SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease

The SGEM Bottom Line: There are clearly patients with primary atrial fibrillation who can be managed safely as outpatients. There are no evidence-based criteria for identifying high-risk patients who require admission, so for now we will have to rely on clinical judgement.

This SGEM Xtra episode is the result of some feedback I received from a listener following SGEM#337 episode on the GRACE-1 guidelines for recurrent low-risk chest pain.

The person lamented that it would be nice if a cardiac case scenario was of a female patient. This made me review past SGEM episodes which confirmed there has been a gender bias. While there were a half-dozen episodes that did have female patients, they were the minority. So, I felt a good way to address the issue would be to invite an expert like Dr. DeMeester to discuss this gender bias.

There is a difference between gender and sex. Despite having different meanings they are often used interchangeably. Gender refers to social constructs while sex refers to biological attributes.

This is not the first SGEM episode that has addressed the gender gap in the house of medicine. I had the honour of presenting at the 2019 FeminEM conference called Female Idea Exchange (FIX19).

My FIX19 talk was called from Evidence-Based Medicine to Feminist-Based Medicine. It looked at the three pillars of EBM: relevant scientific literature, clinicians, and patients. I realized that each of the three pillars contained biases against women. In the presentation, multiple references were provided to support the claim that a gender gap does exist.

The conclusion from the FIX19 talk was that we should be moving from Evidence-Based Medicine (nerdy and male dominated) to Feminist-Based Medicine (recognizing the inequities in the house of medicine) to Gender-Based Medicine (acknowledging the spectrum of gender and sexuality) and ultimately to Humanist- Based Medicine.

The SGEM did a regular critical appraisal of a recent publication with Dr. Ester Choo (SGEM#248). It covered the study published in AEM looking at the continuation of gender disparities among academic emergency physicians (Wiler et al AEM 2019).

We also did an entire SGEM Xtra episode with Dr. Michelle Cohen on the broader issue of the gender pay gap (SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine). This was based on the Canadian Medical Association Journal article focusing on closing the gender pay gap in Canada (Cohen and Kiren 2020).

Five questions about gender disparities when it comes to cardiovascular disease.

1. What is the burden of cardiovascular disease in females and is it the same as males?
2. We know females are often excluded from being subjects in medical research. Are female represented proportionally in cardiovascular disease  clinical research?
3. Are there differences between males and females with regards to cardiovascular disease risk factors?
4. Do females who have a cardiovascular event present differently to the emergency department?
5. Have any sex differences been identified in the treatment and outcomes of females with cardiovascular events?

Please listen to the SGEM podcast to hear Dr. DeMeester’s answers to these five questions.

The Lancet gathered a group of international experts to answer this question. The commission published recommendations to reduce the global burden of cardiovascular disease in women by 2030 (Vogel et al). This Includes:

• Acknowledging the current burden of disease
• Raising awareness about the differences in presentations and sex-specific and under-recognized risk factors
• Increasing the number of women included in clinical trials

The European Society of Cardiology supported this initiative. They published an article called: Cardiovascular Disease in Women – Reducing the gender gap in prevention, diagnosis and treatment of cardiovascular disease. 

The Lancet also created a number of infographics to help with the knowledge translation of these recommendations.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients get the best care, based on the best evidence.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Additional Reading:

• Davies RE, Rier JD. Gender Disparities in CAD: Women and Ischemic Heart Disease. Curr Atheroscler Rep. 2018 Sep 4;20(10):51. doi: 10.1007/s11883-018-0753-7. PMID: 30178384
• Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart 2020;106:487-492.
• Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115. Epub 2018 Aug 6. PMID: 30082406; PMCID: PMC6112736
• Nguyen PK, Nag D, Wu JC. Sex differences in the diagnostic evaluation of coronary artery disease. J Nucl Cardiol. 2011;18(1):144-152. doi:10.1007/s12350-010-9315-2
• Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, Daneshvar M, Spertus JA, D’Onofrio G. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. 2018 Feb 20;137(8):781-790. doi: 10.1161/CIRCULATIONAHA.117.031650. PMID: 29459463; PMCID: PMC5822747
• Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd- Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62
• Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in- hospital mortality. JAMA Internal Medicine, American Medical Association, 22 Feb 2012, jamanetwork.com/journals/jama/ fullarticle/1355992
• Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update; a report from the American Heart Association http://Circ.ahajournals.org/Content/125/1/e2.Full, 3 Jan. 2012, circ.ahajournals.org/content/125/1/e2.full
• Alexander KP, Chen AY, Newby LK, Schwartz JB, Redberg RF, Hochman JS, et al. Sex differences in major bleeding with glyco-protein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative. Circulation. 2006;114:1380–7
• Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97
• Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009;95:20–6
• Bank IEM, de Hoog VC, de Kleijn DPV, et al. Sex-Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain. J Am Heart Assoc. 2017;6(6):e005373. Published 2017 Jun 21. doi:10.1161/JAHA.116.005373