there was no significant difference between ischemic lesion volumes.

Thus, compared with men, women are less likely to achieve independence after acute ischemic stroke. The disparity in stroke outcome is not explained by differences in ischemic lesion volume or the presence of intracranial artery occlusions.

Previous studies have documented the under diagnosis of coronary heart disease… READ MORE

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