TWO recent news stories have motivated me to share some thoughts about coronary disease, its diagnosis and treatment, and outcomes.
The study by Khan and colleagues in the MJA on 6 August received wide media coverage. The research article reported sex differences in the management and outcomes of acute coronary syndromes in Australia. Sex differences in coronary disease management have been reported in observational studies before, with discussion analysing factors such as “atypical” presentation and differing pathophysiology. Khan and colleagues analysed data from an existing coronary care registry that enrols patients from 41 sites around Australia. They attempted to minimise confounding factors by looking only at ST-elevation myocardial infarction (STEMI) – proposing that management for a defined syndrome should be relatively standardised.
While the news reports picked up differences found in revascularisation rates, the study also found that women tended to be older at presentation, to receive less medication for secondary prevention at discharge, and to be referred less frequently for cardiac rehabilitation.
Other interesting features emerged. Revascularisation by percutaneous coronary intervention (PCI) rates were higher in men with STEMI than women (77.8% v 65.0%; P < 0.001), but revascularisation via thrombolysis occurred at virtually identical rates (32.3% v 31.5%; P = 0.93). Almost as many women as men were smokers (37.7% v 40.1%) and women had higher rates of both hypertension and diabetes. Of those women who did undergo PCI, more women than men were described as having non-significant coronary disease (12.1% v 3.7%).
These changing patterns suggest that the dramatic growth of PCI as an intervention may not match the evolving needs of the coronary disease population – older women with multiple risk factors who may be receiving less focus on both primary and secondary prevention.
Another recent article found better outcomes for women in Florida, in the US, with acute myocardial infarctions if they were treated by female rather than male doctors in the emergency department. The precise mechanism is unclear, but it appears that doctors who identify with their patients may be more perceptive about their risks and needs. The study looked at outcomes only, but not the specific interventions that differed, leaving a number of questions unanswered.
Neither of these articles gives us a clear direction for improvement, but both can cause us to think twice about what we recommend for patients with coronary disease. The population has moved on from the days of the “widow-maker” STEMI – acute plaque rupture in a middle-aged man, which was the model for the development of rapid artery-opening.
Coronary disease is more complex, as is the population who has it. Treatment goes way beyond the invasive intervention, from primary and secondary prevention to systematic use of rehabilitation.
The Yentl syndrome was defined decades ago. It refers to a fictional 19th century Jewish heroine who dressed as a man in order to access education. As we think more about the evolving epidemiology of coronary disease, we might adapt the treatment to the person rather than expecting the person to disguise herself to receive it.
Dr Sue Ieraci is a specialist emergency physician who has also held roles in departmental management and medical regulation. She is an executive member of Friends of Science in Medicine.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.
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