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Electrophysiology is not a man’s world

Professor Andrea Sarkozy (Cardiology Department, University Hospital of Antwerp, Antwerp, Belgium) has had support from her male colleagues throughout her career, but acknowledges that other women in electrophysiology have not had a similar experience. She talks to Congress News about the potential barriers to women working in electrophysiology, what the European Heart Rhythm Association (EHRA) is doing to help overcome these barriers and gender-specific gaps in research.

Arrhythmias and Device Therapy

What percentages of electrophysiologists are female?

The exact percentages of female electrophysiologists within the European Union are unknown, but 20% of current EHRA members are female as are 11% of trainees in cardiac electrophysiology in the USA. 

What do you think the barriers are that may be preventing women from becoming electrophysiologists?

There is a misconception that electrophysiology is a “man’s world” and this—coupled with an overestimation of the difficulties of combining training and an electrophysiology career with family, and an absence of female role models—may put off cardiology trainees from specialising in electrophysiology. The Women in EP committee, created in 2013 by the previous EHRA President Professor Karl-Heinz Kuck (Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany), has attempted to address these issues. A survey was conducted in 2014 to understand the needs of the electrophysiology community, and the results are available online.

In 2016, a voluntary database of practising female electrophysiologists was set up and currently has more than 170 members. It is available for the Programme Chairs of all EHRA and European Society of Cardiology (ESC) scientific activities. Also, there are always two Women in EP sessions at EHRA EUROPACE - CARDIOSTIM, and one joint session at the Heart Rhythm Society (HRS) congress. These initiatives aim to increase the visibility of female electrophysiologists and improve networking. I would recommend to all interested colleagues to join our database, and participate in our sessions.

For you, what have been the challenges of working in a traditionally male environment?

I had the chance to work with excellent mentors and colleagues during my training and early professional career. Throughout my fellowship training, under the leadership of Professor Paul Dorian, in the St. Michael’s Hospital (University of Toronto, Canada) I never felt discriminated because of my gender.

I then worked for eight years as a staff member at the University Hospital of Brussels (Belgium)—under the mentorship of Professor Pedro Brugada—with Professor Jean-Baptist Chierchia and Professor Carlo De Asmundis as close colleagues. During that time, I had three children. Professor Brugada was always extremely supportive and understanding about my family choices, and Professors Chierchia and De Asmundis were always prepared to help out. Their support during this period was extremely important. Unfortunately, I know that not everybody has had similar experiences. Recently, I had to make a career choice in which my family took priority, which was difficult. In situations like this, a solid family background is important and helps with decision-making. But this is not gender specific, and is exactly the same for my male colleagues.          

Concerns about radiation exposure have been cited as a reason for the relatively low number of female interventional cardiologists. Do you think radiation exposure may be a barrier to women working in electrophysiology?

Surveys suggest that occupational exposure is a concern to both men and women. However, female cardiologists make more alterations to their training and career to reduce or avoid radiation exposure, because of concerns related to the risk to a developing foetus during pregnancy. Therefore, concern about occupational radiation exposure before and during pregnancy does appear to be one of the main reasons for the continuing under-representation of females in interventional cardiology and in electrophysiology. However, surveys also indicate that physicians overestimate the teratogenic risk associated with radiation exposure during pregnancy. A lack of accurate knowledge, and misinformation about the risks of occupational radiation exposure before conception and during pregnancy, can cause unfounded fears that lead to anxiety, and altered career and family choices. On the other side, negligence and non-compliance with current radioprotection practices can be hazardous. Several guidelines have recently been issued by the International Commission on Radiological Protection (ICRP) that deal with radiological protection in medicine, specifically in cardiology. These guidelines also address occupational exposure during pregnancy, and propose new recommendations. Furthermore, EHRA is publishing a new consensus document to describe current knowledge about the risks, and this will outline current international recommendations and legislation on occupational exposure during pregnancy. This will help to spread accurate scientific information, allowing informed career and family choices for cardiology trainees and practising electrophysiologists.

What do we know about how female gender influences arrhythmic disease states?

Sex-dependent differences in cardiac arrhythmias have been long described, from cellular electrophysiological properties to gender-specific clinical presentation and management. For example, female gender has long been recognised as an important prognostic factor in some channelopathies, such as long QT or Brugada syndrome. The increased risk of thromboembolic complications in female patients with atrial fibrillation is also well described, and has important therapeutic consequences (as highlighted in current guidelines). These are well-known examples, but it has become increasingly apparent that many gender differences are not fully recognised in clinical practice.

Data from registries and surveys indicate that implantable cardioverter defibrillators (ICD) and cardiac resynchronisation therapy (CRT), as well as simple and complex ablation procedures and even anticoagulation therapies, are less often used in female patients than in male patients. The ESC Guidelines for the management of atrial fibrillation addressed gender inequality in offering available therapies. It is stated in this document as a Class I recommendation that “atrial fibrillation clinicians must offer effective diagnostic tools and therapeutic management to women and men equally to prevent stroke and death”. Another striking fact is that only 20% to 30% of the study population in most cardiovascular randomised controlled trials are female. For example, in the five big studies on CRT, only 20% were women. This is difficult to explain. Large case-based meta-analyses have indicated that women derive similar or greater benefit from this therapy. Recent large trials on non-vitamin K antagonists anticoagulants (NOAC) in atrial fibrillation, and registries of catheter ablation of supraventricular tachycardias, atrial fibrillation, and ventricular arrhythmias, demonstrate similar findings. An EHRA/HRS scientific consensus statement on sex differences in cardiac arrhythmias will call attention to this, highlighting the need to include more females in trials—so that sufficient evidence is available in both genders.

Gender issues in ICD and CRT therapy 

Sunday, 18 June at 08:30 in the room COUMEL

View the programme