Marked Gender Disparities in CVD Treatment, Outcomes Seen in CREATE Registry

Shelley Wood

April 20, 2012

April 19, 2012 (Dubai, United Arab Emirates) — Not only are women experiencing ACS in India less likely to receive appropriate care, they are also more likely to die following treatment.

Presenting new gender data from the CREATE registry in a press conference at the World Congress of Cardiology (WCC) 2012, Dr Prem Pais (St John's Medical College and Research Institute, Bangalore, India) observed that variations in treatment, including access to evidence-based drugs and interventions, account for only 20% of the increased mortality seen in women.

Similar findings on gender disparities have been reported previously from countries around the globe, but CREATE is the first large, multicenter registry from India to show such stark differences in both care and outcomes in that country and to hint at cultural drivers.

Differences From Start to Finish

Dr Prem Pais

CREATE prospectively enrolled 20 468 patients across 89 centers in 50 Indian cities, as previously reported by heartwire . Less than one-quarter of the patients enrolled over the course of the study were women; the current analysis, presented as a poster Thursday morning, compared baseline factors and outcomes between men and women in the registry.

According to Pais, women were on average four years older than the men in the study, with higher rates of diabetes, hypertension, and heart failure and higher heart rates. Smoking was the only major risk factor more common in men. Women took, on average, 35 minutes longer to get to the hospital and, once there, were significantly less likely to undergo angiography, thrombolysis, or coronary interventions.

Use of what Pais characterized as the "cheaper" medications--aspirin and beta blockers--were given at roughly the same rates in men and women, but more expensive drugs--ACE inhibitors and angiotensin-receptor blockers (ARBs), as well as statins--were used much more commonly in men.

At one month, he said, rates of death were significantly higher in women than in men (rates of reinfarction and stroke were no different).

Differences in Baseline Characteristics, Treatments, and Outcome Between Men and Women

Characteristic or outcome Men Women p
Time from symptoms to hospital (min) 340 415 <0.0001
Angiography (%) 24 19.3 <0.0001
Any revascularization (%) 52.7 37.5 <0.0001
Thrombolysis (%) 44.9 30.9 <0.0001
Antiplatelet drugs (%) 98.3 97.6 0.003
Beta blockers (%) 60.5 59.7 0.314
ACE inhibitors/ARBs (%) 56.4 54.6 0.023
Lipid-lowering drugs (%) 53 50.6 0.004
Death at 30 d (%) 6.2 8.6 <0.0001

After adjustment for age and risk factors, mortality at 30 days remained almost 25% higher in women. When other characteristics and treatments were taken into account, these explained only 20% of the increased mortality, Pais said.

Elaborating to heartwire , Pais said that some of this difference may be explained by factors specific to India and Indian culture, but others, he suspects, are more universal. "At least in India, and I'm sure many other countries, the large number of people having a heart attack go to a secondary-care hospital, where they are looked after by a physician and not necessarily a cardiologist. And there still remains the impression that heart disease is a man's disease. So the level of responsiveness remains a little low."

Second, he said, in India, where 80% of patients have to pay for their own treatment, a stent may cost six or eight months' worth of a family's income. So sometimes people think twice, he said, particularly if the patient is a woman. "Sometimes the woman herself says no, I don't want to do it."

Dr Carolina Nazzal

Dr Carolina Nazzal (University of Chile, Santiago) touched on similar issues during the Wednesday press conference, noting that unexplained cultural factors also likely underpin treatment and survival disparities between genders in her country. In Chile, she explained, government-mandated treatment now requires identical care for men and women suffering MI, and this has helped close the mortality gap somewhat, yet women still are more likely to die in the hospital, she says.

Gender-disparity research is invariably a part of the selected science served up for the media at the major cardiology meetings, a fact acknowledged by the speakers yesterday. Most pointed out that progress in this field has been undeniable, in part thanks to organizations like the World Heart Federation and the American Heart Association helping to increase awareness and stepping up efforts to track outcomes and quality.

CV Risk Remains Underestimated in Chile

In a separate poster presentation Thursday, Nazzal reported on another area of gender-based research, in this case women's understanding of cardiovascular disease risks and symptoms.

In a survey of almost 1000 women in Santiago, Nazzal and colleagues found that while the majority of women recognized key risk factors for heart disease, few understood its toll. Asked what they thought was their "greatest health problem," only 10% identified heart disease--fifth after breast cancer, cancer more generally, obesity, and diabetes. Heart disease/heart attack placed fifth again when the question was phrased as to what was the leading cause of death in women (cancer was first, followed by breast cancer, violent crime, and diabetes).

Strikingly, more than 50% of women said that when they think about heart disease, they think of someone "dying quickly"; when the same question was asked about stroke, almost 60% said they thought of stroke as a long-term disease that reduces quality of life.

"Women have a good understanding of the risk factors for CVD, but they have not displayed an understanding of the link between these factors and chances for being affected by CVD," she said. "These results reveal the urgent necessity to increase awareness of CV risk in women."


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