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Women’s Hearts May Respond Better to Treatment, If They Get It

March 15, 2005 -- BETHESDA, MD -— Certain female patients appear to get more benefit than male patients from a type of heart attack treatment, but women with an acute coronary syndrome receive less aggressive treatment than men, according to two new studies in the March 15, 2005, issue of the Journal of the American College of Cardiology.

In the first study of its kind, researchers in Germany found that emergency catheter procedures to treat heart attacks appear to rescue more heart muscle in women than in men.

“We believe that women may have some biological superiority compared with men,” said Julinda Mehilli, M.D., at the Deutsches Herzzentrum in Munich, Germany. “The most plausible hypothesis is a higher tolerance to oxygen deprivation by the heart muscle tissue in women, at least in part due to preconditioning (women have pre-infarct chest pain more frequently than men),” said Dr. Mehilli.

The researchers studied the cases of 202 female and 561 male heart attack patients who underwent emergency angioplasty or stenting and treatment with platelet glycoprotein IIb/IIIa inhibitors as part of three randomized trials. By using an imaging technique called 99m-technetium (Tc)-sestamibi scintigraphy, the researchers measured the amount of heart muscle in jeopardy due to heart attack. Although there was no statistically significant difference between women and men before treatment, afterwards the damaged area was smaller on average in the women’s hearts. There was no difference in clinical outcomes, including death or another heart attack, after six months of follow-up.

“Our study showed that more jeopardized myocardium during acute myocardial infarction could be salvaged using mechanical reperfusion and adjunct platelet glycoprotein IIb/IIIa inhibitors in women than in men. Considering the more adverse cardiovascular risk profile and a longer pain-to-admission time interval for women, the higher degree of myocardial salvage achieved in women may have contributed to the similar clinical outcome that was observed in both genders,” Dr. Mehilli said.

Dr. Mehilli said the results should encourage clinicians to pursue aggressive treatment of female heart attack patients, even when they are older or sicker than male patients.

“Even though women with acute myocardial infarction present late at hospital and have a more adverse risk profile than men, there are no reasons to withhold active interventional treatment in them,” Dr. Mehilli said.

Dr. Mehilli noted that this study looked at catheter procedures only and did not include patients who were treated with drugs, such as tPA or streptokinase, which can dissolve clots blocking blood flow in coronary arteries.

The second study on gender differences indicates that women are not receiving recommended treatments as often as men. Using data on 40,912 patients collected from 391 U.S. hospitals, researchers analyzed the diagnosis and treatment of patients whose electrocardiograms showed non-ST-segment elevation (NSTE), which indicates a type of heart strain or heart muscle damage that is not quite as severe as a heart attack.

“We found that women were less likely to receive many of the standard and recommended therapies and procedures for this condition,” said Andra L. Blomkalns, M.D., F.A.C.C., at the University of Cincinnati College of Medicine in Ohio.

Dr. Blomkalns said that although this study does not explain why the gender disparity exists, it is further evidence of a disturbing trend.

“More women than men have died of cardiovascular disease since 1984. While the death rate for men is declining, that for women is increasing. Therapies are getting better, yet the benefit does not seem to translate to women. My entire research career is dedicated to answering the question of why. One basic hypothesis is that women are just not getting the therapy,” Dr. Blomkalns said.

Other studies have indicated that clinicians, and even patients themselves, are slower to recognize heart attacks and related cardiac events in women than in men. But this study compared how patients were treated after diagnosis, so differences in recognition of heart disease would not explain the gender disparity these researchers observed, Dr. Blomkalns pointed out.

She also noted that this analysis took into account that female heart patients tend to be older and sicker than male patients; yet even after making that statistical adjustment, women were less likely to get recommended treatments and tests.

Despite receiving less treatment, the women in this study were just as likely to survive as the men.

“The fact that mortality was not different is a huge point. One might ask, ‘If mortality is the same, why worry about the treatment differences?’ My answer to that is that we need to see equal treatment before we can judge the mortality implications. Might women do even better if they got guideline-recommended therapy?” Dr. Blomkalns asked.

Nanette K. Wenger, M.D., F.A.C.C., at the Emory University School of Medicine in Atlanta, who was not connected with this study, said it made several important points.

“Women who come into emergency rooms often are not initially recognized as having an acute coronary syndrome, so their early therapy is delayed,” said Dr. Wenger. “But I see no excuse for the discharge difference, that there is less use of aspirin, ACE inhibitors and statins. To me that means there is a potential to improve outcomes on the admission end by earlier and better recognition, and on the discharge end by following standard guidelines,” she said.

Dr. Wenger also noted that women in this study were more likely to get transfusions. She said the higher bleeding risk among women has been seen in other studies. She urged further research to explain the excess risk among women.

Rita F. Redberg, M.D., F.A.C.C., at the University of California in San Francisco, who also was not connected with this study, commended the authors for analyzing treatment patterns separately for female and male patients.

“It’s disappointing to see gender differences still existing in recent data. I would have liked to have seen more analysis linking the treatment to the outcomes,” Dr. Redberg said. “It is also important to know if there was a difference in outcomes in the women by the therapies they received; in other words, did the women who received guideline-driven therapies achieve better outcomes than the women who didn’t receive guideline therapies. These studies allow us to optimize care for men and women.”

Source: American College of Cardiology

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