Gender disparities in atherosclerotic cardiovascular disease treatment

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide, yet researchers at Baylor College of Medicine have found that those 55 and younger are not treated as aggressively, and women receive less than optimal preventative care when compared to men among this group of young patients with ASCVD.

The study, one of the largest to date published in JAMA Cardiology¸ reviewed medical records of 147,600 veterans with premature ASCVD, which includes patients who suffered from heart disease, stroke, or peripheral arterial disease at a young age. The investigators found that not only were women significantly less likely to receive antiplatelets, statin or high-intensity statin therapies, they also were less likely to adhere to their statin therapy regimen when compared with men.

Dr. Salim Virani, professor of medicine - cardiology at Baylor and a staff cardiologist at the Michael E. DeBakey Veterans Affairs Medical Center, Dr. Michelle Lee, research fellow at Baylor and the DeBakey VA, and their team of researchers reviewed the medical records of veterans and found groups that were diagnosed with premature ASCVD (ages 55 and younger) or extremely premature ASCVD (40 or younger).

“Within this younger group of patients with ASCVD, there is a lot to be gained by treating them aggressively with evidence-based therapies not just to improve future cardiovascular outcomes but also to reduce disability,” Virani and Lee said. “Yet we found that both men and women received suboptimal aspirin and statin therapy and had poor adherence to statins. And more so for women for both treatment and adherence.”

The most pronounced disparity involved high-intensity statin therapy. For women, 23.5% with premature ASCVD and 10.4% with extremely premature ASCVD were using this type of therapy. For men, 38.1% in the premature and 27.2% of men in the extremely premature ASCVD group received this treatment.

There are a lot of factors that relate to both clinicians and patients that could explain these disparities, Virani said. For example, a younger patient with ASCVD may be perceived by their treating clinicians as low risk given their young age, may think of themselves as low risk, or may think of their ASCVD event as a one-time event in their life. These young patients also may not be aware of their cardiovascular risk factors. A younger group may have a different focus in life such as career, kids and aging parents, and their own health might not be their top priority given these competing demands on their time, especially for women with premature ASCVD.

“This study focused on veterans, so there could be other factors related to their service that play a role in this,” Virani said. “However, we do see these results as reflective of the larger population in general.”

The next step is to raise awareness of health disparities and to narrow the sex-based healthcare delivery gap for women. Clinicians should discuss and emphasize the importance of preventative therapies for their patients, especially women, he said.

“The results show us that more needs to be done to implement and improve guidelines for treatment, such as identifying and understanding why these disparities in healthcare take place. Awareness is part of that process, but we need to provide clinicians with tools that provide cognitive support at the point-of-care to assist them in taking care of these patients. For a young patient, our discussion may also need to focus on how these therapies not only reduce their chance of getting a second or third cardiovascular event in the future but also reduce the risk of disability with heart disease, stroke or peripheral arterial disease.”

Others who took part in this study include Drs. Michelle T. Lee, Dhruv Mahtta, David J. Ramsey, Jing Liu, Arunima Misra, Khurram Nasir, Zainab Samad, Dipti Itchhaporia, Richard S. Schofield, Christie M. Ballantyne, Laura A. Petersen and Safi U. Khan. They are affiliated with one or more of the following institutions: Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston Methodist, the Aga Khan University, Karachi, Pakistan, Hoag Memorial Hospital, University of California at Irvine, West Virginia University, and the University of Florida.

This work was supported by a Department of Veterans Affairs Health Services Research & Development Service Investigator Initiated Grant (IIR 16–072), an American Heart Association Beginning Grant-in-Aid (14BGIA20460366), the American Diabetes Association Clinical Science and Epidemiology award (1-14-CE-44), and the Houston VA Health Services Research & Development Center for Innovations grant (CIN13-413), The Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).