Australian women receive sub-optimal heart care: Study

Evelyn Lewin

24/07/2019 3:33:00 PM

New research has found women are less likely to be prescribed recommended medications.

Woman holding heart
Almost half the people who die from coronary heart disease are women, yet research shows they are less likely to be prescribed the appropriate treatment.

Coronary heart disease (CHD) remains the second leading cause of death for women in Australia, after dementia and Alzheimer’s disease.
In 2015, women accounted for 44% of CHD deaths and 52% of all cardiovascular disease (CVD) deaths.
Yet, a new large-scale analysis by La Trobe University researchers, published in the BMJ’s Heart, found women are more likely to be under-treated for the disease when compared to similarly affected men.
The research involved analysing GP records of 130,926 patients aged over 18 years with a history of CHD from 2014–18.
Key findings include:

  • Women are less likely than men to be prescribed any of the four recommended medications for CHD (antiplatelet agents, angiotensin-converting enzyme [ACE] inhibitors, beta-blockers, statins)
  • Of the four medications recommended for daily use, only about 22% of women were prescribed all four, compared to 34% of men
  • 21% of women were not prescribed any of these four medications, compared to 10% of men
  • Younger women, aged less than 45 years, were substantially under-prescribed, with only 2% of women in that age group receiving three or more medications, compared to 8% of men
‘There’s a widely-held assumption that CHD only affects older men, but almost half of people who die from the disease are women,’ La Trobe epidemiologist and lead researcher Professor Rachel Huxley said.
‘Our study shows that people with a history of CHD, particularly women and people aged less than 45 years, are less likely to have their condition managed according to current clinical guidelines.’
Women’s Heart Clinic cardiologist and heart failure specialist Dr Monique Watts told newsGP the results are not surprising, as heart disease is generally perceived to be a men’s disease.
‘We know that practitioners are less likely to expect heart disease in women so it follows that treatment might be underdone,’ she said, adding that disparities in presentation also contribute to treatment issues.
‘Women with heart disease often present quite differently [to men], with different features, so therefore the treatment might not be necessarily as straightforward in the minds of the treating team, even though when it comes to the statistics we can say, “Well, actually, these women also have ischaemic heart disease and will benefit from the same evidence-based therapies”.’

Dr-Monique-Watts.jpg ‘Ischaemic heart disease is ischaemic heart disease – whether it’s in a man or a woman,’ says Dr Watts.

The study suggests that under-prescribing in younger women may be due to a misperception that younger patients are at lower risk, and that lifestyle modifications are sufficient to achieve treatment targets.
It also highlights the importance of GP management for patients for secondary prevention of CVD.
After first hospitalisation with CHD, those who visited a GP compared to those who did not during the two-year follow-up period had 11% lower risk of a CVD emergency readmission. Similarly, patients who had a chronic disease management plan had 5% lower risk of readmission compared with those who did not.
However, while the research found women were under-prescribed, they were more likely to achieve treatment targets than men. This led researchers to speculate whether the overrepresentation of younger women contributed to that finding.
Dr Watts believes the main message GPs should take from the research is the importance of considering CHD in women, and treating it the same way as for men.
‘[GPs] have to have it at the front of their minds that ischaemic heart disease is ischaemic heart disease – whether it’s in a man or a woman,’ she said.
‘[GPs] shouldn’t be fearful of putting a young person on a medication that could save their life, just because it might mean they’re on a medication for a long time.’
According to Dr Watts, every time a GP sees a patient with CHD, they need to ask themselves whether the patient is on aspirin, a statin, a beta-blocker and an ACE inhibitor.
There are times when medications may not have been prescribed, for example if they are not tolerated, Dr Watts says. In those cases, she says alternatives may be considered, but if a GP sees a patient with CHD who isn’t on these four medications, the question of ‘why not? has to be raised.
‘Patients may slip out of specialist care or be lost to follow up. GPs are often the only ones that have the opportunity to say, “Hang on a second. You had this particular diagnosis, you should be on this medication”,’ she said.
‘GPs are in a unique position to do that, and this kind of evidence can give GPs the confidence to do the best for their patient, male or female.’
The RACGP’s endorsed clinical guidelines, Reducing risk in heart disease: An expert guide to clinical practice for secondary prevention for coronary heart disease, state statin therapy, aspirin, ACE inhibitors and beta-blockers are all recommended in patients with CHD post-myocardial infarction, except in exceptional circumstances or unless contraindicated.

cardiovascular disease coronary heart disease women’s heart health

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A.Prof Christopher David Hogan   25/07/2019 4:28:34 PM

There is a part of me (actually all of me) that reacts negatively to the phrase "GPs should....." especially when the author may not understand the context of general practice. Rather than assume the answer is GP inaction or distraction, it is better to say “why is this happening”.
Such studies make GPs cautious about handing over their data if it is to be merely used for GP bashing.
That aside, there is another sad element to this report -it is not new. I remember similar papers issued about 20 years ago. Then of course, blame was apportioned with the vague whiff of an accusation of sexism & societal stereotyping. Given the gender mix of modern General Practice this would not happen now.
Why do these warnings need to be repeated?
Is it that our patients do not consider it an issue & do not seek help?
Is it that we do not look – for indeed more is missed by not looking than not knowing?
Is it that our female patients who often give the impression of being more health conscious & health aware are just not accepting appropriate evidence-based therapy?
Is it that our females patients will not accept the use of statins & other similar medication?
This is the trouble with retrospective studies- they can tell what but not why.
Auditing & prospective studies are better placed to answer this question.