According to the 2021 ACC/AHA/SCAI guidelines for Coronary Artery Revascularization, women are less likely to receive cardiac catheterization and more likely to have worse outcomes than their male counterparts.
They’re also less likely to be recommended for cardiac catheterization compared to males, despite both parties having the same clinical guidelines, according to Abbott.
Abbott Divisional VP of Global Clinical Affairs Jennifer Jones-McMeans has been looking to address gender biases in cardiovascular care, particularly for women suffering from coronary artery disease (CAD) who report poorer clinical outcomes and patient experience compared to their male counterparts.
Jones-McMeans completed a Q&A with MassDevice on the topic. Here are her thoughts:
Q: If the clinical guidelines for both males and females are the same, what (if any trend or indicator has been observed) is behind the reduced likelihood of women receiving cardiac catheterization?
A: Numerous factors contribute to this reduced likelihood, but almost all can be traced back to one simple fact: that, even though all sexes have the same basic heart anatomy, women with heart disease or cardiac events may present differently due to individual differences in physiology. In general, women have smaller coronary arteries and radial artery vessels, and they tend to have more comorbidities, such as diabetes or hypertension. Furthermore, natural hormonal phases and fluctuations have significantly impacted women’s cardiovascular health. For instance, post-menopausal women are at greater risk of cardiac events. Post-partum women with adverse pregnancy outcomes are also at high risk for future cardiac issues.
A difference of a few millimeters in artery size or a dip in estrogen levels may not seem significant, but those small differences compound when you consider the changes in how symptoms present, how medications are distributed through the body, and how medical devices are sized and inserted. For example, women have worse outcomes than men in percutaneous coronary intervention (or receiving a stent to treat coronary artery disease), most likely due to inaccurate estimation of the size of a stent needed for a woman’s smaller artery. In this way, physiological differences can contribute to the misdiagnosis and treatment of a cardiac event or illness, which results in women not receiving proper cardiac care as often as men, especially for women more than 65 years of age.
Q: The increased likelihood of worse outcomes for females compared to males — can that be correlated to fewer catheterizations, or are there other factors at play?
A: Multiple factors contribute to these outcomes, as discussed above. Misdiagnosis and ineffective treatment plans, including the lack of catheterization when warranted, will impact the patient’s outcomes and overall mortality rates. Treatment strategies should be based on the patient’s unique clinical presentation and take into account physiological differences. For example, there is evidence that a high-risk woman with a non-ST-elevation myocardial infarction might need more invasive strategies than a woman at low risk. During cardiac events, women are also less likely than men to report the “chest pain” commonly associated with heart attacks. Failing to account for such differences and individual risk levels in treatment plans can result in poor patient outcomes.
With the impact of socioeconomic status, education, and healthcare access on medical care, do those tie into the inequities purely between males and females? For instance, are we seeing similar trends, and are the women less likely to receive cardiac catheterization tending to fall into that underserved community territory?
A: Recent research has put data to a trend we have been seeing in the field for some time: women who present with heart disease are less likely to receive the care they needed and have poorer outcomes overall. Percutaneous coronary intervention (PCI) is a good example. This procedure involves using a catheter to install a device called a stent to open blood vessels. When treating women with PCI, there are several additional considerations.
In the words of Dr. Natalia Pinilla, “Women usually have smaller caliber blood vessels and more tortuosity. We are very cautious when doing heart interventions because there is a higher risk of complications; like blood vessel tears, due to vessel caliber and narrowing percentage overestimation. This is how procedural complications are higher in women population compared to men.”
Social determinants of health (SDoH) also play a role here and impact the treatment of patients as well as access to diagnostic tools and quality care. Today, it’s well established that patients from historically oppressed or disadvantaged backgrounds have less access to quality care, on average. We see evidence of that in the fact that women and Black patients are much less likely than white men to receive invasive revascularization when presenting with a blocked artery.
Q: What are the actions that can be taken to increase access (or buck trends if this is more of a care decision-making issue) so that women can begin to receive the proper care in this area?
A: In addition to the adjustments to diagnostic measures and treatment plans mentioned above, we also need to think about how medical interventions are developed and tested today. This means diversifying clinical trials and ensuring they include women and people of color as participants. If a new cardiac stent is being evaluated, for instance, then the stent should be tested on men and women to ensure it is measured appropriately. After all, that’s not a one-size-fits-all situation. As clinical trials become more diverse, we hope to see more nuance in the applications for medical interventions and devices for women and people of color presenting with cardiac disease.
Q: If you can provide a status update on the Beyond Intervention initiative (what the aim of the new supplement is, if any new data worth mentioning has come in, etc.), that would be great as well.
A: We launched the Beyond Intervention initiative in 2020 to analyze the vascular care landscape, adjust care to better meet the unique needs of diverse patient populations, and re-envision the future of vascular care. Although heart disease is the leading cause of death for women in the U.S., women account for just 38% of participants in cardiovascular clinical trials (despite being about 50.5% of the U.S. population). Our goal is to create a reality in which the percentage of those treated within clinical trials matches the percentage of those burdened with the disease.
This supplement, “Addressing Racial and Gender Bias in Cardiovascular Care: Why Improving Health Equity Is an Urgent Need for the Healthcare Community,” shines a light on many of the issues we’ve discussed, providing scientific data and experiential insight into the cardiac care experience for women. For example, women have reported experiencing more challenges than men in their cardiac care, including access to care and good relationships with their physicians. Marginalizing women’s vascular health has clinical and economic consequences directly at odds with the ideals of the Institute for Healthcare Improvement’s “Triple Aim” initiative, which seeks to improve population health, improve patient experience and quality of care, and lower the cost of care.
This supplement also proposes a solution to the challenges we’ve discussed: health equity. In particular, conscious inclusion in every element of the healthcare industry, from R&D to clinical research to trial participant demographics and primary care providers. Clinical trials need to be representative of women and other under-represented groups. If we are to better understand and treat the diverse patient population of the U.S., we need diverse and inclusive researchers and caregivers.