Cath Lab Digest

How do women and men compare in risk for heart disease?

Heart disease is more prevalent in men than women, but remains the leading cause of death for both sexes. Cardiovascular disease, on the other hand, which also includes heart failure, hypertension and stroke, is more prevalent in women. Likewise, each year, more women than men die of cardiovascular disease. One out of every four women will die of heart disease, and one out of every two will die of cardiovascular disease.

Do you think most healthcare providers are adequately educated about women and heart disease?

There is definitely an increasing awareness, but I still hear physicians, particularly cardiologists, who come right out and say they don’t think there is any difference between women and men in terms of heart disease. There is now over a decade of research that shows otherwise, and for a group that prides itself on evidence-based care, it is disheartening to hear such an inaccuracy being spoken. Certainly, patients notice. I’ve had plenty of patients come in and tell me, “Well, my doctor said there is no difference between women and men, but that doesn’t sound right to me.”

So patients also have a certain level of awareness. But is it enough?

It, too, is growing, and oftentimes patients are out in front of their doctors in this regard. Patients hear about the differences and it rings true, particularly for women. It’s almost like they’ve been waiting for us to figure this out. They already have a sense that they are a little different, and sometimes have felt disregarded in suggesting something was wrong with their heart. We still need to educate ourselves and our patients so that awareness continues to grow.

What do you think of the Red Dress Project from the National Heart, Lung, and Blood Institute, and the Go Red for Women Campaign from the American Heart Association? Those seemed to have raised awareness.

Yes, I would agree. They are fantastic programs that have definitely raised awareness. The percentage of women who can identify heart disease as their leading cause of death has increased from 30% to over 55%. I remember the first time I saw an announcement, which was a fold-out ad with women in red dresses. It certainly caught my eye. It has been a very effective campaign, similar to the pink ribbon campaign for breast cancer. We need things like that to happen.

What are the considerations that must be taken into account when women undergo a coronary intervention?

In general, the gap in outcomes between women and men has narrowed over time, so that there is not much difference in terms of outcomes, with one big exception. Currently, the single most significant difference between women and men having a percutaneous coronary intervention (PCI) is bleeding and vascular complications. Women have two to three times the risk compared to men.

Why is that?

No one knows exactly why. There are several thoughts, and it’s likely multi-factorial. One thought is that women have smaller vessels and may have multiple sticks, or more posterior wall sticks, which then increases the risk of bleeding. Another thought is that women’s hormonal milieu results in greater vessel fragility. For example, we know women are more likely to get dissections due to estrogen levels, so maybe there is something inherent in the vessels themselves. A third thought is related to anticoagulant/antiplatelet dosing, and there is certainly some evidence of that, but at the same time, even if dosing is done correctly, women will still have a higher risk of bleeding and vascular complications.

The transradial approach is well suited for women, then, since it lessens bleeding and offers decreased vascular complications. Is that why you began to use it?

Yes, I specifically switched to transradial access for that reason. I take care of both women and men (about 70% women and 30% men), but as Director of our Women’s Heart Health Program, one of my jobs is to improve the outcomes of female patients. Bleeding and vascular complications is certainly an area that needs improving. Since we don’t know why women have more complications, it becomes difficult to address directly. Vascular closure devices certainly weren’t the answer, and cutting back on anticoagulants and antiplatelet therapies wasn’t the answer. It wasn’t until I read an article discussing the reduction in bleeding complications with the transradial approach that I felt like I had found an answer.

What is the difference in bleeding between femoral and transradial access?

Transradial access offers significantly less bleeding, with a greater than 50% reduction in the odds of a bleeding complication. Since women have higher risks of bleeding at baseline, they drop down significantly in risk, nearly to the level of men, who also have a drop. But women are getting a much bigger bang for their buck, so to speak, in terms of their reduction in bleeding complications.

Can you tell us about your practice and research?

I am an interventional cardiologist. I am also trained in preventive cardiology, and I focused my broad training on women’s heart disease. In doing so, I became interested in sex differences and how this information can be used to improve outcomes, for both sexes, but the group most in need of improvement at this point is women. For the last 50 years, our research data has been derived predominantly from men, and we have been applying it to women, thinking that it will give them the same benefit. What we have found out is that this is not the case. We need to use sex-specific data in treating our patients. My process is about taking the information that we have learned over the last decade or so about how women are different, and applying it to patients in hopes of improving their outcomes.