Are women dying unnecessarily of heart disease?
Professor Emily Banks

Some of Australia’s leading experts on heart health met at a roundtable in Sydney in December 2018 to discuss worrying findings that women with heart disease may get poorer treatment and have worse outcomes, compared with men.

Jointly organised by the Sax Institute, the Heart Foundation and the University of Sydney, the roundtable gathered together more than 30 experts in the field – cardiologists, GPs, cardiac nurses, researchers, public health professionals and policy makers – to look at the data around the treatment, care and outcomes of Australian women with heart disease and to discuss what next steps the research community needs to take. The roundtable was organised as part of the Heart Foundation’s Women and Heart Disease Program, which has awarded a research grant to Professor Emily Banks, Senior Adviser at the Sax Institute and her team to investigate barriers to understanding heart disease in women.

One prompt for discussion was a study recently published in the Medical Journal of Australia that found poorer treatment and outcomes in women, sounding alarm bells among many in the cardiology community. Outlining these study findings to roundtable attendees, lead author Professor Clara Chow from the University of Sydney’s Westmead Applied Research Centre said her research looked at sex differences in the treatment and outcomes of ST-elevation myocardial infarction (STEMI), as this severe form of infarction has a clear diagnostic path and very well defined treatment protocols.

The cohort study of over 3,000 STEMI patients, around a third of whom were female, found that women in hospitals across Australia were less likely to have undergone revascularisation (a procedure to restore normal blood circulation), even after adjusting for risk category. Women were also less frequently referred for cardiac rehabilitation and were less likely to be discharged with prescriptions for preventive medications such as beta-blockers or statins. At 6 months, women were significantly more likely to have had another serious cardiovascular event, and were also more likely to have died.

Confirming findings

Professor Emily Banks

The results broadly line up with the preliminary findings of the research team led by Professor Emily Banks looking into sex-based variations in cardiovascular disease. This team is using data from multiple major sources, including the Sax Institute’s 45 and Up Study. Professor Banks presented new and as yet unpublished data at the roundtable, showing lower revascularisation rates for women with acute myocardial infarction, compared with men, as well as lower use of preventive medications following hospitalisation for serious cardiovascular disease.

A wide-ranging discussion followed these two presentations, initiated with a comment that although international findings about sex-based differences in heart disease have been known for some time, lack of Australian data had not given this issue the attention it deserves. Lack of male champions willing to advance the issue, as evidenced by the small number of men around the table, might also be part of the problem, one attendee noted.

The key issue, many agreed, was to work out whether variations in acute coronary syndrome treatment and outcomes were warranted or unwarranted – in other words, whether they were unavoidable or due to biases in the healthcare system, among health professionals or even in the patients themselves.

Professor Banks noted that because the treatment of STEMI was so guideline- and protocol-driven, it was unclear why the treatment of women should be different. She said it was important to look at clinician and patient decision-making, and whether there were social factors driving the lower uptake of cardiac rehabilitation and lower prescription rates for statins in women.

One participant wondered whether it wouldn’t be useful to break down the data according to the gender of the treating cardiologist. She pointed to a recent study which showed that women were more likely to survive a myocardial infarction if their cardiologist was female.

What next?

The consensus around the table was that while the evidence does indeed show differences in the way men and women are treated, it is still difficult to quantify to what extent this is unwarranted – even though in some areas, such as STEMI, the data are starting to look like this is the case. At the same time as striving to understand what is driving the variation, participants agreed that steps needed to be taken to address the issue. Professor Chow pointed to the need for intervention studies to look at potential reasons for gender differences in treatment and outcomes.

Professor Banks said there was “a whole landscape of different places where sex differences live”, including factors related to presentation, decision-making, healthcare service and system-level barriers. There were two separate questions, she said: where the variation was happening, and why.

“We have quite good illumination on lower revascularisation rates but we don’t have a good understanding about why. You could imagine a multifaceted intervention that tried to address multiple points at which that might be happening,” she commented.

In summarising, Professor Banks said there was some “low-hanging fruit” where action could be taken right away. One initiative would be to ask the NSW Bureau of Health Information to report patient experience for cardiovascular disease by sex. A second action would be to engage with the Agency for Clinical Innovation Cardiac Network on this issue. And a third would be to explore the presentation of data by sex for future research projects funded by the Heart Foundation.

Further work will be undertaken over the next few months to scope out potential research questions, and the discussion is set to continue more formally this year in June 2019 at a multidisciplinary forum to be held at the University of New South Wales, organised by the Heart Foundation in conjunction with the George Institute.