“There is a bias in our care”
Martha Gulati, MD, MS kicked off the “Saving Women’s Hearts Through Prevention” symposium ahead of the American Society for Preventive Cardiology’s 2022 Congress, which took place Friday through Sunday in Louisville, Kentucky.
Women who develop cardiovascular disease are more likely to die than men, and the reasons for this run all the way through the care process – from enrollment in clinical trials, to the emergency department, to getting good medicine, said Martha Gulati, MD, MS, the Cedars-Sinai cardiologist who this weekend became president of the American Society for Preventive Cardiology (ASPC).
Gulati is associate director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai and holder of the Aveda Dan Friedman Women’s Cardiovascular Medicine and Research Endowed Chair. She presented the disturbing facts about how the healthcare system treats women with atherosclerotic cardiovascular disease (ASCVD) to kick off a symposium, “Saving Women’s Hearts Through Prevention” held ahead of PHAC 2022 , which took place from Friday to Sunday in Louisville. , Kentucky.
Since 2011, when Gulati co-wrote the book Save women’s hearts on prevention strategies for women, there has been some improvement in enrolling young women in clinical trials. But, she said, there are still not enough women over 55 enrolled in the studies. “And, of course, it’s at that age — over 55 — that most women develop cardiovascular disease,” Gulati said.
Additionally, government-sponsored trials in particular appear to recruit fewer women than trials in general, she said.
How can this happen? Gulati said Emory University cardiologist Nanette Wegner, MD, coined the term “the bikini approach” when it comes to research priorities for women — most funding and research. attention goes to diseases of the breast or reproductive organs, with less attention to other diseases. which cause significant mortality among women.
Still, Gulati presented data that shows women in the United States have a 10 times greater risk of dying from cardiovascular disease than from breast cancer. “Even if we are talking about prevalence, and the definition of prevalence includes hypertension, it is 1 in 2 women who experience some form of cardiovascular disease, or 60.8 million women, compared to 3.8 million women with breast cancer.”
“It’s not to downplay the effect of breast cancer or its significance, or the need for screening,” Gulati continued. “But what about cardiovascular disease?
Women, she said, are underscreened for cardiovascular disease and too few are aware of their risk. The inequity does not stop there:
- Women are less likely to receive treatment according to guidelines after myocardial infarction (MI), and statins remain underused in women with acute MI;
- A recent article in the Journal of the American Heart Association (YHAHA) found that when women present with chest pain, they are less likely to be triaged as urgent or undergo an electrocardiogram;
- The YHAHA investigators found that women waited at least 10 minutes longer than men for an initial assessment, were less likely to receive an EKG, and were less likely to be seen by a cardiologist; and
- Finally, women who had an MI were more likely to be readmitted to hospital, which has been a standard quality measure for a decade.
Says Gulati, “There is a bias in our care.”
She discussed the use of risk assessment tools, noting that certain risk factors, such as diabetes, can lead to higher cardiovascular risk in women than in men. Some risk factors, such as lupus and rheumatoid arthritis, may not be included in a risk score, but are more common in women. The 2018 update to the ACA/AHA guidelines for blood cholesterol management, endorsed by the APSC, showed how the ASCVD risk score is a useful tool, but just a starting point.
Gulati then turned to a key area where preventive cardiology can make a difference with young women: during pregnancy: many women will show up as low risk in the ASCVD score, especially when they are young. However, this “disregards a lot of things you may already know about them – and some of those things are related to pregnancy”.
“Nature’s Free Stress Test”
Pregnancy is called “nature’s free stress test” because women with high blood pressure or gestational diabetes are the ones most likely to have cardiovascular problems in the future – or sooner, if they have. complications during or after childbirth.
“We know that pregnancy-related mortality continues to rise in the United States,” Gulati said. “You can see it’s really, for all of the Western world, the United States has the highest maternal mortality, and the leading cause is due to cardiovascular disease.” She highlighted how maternal mortality disproportionately affects women of color, especially black women.
Most of these events are preventable, Gulati said. “We shouldn’t think it’s just inevitable that these people will die,” she said. “When we talk about maternal mortality, it is important to understand that we are talking about that first year, or after childbirth as well. And most deaths, of course, occur after childbirth.
Health systems should be able to identify women at risk early on. “We should also take their symptoms seriously after childbirth…We estimated that 68% of cardiovascular causes of maternal mortality would in fact be preventable.”
Gulati discussed the period after childbirth, the “fourth trimester,” which has also been endorsed by the American College of Obstetricians and Gynecologists. Access to care during this time is crucial, and HHS has now created a waiver that allows states to expand Medicaid coverage for the first year, even if the state has not approved the rest of the year. Medicaid expansion. According to the Kaiser Family Foundation tracker, 23 states have expanded coverage, 11 plan to expand coverage, and 2 states have added limited coverage.
Knowing more about a woman’s history during pregnancy will allow doctors to identify “risk factors” that can serve as early warning signals for the future. The key is to identify these women, Gulati said. “So that’s really our challenge,” she said. “We know that women have poorer outcomes after acute myocardial infarction. If the only thing we have done to close the gap is to provide women with medical treatment according to guidelines, at least that is one way to reduce the risk of death among women.
“I think secondary prevention will always be part of our work,” she concluded. “But of course, if you do a lot of primary prevention – identifying both risk factors that are different between men and women and risk factors, and being aggressive in assessing risk in women, I think that’s our role too.”