The care of patients with ischaemic heart disease from a gender perspective

Abstract

In summary, there are gender and age differences in prevalence, prognosis and manifestation of cardiovascular disease, a phenomenon which has been known for a long time. Nevertheless, it is only since the end of the 1980s that this has been generally discussed and that research has been commenced with specific reference to female coronary artery disease, not only in Sweden but internationally as well. The reason for this gender difference is not known, but it has been suggested that women are cared for and treated differently. In recent years, reports have been received from different centres which indicate that there are gender differences in the use of diagnostic and therapeutic measures in cardiovascular disease. Because of this gender difference in prognosis, investigation and treatment, special measures need to be applied in the care of female cardiovascular patients. It is also very important that randomized studies include a sufficient number of women in order to be able to answer gender-specific questions. The good prognosis for women with angina shown in the Framingham study most likely reflected a high prevalence of women with chest pain originating from disease other than that affecting the coronary arteries. This created the impression that women tolerated angina better; thus, angina in women has been given less attention. It is likely that this has led to incorrect decisions concerning investigation and treatment alternatives, resulting in an inability to identify the high-risk woman in time. When she is finally admitted to proper care, she is older, has concomitant diseases and revascularization often has to be performed at an acute, unstable stage, which leads to higher mortality and morbidity in connection with the intervention. This phenomenon has been described as the so-called 'Yentl syndrome' i.e. a woman has to masquerade as a man in order to receive the same treatment. More medical research needs to be done on women's health to come to terms with this problem. Hitherto, major efforts have been made to obtain homogenous groups in research studies, which is why there are lots of results containing data on middle-aged white men. Even in tests on rats the females are excluded. The results of studies performed exclusively on men cannot be generalized to apply to women without evidence that the results can be used safely and effectively on both sexes. Research on health problems that are common to both sexes must include both men and women, preferably of all ages. It is also important to point out that unnecessarily restrictive inclusion criteria diminish the ability to generalize the results. Moreover, the chance increases of being able to detect a difference in the effects of treatment in a population with an increased risk, such as the elderly and women with a high frequency of recurring coronary artery disease. There are sill many questions to be answered before we can treat women with coronary artery disease properly.