Last month, I wrote about my roles in research, practice, and education. This month, I’ll delve into how research and practice interface around a critical health issue: coronary heart disease in women.
A study recently published in JAHA suggests that both delay between symptom onset and hospital presentation and post-PCI coronary blood flow are independently associated with excess mortality in women1.
A key finding for clinical practice is that if delay between symptom onset and hospital presentation is less than two hours, that sex difference in mortality is not significant. One takeaway is that though it’s not the only factor, delay matters— and it’s something we can target now, in primary care (where I work) and in public health.
A key point for research is that PCI doesn’t seem to improve coronary blood flow in women as much as it does in men. What does this mean? Here’s the rub: the whole paradigm of coronary heart disease— from defining acute coronary syndrome to medical management and PCI— is based on the flawed assumption that men and women are essentially the same (as Pande & Jacobs discuss in an accompanying editorial2).
Recall that women have historically been drastically underrepresented in heart disease research, so the foundational assumptions are based on men. Though the evidence is mounting on some of the mechanisms of sex differences— microvascular disease, endothelial dysfunction, MINOCA— this hasn’t yet resulted in meaningful differences in approach to ACS treatment. Before this study’s publication, it had not been clear whether women didn’t do as well post-PCI simply because they were less likely to get in in a timely fashion, or because it didn’t work as well for them. Now we have data suggesting that both are true. Are we using a hammer when we really need a screwdriver? There is an enormous need for research in this area designed with sex differences as a presupposition and with establishing effective treatments as the goal. It will be a long road and we won’t have “the answer” tomorrow.
So as a clinician, knowing that the data isn’t there yet to show us how to improve women’s outcomes in PCI, one of the best tools I have is education and communication with my patients and fellow clinicians around treatment delay. We’ve made great progress educating patients and providers about women’s risks of heart disease (thanks in large part to AHA’s Go Red for Women campaign). Yet women still have longer delays in accessing treatment and worse outcomes in ACS than their male counterpoints.
Since heart disease is the number one killer of U.S. women and men3, preventing and detecting it are high priorities for PCPs like me. Even though short appointments and competing priorities mean finding time for prevention and risk assessment is tricky, we need to do better in our discussions around cardiac risk. We’re doing well at initiating discussions around statin prescriptions and, to a lesser extent, lifestyle measures. We need to work on discussions about symptoms of ACS and response to symptoms.
What are you doing now to improve women’s cardiovascular outcomes? Will you commit to taking one of these steps?
- Cenko E, van der Schaar M, Yoon J, Kedev S, Vavlukis M, Vasiljevic Z, Ašanin M, Miličić D, Manfrini O, Badimon L, Bugiardini R. Sex‐specific treatment effects after primary percutaneous intervention: A study on coronary blood flow and delay to hospital presentation. J Am Heart Assoc. 2019; 8:e011190. DOI: DOI: 10.1161/JAHA.118.011190.
- Pande, AN & Jacobs, A. Reperfusion and time to presentation in women: Too little too late. J Am Heart Assoc. 2019; 8. DOI: 10.1161/JAHA.118.011835
- Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L,Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2019 update: a report from the American Heart Association [published online ahead of print January 31, 2019]. Circulation. doi: 10.1161/CIR.0000000000000659.
- Greenwood B, Carnahan S., & Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. PNAS August 21, 2018 115 (34) 8569-8574; published ahead of print August 6, 2018 DOI: 10.1073/pnas.1800097115
Elizabeth Knight, PhD, DNP is a family nurse practitioner, scientist, and educator at Oregon Health & Science University. Since arriving in Portland this year, she splits her non-work time between finding awesome trails and finding awesome restaurants. Her clinical interest is in primary care for underserved populations and her research interests include women’s cardiovascular health and access to care. She tweets @TheKnightNurse.