Yentl resurgat: inadequate management of cardiovascular risk in women

Despite huge strides in treatment, cardiovascular disease (CVD) remains the biggest killer of Australians.1 In medicine the Yentyl syndrome2 refers to the need to prove that a female population has the same or similar risk factors as a male population before women will receive equal medical treatment for a particular condition. However, except for female hormones, no cardiovascular risk factor has been recognized as acting in one gender and not the other3 and women can benefit as much as men from risk factor reduction. While as recently as 2007 the British Medical Journal could frame treatment of cholesterol in women as a Yes/No debate,4,5 Australian guidelines are gender neutral in their recommendations for managing cardiac risk factors.6 However, women may not recognize this and different strategies may be needed to be used to inform women of the benefits of risk factor reduction. Two articles in this issue of the journal add to a growing body of evidence suggesting that CVD in women is not managed as well as it could be. The first suggests that cardiovascular risk factors in people with coronary heart disease (CHD) are not treated according to evidence-based guidelines and that this difference is greater for women (Driscoll et al.7) and the second suggests that for older women living in rural and remote areas of Australia this inadequate management of heart conditions is greater than for those women living in urban areas (Jordan et al.8). Despite these differences, women continue to live longer than men, but this gap is closing, with life expectancy for women now only 4.7 years longer than men compared with 6.5 years in 1987.1 With 105 male deaths for every 100 female, does this matter? According to a report from the Australian Institute of Health and Welfare in 2010,1 CHD, stroke and other heart diseases (including heart failure) are the three leading causes of death among women. They caused more than one in three deaths in women in 2006 and are in the top 10 causes of disability for women. Contrary to popular belief that these are diseases of older women, CVD is responsible for more than one-quarter of premature deaths among women. About two million Australian women have CVD – about 226 000 women have CHD, 168 000 have had stroke and 176 000 have heart failure. But do women recognize these dangers? A study of 65 rural Australian women found that while 64% thought breast cancer (2706 deaths in women in 2006) was the major health challenge for women, only 27% correctly identified heart disease (more than 10 000 deaths in 2006) as the most significant health problem.9 The ways in which women identify and respond to ill health are also different to men. A systematic review of 44 articles10 showed that compared with other groups, women and the elderly were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of acute myocardial infarction. In an Australian study of 16 women who presented to hospital between 1 and 168 h after myocardial infarction, while nine rang for an ambulance, seven went to visit their general practitioner (GP) for help. Consideration for significant others, including a single woman's cat, a sick husband and a planned holiday contributed to the delay.11 Marriage seems to help men get help for their health problems quicker, but the reverse seems to be true for women. In a recently published Canadian study,12 men with chest pain and a myocardial infarction presented earlier for care if they were married, a benefit that was not seen in married women. Earlier presentation for medical care appears to be one reason for the lower risk of cardiovascular death seen among married men, when compared with their single counterparts. Perhaps men are conditioned to their womenfolk underplaying their symptoms and may therefore fail to recognize when they are significant (as in the story of David and Jackie on the Heart Foundation website).13 In a family, women put the needs of the family first. Many years ago I saw an older woman with angina whom I wanted to send for coronary angiography. She refused to go until her husband had a bypass graft. She died before he had his surgery. In rural areas, the factors that disadvantage women in the health system may be more marked because of difficulties of access especially for older women who are still less likely to drive than older men14 and thus depend for transport on their relatives. Combined with the shortage of specialists in rural and remote areas,15 the finding that women in these areas of Australia are less likely to have seen a cardiologist or had an echocardiogram is not surprising. Finally, there is the question of gender bias in GPs' diagnostic decision-making about CHD. GPs in the study by Driscoll et al.7 in this issue were more likely to be male, but recent research does not support the idea that women receive better quality care from female doctors..16 Doctors and patients also relate the importance of a problem differently: for older patients the strongest factor is the emotional experience, whereas for doctors it is an unfavourable prognosis.17 This may partly explain why many important diagnostic and therapeutic procedures for CVD tend to be less common among women than men. In 2006–2007, while women were as likely as men to have heart valves repaired or replaced, they were less likely to have coronary angiography or echocardiography; undergo carotid endarterectomy; receive coronary artery bypass grafting or percutaneous coronary interventions; or have a heart defibrillator implanted even when they were in hospital with an appropriate diagnosis. However, once in hospital with a stroke or transient ischaemic attack, women were as likely as men to have a computed tomography or magnetic resonance imaging.1 It may also be a methodological issue. Age may be an inadequate surrogate for frailty in adjusted analyses. In addition the study by Driscoll does not tell us how close or how far away from targets patients were. Women and their doctors may have decided that close enough was good enough and that the risks of intensifying treatment outweighed the benefits. It may also be a matter of women's choices. Older women are twice as likely as men to oppose using medical technologies to extend life. More older women voice ‘other-oriented’ reasons for their opposition, particularly not wanting to be a burden on others, leading them to reject invasive tests and surgical treatment more than men.18 Older women and those in rural areas may also be more likely to see complementary and alternative medicines as choices for treatment.19 But there may be a simpler explanation for the finding of women's disadvantage in the management of cardiovascular risk. Perhaps in a health system that fails to deliver cardiovascular prevention well for anyone, women, who are not only more likely to be older and frailer, but also more likely to be economically and educationally disadvantaged than men,1 are less likely to get preventative care. Far from being a disease of middle-aged men as it was in the 1970s, CVD is now a disease of elderly women. The‘greying’ of Australia's population has major consequences for our healthcare system. Women make up 59% of those aged 80–84 years and 68% of those aged 85 and older. It is in the interests of all to ensure that the mothers, grandmothers and great grandmothers get the care they deserve.

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