Hospital investigation of men and women treated for angina

Critical assessment of health disparities across subpopulation groups through a social determinants of health perspective: The case of type 2 diabetes patients

BACKGROUND

Studies on diabetes have shown that population subgroups have varying rates of medical events and related procedures; however, existing studies have investigated either medical events or procedures, and hence, it is unknown whether disparities exist between medical events and procedures.

PURPOSE

The objective of this study is to investigate how diabetes-related medical events and procedures are different across population subgroups through a social determinants of health (SDH) perspective.

METHODS

Because the purpose of this manuscript is to explore whether statistically significant health disparities exist across population subgroups regarding diabetes patients' medical events and procedures, group difference test methods were employed. Diabetes patients' data were drawn from the Cerner Health Facts® data warehouse.

RESULTS

The study revealed systematic disparities across population subgroups regarding medical events and procedures. The most significant disparities were connected with smoking status, alcohol use, type of insurance, age, marital status, and gender.

CONCLUSIONS

Some population subgroups have higher rates of medical events and yet receive lower rates of treatments, and such disparities are systematic. Socially constructed behaviors and structurally discriminating public policies in part contribute to such systematic health disparities across population subgroups.

[Myocardial ischaemia detection in women]

Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms.

Gender Inequalities in the Management of Angina Pectoris: Cross-Sectional Survey in Primary Care

Background and Aims: To determine the extent of gender differences in the routine clinical care of patients with angina pectoris in primary care. Methods: A cross-sectional survey of general practitioner (GP) medical records undertaken by trained data managers in 6 GP practices. 925 adults (489 men) with a clinical diagnosis of angina (prevalence= 2.4%, 95%CI 2.3–2.6). Data extracted included: level of care; risk factor recording; prescribed medication; exercise ECG and coronary revascularisation. Adjusted male-to-female odds ratios (AOR) adjusted for age, angina duration, and previous myocardial infarction, (MI). Results: Women with angina were older than men (71 v 65 years) with a lower prevalence of MI (30% v 43%), but a longer duration of angina (5 v 4 years). Men were more likely to receive once daily aspirin (AOR = 2.07, 95% CI 1.56–2.74) and be prescribed triple anti-anginal therapy (1.58, 95% CI 1.03–2.42). Men were also significantly more likely to undergo exercise ECG (1.56, 95% CI 1.14–2.15) and surgical revascularisation (1.71, 95% CI 1.03–2.85). Women tended to receive GP care alone (AOR = 0.64, 95% CI 0.46–0.89), whilst men received specialist cardiac care (1.47, 95% CI 1.09–2.00). Beta-blocker use following MI was similar (0.99, 95% CI 0.59–1.69). Conclusion: Differences in the management of men and women are unaccounted for by differences in age, previous MI or duration of angina. Gender differences in management of CHD reported from secondary care may also exist in primary care.

The clinical profile of women with stable ischaemic heart disease in Spain. More effort is needed in secondary prevention. SIRENA study

OBJECTIVES

Cardiovascular diseases are the leading cause of death for women, especially ischaemic heart disease, which is still considered a man's disease. In Spain, there are various registries on ischaemic heart disease, although none are exclusively for women. The objectives of the SIRENA study were to describe the clinical profile of women with ischaemic heart disease treated in cardiology consultations, to estimate its prevalence of cardiovascular risk factors and understand its clinical management.

PATIENTS AND METHODS

A multicentre observational study was conducted with a sample of 631 women with stable ischaemic heart disease, consecutively included during cardiology consultations. Forty-one researchers from all over Spain participated in the study.

RESULTS

The mean age was 68.5 years. The clinical presentation was in the form of acute coronary syndrome in up to 67.2% of the patients. The prevalence of cardiovascular risk factors was high (77.7% of the patients had hypertension, 40.7% had diabetes and 68% had dyslipidaemia), with 30.7% having uncontrolled hypertension, 78.4% having LDL-cholesterol levels higher than 70mg/dL and 49.2% having HbA1c levels greater than 7%. The considerable majority of the patients underwent optimal medical treatment with antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone system blockers and hypolipidaemic agents. Coronary angiography was performed for 88.3% of the patients, and 63.4% underwent percutaneous coronary intervention.

CONCLUSIONS

Women with stable ischaemic heart disease in Spain initially present some form of acute coronary syndrome and a high prevalence of inadequately controlled cardiovascular risk factors, despite undergoing optimal medical therapy. A high percentage of these women undergo coronary revascularisation. Increased efforts are required for secondary prevention in women with stable ischaemic heart disease.

Gender- and age-related differences in clinical presentation and management of outpatients with stable coronary artery disease

INTRODUCTION

Contemporary generalizable data on the demographics and management of outpatients with stable coronary artery disease (CAD) in routine clinical practice are sparse. Using the data from the CLARIFY registry we describe gender- and age-related differences in baseline characteristics and management of these patients across broad geographic regions.

METHODS

This international, prospective, observational, longitudinal registry enrolled stable CAD outpatients from 45 countries in Africa, Asia, Australia, Europe, the Middle East, and North, Central, and South America.

RESULTS

Baseline data were available for 33280 patients. Mean (SD) age was 64 (10.5) years and 22.5% of patients were female. The prevalence of CAD risk factors was generally higher in women than in men. Women were older (66.6 vs 63.4 years), more frequently diagnosed with diabetes (33% vs 28%), hypertension (79% vs 69%), and higher resting heart rate (69 vs 67 bpm), and were less physically active. Smoking and a history of myocardial infarction were more common in men. Women were more likely to have angina (28% vs 20%), but less likely to have undergone revascularization procedures. CAD was more likely to be asymptomatic in older patients perhaps because of reduced levels of physical activity. Prescription of evidence-based medication for secondary prevention varied with age, with patients ≥ 75 years treated less often with beta blockers, aspirin and angiotensin-converting enzyme inhibitors than patients <65 years.

CONCLUSIONS

Important gender-related differences in clinical characteristics and management continue to exist in all age groups of outpatients with stable CAD.

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care

Background

Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care.

Methods

A cross-sectional survey undertaken in 8 sentinel centres serving 63,724 individuals in the city of Liverpool (15% of the city population). Aspects of clinical care assessed included: risk factor recording (smoking, cholesterol, blood pressure, body mass index); secondary prevention (aspirin, beta-blocker, statin); cardiac investigation (exercise ECG, perfusion scanning, angiography); and revascularisation (percutaneous coronary intervention, coronary artery bypass grafting). Male-to-female adjusted odds ratios (AOR) were calculated (adjusted for age, angina duration, age at diagnosis and previous MI) using logistic regression.

Results

1,162 patients (610 men; 552 women) with angina were identified. Women were older than men (71 vs 67 years), with a shorter duration of angina (6 vs 7 years), and a lower prevalence of previous MI (25% vs 43%). Men were significantly more likely than women to undergo detailed risk factor assessment (AOR = 1.35, 95%CI 1.06 to 1.73); receive 'triple' secondary prevention with aspirin, beta-blockers and statins (AOR = 1.47, 95%CI 1.07 to 2.02); access exercise ECG testing (AOR = 1.31, 95%CI 1.02 to 1.68); angiography (AOR = 1.61, 95%CI 1.23 to 2.12); and undergo coronary revascularisation (AOR = 1.93, 95%CI 1.39 to 2.68).

Conclusion

Systematic gender differences exist in the comprehensive clinical management of patients with angina in primary care.

Sex inequalities in access to care for patients with diabetes in primary care: questionnaire survey

BACKGROUND

Health experiences differ between men and women. The health services have focused their attention on gynaecological health problems in women, however women with non-gynaecological health problems could be unintentionally neglected. Given the increased prevalence of diabetes, the healthcare needs and experiences of women with diabetes are increasing.

AIM

To determine the extent of sex inequalities in access to care for diabetes in primary care.

DESIGN OF STUDY

Cross-sectional population-based questionnaire study.

SETTING

Twenty-three general practices spread through 23 different primary care trusts in the former Trent Region, UK.

METHOD

The study consisted of a random sample of 1,673 patients with diabetes. Outcomes measured were odds ratios adjusted for age for measures of physical access to the GP's surgery; ease of obtaining appointments; access to primary care professionals; levels of routine diabetes care received; barriers to physical activity, problems eating and psychological distress as measured by the 18 score Diabetes Health Profile.

RESULTS

Women were less likely than men to report that they had talked to their GP or practice nurse about their diabetes in the previous 12 months and were less likely to report that they were able to book routine appointments at convenient times. Almost 40% of all patients with diabetes reported difficulty in visiting the GP's surgery for their diabetes care, and women were more likely to report difficulties in visiting the surgery than men. Women were more likely than men to be afraid to go out alone (7.9% versus 3.6%) and more likely to be housebound (6.8% versus 2.4%). Women had significantly higher scores for eating problems and barriers to physical activity than men.

CONCLUSIONS

Women report more problems with access to diabetes care than men. If the ambitions of the National Service Framework are to be met, then positive action needs to be taken to improve access to care for women with diabetes.

Gender differences in the management and clinical outcome of stable angina

BACKGROUND

We sought to examine the impact of gender on the investigation and subsequent management of stable angina and to assess gender differences in clinical outcome at 1 year.

METHODS AND RESULTS

The Euro Heart Survey of Stable Angina enrolled patients with a clinical diagnosis of stable angina on initial assessment by a cardiologist. Baseline clinical details and cardiac investigations planned or performed within a 4-week period of the assessment were recorded, and follow-up data were collected at 1 year. A total of 3779 patients were included in the survey; 42% were female. Women were less likely to undergo an exercise ECG (odds ratio, 0.81; 95% CI, 0.69 to 0.95) and less likely to be referred for coronary angiography (odds ratio, 0.59; 95% CI, 0.48 to 0.72). Antiplatelet and statin therapies were used significantly less in women than in men, both at initial assessment and at 1 year, even in those in whom coronary disease had been confirmed. Women with confirmed coronary disease were less likely to be revascularized than their male counterparts and were twice as likely to suffer death or nonfatal myocardial infarction during the 1-year follow-up period (hazard ratio, 2.09; 95% CI, 1.13 to 3.85), even after multivariable adjustment for age, abnormal ventricular function, severity of coronary disease, and diabetes.

CONCLUSIONS

Significant gender bias has been identified in the use of investigations and evidence-based medical therapy in stable angina. Women were also less likely to be revascularized. The observed bias is of particular concern in light of the adverse prognosis observed among women with stable angina and confirmed coronary disease.

The male heart and the female mind: a study in the gendering of antidepressants and cardiovascular drugs in advertisements in Irish medical publication

Stereotypes which suggest that cardiovascular disease and depression are related to gender can have consequences for the mental and physical health outcomes of both men and women. This study examines how these stereotypes may be reinforced by medical publications advertising for cardiovascular and antidepressant medication. A random sample of 61 (with no repeats) advertisements which appeared in Irish medical publications between July 2001 and December 2002 were analysed using both content and semiotic analysis. Results indicate that the meanings created by advertisers for cardiovascular drugs and antidepressants did in fact gender these products. Women were depicted as the predominant users of antidepressants and men as the main users of cardiovascular drugs. The images used identified two stereotyped patients: the 'male' heart patient and the depressed 'female' patient. Furthermore, the imagery and language used to promote the two categories of medication tended to strengthen gendered associations.

Coronary heart disease prevention and age inequalities: the first year of the National Service Framework for CHD

BACKGROUND

The National Service Framework for Heart Disease sets national standards and defines service models for coronary heart disease (CHD). Little is known about the impact of this intervention on age inequalities.

AIM

To determine the changes in the uptake of coronary prevention measures before and after the first year of implementation of the National Service Framework for Coronary Heart Disease, and to compare these changes in uptake of coronary prevention in patients aged 75 years and over with younger patients.

DESIGN OF STUDY

Repeated cross-sectional survey using routinely collected data.

SETTING

Seventeen general practices in 17 primary care groups in the Trent Region.

METHOD

All registered patients at baseline and follow-up aged >/=35 years were categorised into three groups: those with either coronary heart disease or a history of stroke; those with diabetes or hypertension who were not in in the first group; and the remaining population. Data from electronic records was collected to show differences in the proportions of patients with coronary risk factors recorded in the previous year. Data was also collected about differences in the proportions of patients with adequate disease control measures.

RESULTS

Improvements were demonstrated in the recording of coronary risk factors and of disease control measures. However, compared with patients aged <75 years, older patients were significantly less likely to have a serum cholesterol level recorded at baseline; to be on lipid lowering drugs; to be on beta blockers post myocardial infarction and to have well controlled blood pressure. These differences persisted at follow-up.

CONCLUSION

There have been substantial improvements in both the recording of coronary risk factors and disease control measures following the implementation of the National Service Framework for Coronary Heart Disease. However, there needs to be an effort to strengthen the focus on the care of older patients.

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey

OBJECTIVE

To study differences in treatment for men and women with ischaemic heart disease by using standards defined in England's national service framework for coronary artery disease.

DESIGN

Cross sectional survey using routinely collected data.

SETTING

18 practices in 18 primary care groups in Trent Region.

SUBJECTS

5891 men and women aged over 35 years with a diagnosis of ischaemic heart disease or prescription for nitrates recorded on computer.

MAIN OUTCOME MEASURE

Difference in the proportion of men and women with ischaemic heart disease and taking lipid lowering treatment.

RESULTS

Women were less likely than men to have a recording of body mass index (79% (2197/2783) v 82% (2552/3102), P=0.002), smoking (86% (2386) v 89% (2779), P<0.0001), and blood pressure (95% (2643) v 96% (2986), P=0.04). Women were also less likely to have a recording of fasting cholesterol concentration (35% (968) v 50% (1550), P<0.0001) but were more likely to be obese (25% (558/2197) v 20% (514/2552), P<0.0001) and have their most recently recorded blood pressure value over the recommended 140/85 mm Hg (60% (1598/2643) v 52% (1553/2986), P<0.0001). Although a higher proportion of women had a raised serum cholesterol concentration (77% (749/968) v 67% (1043/1550), P<0.0001), men were more likely to take aspirin (76% (2358) v 71% (1979), P<0.0001), have a recorded diagnosis of hyperlipidaemia (13% (418) v 10% (274), P<0.0001), and be prescribed lipid lowering drugs (31% (973) v 21% (596), P<0.0001). These differences remained despite adjustments for the practice where the patient is registered, age, smoking status, obesity, diabetes, and hypertension.

CONCLUSION

The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease.

Social and gender variation in the prevalence, presentation and general practitioner provisional diagnosis of chest pain

OBJECTIVES

To describe the prevalence of Rose angina and non-exertional chest pain in men and women in socioeconomically contrasting areas; to describe the proportions of men and women who present with the symptom of chest pain and who receive a provisional general practitioner diagnosis of coronary heart disease; to assess the effects of gender and deprivation.

DESIGN

Two random general population samples in socially contrasting areas were surveyed using the Rose angina questionnaire: the case notes of people identified with chest pain were reviewed.

SETTING

Glasgow conurbation.

PARTICIPANTS

1107 men and women, aged 45-64, with chest pain.

OUTCOME MEASURES

Prevalence of Rose angina and non-exertional chest pain; the proportions who had presented with chest pain and received a general practitioner's provisional diagnosis of coronary heart disease.

RESULTS

There was no difference between social groups in the prevalence of all chest pain but a greater proportion of those in deprived groups had Rose angina and a greater proportion of these had the more severe grade. The proportion of people who had presented with chest pain was higher among socioeconomically deprived groups but there was no difference in the proportions receiving a general practitioner provisional diagnosis of coronary heart disease. Men were more likely to present with chest pain than women and were more likely to receive a provisional general practitioner diagnosis of coronary heart disease.

CONCLUSIONS

No evidence was found of social differences in patient presentation or general practitioner diagnosis that might explain reported variations in uptake of cardiology services. In contrast, gender variation may originate in part from differences in patient presentation and general practitioner diagnosis. Further investigation of socioeconomic variations in uptake of cardiology services should focus later in the care pathway, on general practitioner referral patterns and clinical decisions taken in secondary care.

Women with angina pectoris receive less antiplatelet treatment than men

In a study investigating the prevalence of underprescription of platelet therapy for women with angina pectoris, the complete medication histories of patients were examined and indicators of possible comorbidity and comedication were recorded. A higher percentage of women than men were not treated with any form of antithrombotic treatment (37% versus 18%), suggesting a serious, and possibly hazardous, undertreatment with acetylsalicylic acid (ASA) in women compared with men.

[Differential characteristics and survival of women with acute myocardial infarction. Registry of Acute Myocardial Infarctions of the City of Valencia (RICVAL). Researchers of the RICVAL]

INTRODUCTION AND OBJECTIVES

The prevalence of women who are admitted to the hospital after acute myocardial infarction is lower to that of men and their prognosis is worse. The reason for these differences is unclear. We studied the demographic and historical variables, the evolution, treatment and early survival in 269 women included in the Register of Acute Myocardial Infarctions of the City of Valencia (RICVAL) and compared them with the 855 men included in the same Register.

PATIENTS AND METHODS

Register of patients admitted into a Coronary Care Unit in the City of Valencia since December, 1st, 1993 until November 30th, 1994.

RESULTS

23.9% of the patients were women with a mean age of 71.9 +/- 9 years; 46.8% of them were diabetics, 55.4% hypertensives, and 6.7% smokers. The women arrived for treatment later than men and 34.9% of them were thrombolised. The incidence in women of severe heart failure (Killip III and IV) was 40.1% and the mortality 29.7%. In women with thrombolytic treatment the mortality was 29.8%. In the logistic regression model performed, female sex predicted a higher mortality rate (odds ratio [OR] = 1.30; confidence interval [CI], 1.05-1.61).

CONCLUSIONS

Early mortality in women after acute myocardial infarction is higher than in men in the RICVAL Register. The longer delay in initiating medical care and thrombolysis might be the cause for the higher proportion of heart failure among women and explain their worse prognosis after an acute myocardial infarction compared to men.