Women with acute coronary syndrome are less invasively examined and subsequently less treated than men

We read with interest the manuscript of Hvelplund A, et al about the gender differences in the management of patients with acute coronary syndrome in Denmark [1]. For this purpose, authors identified all patients admitted to Danish hospitals with acute coronary syndrome in 2005-07 (9561 women and 16406 men). Authors found that significantly less women underwent coronary angiography than men (64% versus 78%, P <0.05; hazard ratio 0.68; 95% CI 0.65-0.70, P <0.0001). Moreover, percutaneous revascularization was also less likely performed in women compared with men. Previous studies in different European countries have shown that women are somewhat less intensively treated, especially regarding invasive procedures [2]. This situation may be even worse since patients included in these studies had a diagnosis of acute coronary syndrome. As atypical chest pain is more frequent in women than in men, many women are not correctly diagnosed of myocardial infarction, or when they are diagnosed, sometimes it is too late and may not benefit from revascularization [3]. Unfortunately, these differences do not only occur in acute setting, but they remain during the follow-up. Thus, when compared gender differences in patients with chronic ischemic heart disease, women appear to be undertreated and underdiagnosed, what may in part explain the poorer risk factors control rates observed in this population [4]. Despite cardiovascular disease is the most important cause of death among women, it seems that many physicians and patients do not actually realize about the coronary risk in women, particularly in those with a history of myocardial infarction [5]. Although this could be at least partially due to confidence in the well-known cardioprotective effect of female hormones, the fact is that physicians do not adequately diagnose and treat women with cardiovascular disease. It is very likely that this undertreatment may have an important role in the cardiovascular prognosis of women. All these data emphasize the need for ongoing medical education to improve the recognition and management of both acute and chronic coronary heart disease in women, with the goal of reducing overall cardiovascular risk.

References

1. Hvelplund A, Galatius S, Madsen M, Rasmussen JN, Rasmussen S, Madsen JK, Sand NP, Tilsted HH, Thayssen P, Sindby E, Hojbjerg S, Abildstrom SZ. Women with acute coronary syndrome are less invasively examined and subsequently less treated than men. Eur Heart J. 2010;31:684-690.

2. Alfredsson J, Stenestrand U, Wallentin L, Swahn E. Gender differences in management and outcome in non-ST-elevation acute coronary syndrome. Heart. 2007;93:1357-1362.

3. Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology, Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernandez-Aviles F, Fox KA, Hasdai D, Ohman EM, Wallentin L, Wijns W. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 2007;28:1598-1660.

4. Barrios V, Escobar C, Bertomeu V, Murga N, de Pablo C, Calderon A. Sex differences in the hypertensive population with chronic ischemic heart disease. J Clin Hypertens (Greenwich). 2008;10:779-786.

5. Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, Ganiats TG, Gomes AS, Gornik HL, Gracia C, Gulati M, Haan CK, Judelson DR, Keenan N, Kelepouris E, Michos ED, Newby LK, Oparil S, Ouyang P, Oz MC, Petitti D, Pinn VW, Redberg RF, Scott R, Sherif K, Smith SC Jr, Sopko G, Steinhorn RH, Stone NJ, Taubert KA, Todd BA, Urbina E, Wenger NK. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115:1481-1501.

Conflict of Interest:

None declared