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Controversial issue: are women different?

  • Gender gap in cardiovascular risk factors, morbidity and mortality, presented by D Vanuzzo (Udine, IT) - Slides
  • Does undertreatment of women influence outcome? Presented by S Sans Menendez (Barcelona, ES)
  • Are treatment effects different? Presented by E E Van der Wall (Leiden, NL) - Slides
  • Microvessel disease in women, presented by N C Bairey Merz (Los Angeles, US) - Slides

The topics reviewed in this session included the gender gap in CVD risk factors, morbidity and mortality, whether undertreatment of women influences outcome, whether treatment effects differ between the genders and lastly, microvessel disease in women.

Gender gap in cardiovascular risk factors, morbidity and mortality

Dr. Diego Vanuzzo from Italy started the session by pointing out that cardiovascular diseases are the leading cause of death in European women: 54%, compared to 43% in men. In 2008, the life expectancy in Europe was 82.4 years among women versus 76.4 among men. However, this gender gap shows a 3-fold variation among countries. Italian data show that the major gap in life expectancy between women and men is due to CVD and cancer and importantly, in the age range 0-74 years, 62% of the difference is amenable to primary prevention. With regard to CVD risk factors, although there are risk factors that are unique to women (gestational diabetes, pregnancy-induced hypertension and preeclampsia as well as polycystic ovarian syndrome), their predictive power is largely mediated by traditional risk factors common to both genders. However, several studies have found smoking to be a stronger risk factor in women than men. Dr. Diego concluded by stating that in absolute terms life expectancy with disability is longer in European women compared to men. Also, the cardiovascular gender gap is substantially related to lifestyle habits like smoking and alcohol intake, fostering indications for prevention.

Does undertreatment of women influence outcome?

Dr. Susana Sans Menendez from Spain reviewed the evidence regarding whether undertreatment of women influences the outcome after cardiovascular disease. Studies have shown that women receive fewer cardiac procedures after AMI than men, and survival is poorer. There is robust evidence that women with stable angina are both underinvestigated and undertreated in contemporary practice. In acute coronary syndromes, the Crusade study found that a smaller proportion of women than men received medical treatment within 24 hours, women also received less discharge medical treatment. Consequently, short-term fatal outcomes are more frequent in women. Part of the adverse outcomes are due to undertreatment compared to men. There is a residual risk related to gender which only in part is due to more adverse morbid and risk factor profiles and in part to inadequate reperfusion devices. Dr. Sans concluded that barriers that contribute to treatment disparities in women, as well as the influence of other clinical characteristics on differences in treatment patterns and outcomes among women and men require further investigation.

Are treatment effects different?

Dr. Ernst van der Wall from the Netherlands discussed whether the effects of treatment may differ between men and women. Historically, randomized clinical trials have included a majority of men, although the proportion of women has increased. An overview of blood pressure-lowering regimens found a similar protection against major CVD events in men and women. A meta analysis of statin therapy showed a reduced risk of CHD events in men without prior CVD, but not in women. No differences between the genders were found regarding total mortality. Another study found that women might be less responsive to aspirin than men. Dr. van der Wall pointed out that heart failure may be a different disease in women than men, and that women admitted to hospital with heart failure have better one-year survival than men. Perhaps treatment should be more gender specific? While studies have shown that testosterone treatment may not benefit men with heart failure, it may benefit women. He concluded by saying that prescribing physicians should be aware of gender-specific treatments, that all guidelines should account for gender-specific differences and that these should be implemented accordingly.

Microvessel disease in women

Lastly, Dr. Noel Bairey Merz from Los Angeles, USA, spoke on microvascular coronary dysfunction in women with ischemic heart disease. She described a systematic approach to examining why CVD treatment strategies previously failed in reducing the CVD mortality gap in the United States, where women since the early 1980’s have had higher CVD mortality rates than men. Their group has engaged in clinical translational research ranging from observation, mechanisms, intervention and translation. A large proportion of women who present with angina do not have occluded coronary vessels, despite having extensive atherosclerosis. They often have microvascular coronary dysfunction, e.g. abnormal coronary vasomotion to acetylcholine. The latter has been found to independently predict cardiac events in women with no obstructive coronary artery disease. Microvascular coronary dysfunction can be detected using a variety of techniques; cardiac MRI may be such an ideal noninvasive modality. Their group is further exploring detection, evaluation and treatments of ischemic heart disease in women. She ended by showing that the gender gap in CVD mortality has been reduced after the gender specific guidelines were implemented in the US.

This session attracted a large audience, and several questions to the speakers were posed. Among others, it was stressed that studies examining potential gender differences in CVD must take into account the underlying pathophysiology, which may differ between men and women, e.g. in heart failure, and that the pathology in acute coronary syndromes may differ between the genders.

This symposium was proposed by the EACPR section on Prevention, Epidemiology and Population Science.




Controversial issue: are women different?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.