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Myocardial Infarction in Women:  An Equal Opportunity Event Dealt with Unequal Knowledge and Imbalanced Diagnostic Approach and Disparate Treatment

Disclosure: Dr. Piña has nothing to disclose
Pub Date: Monday, January 25, 2016
Authors: Ileana L. Piña, MD, MPH, FAHA, FACC
Affiliation:  Albert Einstein College of Medicine and Montefiore-Einstein Medical Center

Citation

Mehta LS, et al; on behalf of the American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute myocardial infarction in women: a scientific statement from the American Heart Association[published online ahead of print January 25, 2016]. Circulation. doi: 10.1161/CIR.0000000000000351.

Article Text

“If you know, to recognize that you know, If you don't know, to realize that you don't know: That is knowledge.”  Confucius
Dr. Mehta and colleagues are correct:  CVD is an equal opportunity killer with a persistent excess mortality in women. The statement on Acute Myocardial Infarction in Women is a well-written, quasi- complete work outlining not only the life trajectory of women and hormones,  the risk factors for MI  compared to men, but also its presentation, and sadly, its differences in approach and treatment by the medical community.  Are we any closer to closing the gap?  This work tells us that we are not.   The reasons, as is the disease, are multifactorial.  The solutions, therefore, are also multifactorial.
The Scientific Data

As reviewed in this statement, there are recognized differences in the pathophysiology of CAD in women compared to men.  Highly concerning are the data on younger women and emerging increase in CHD incidence and deaths in women age 45-54, the perimenopausal years.  Mehta et al. have reviewed the current literature on MI in general and found that often, sex specific analyses are not done, in part due to small numbers of women enrolled in studies.  In addition, both journals and regulatory bodies have not historically demanded sex-specific enrollment and analyses.  Thus, at the end of often large and costly trials, we are still left with the disappointing small numbers and the “post hoc” analysis of women where firm and true conclusions are impossible to render.

This gap can only be closed with prospective and expected enrollment of women in CHD clinical trials, where targets by sex are planned a priori and executed.  In addition, prespecified analyses by sex must be expected by sponsors, the trial clinical community and regulators as well as journal editors.  Not publishing works that fail to analyze their findings by sex would be a powerful message to researchers. 

The Medical Community

The Acute Myocardial Infarction in Women statement also highlights the disparities in care that occur in practice where women’s symptoms may not be readily recognized as infarction or angina.  In addition, even if symptoms were recognized, women are less likely to receive aggressive life-saving interventions and less evidence-based medical therapies.  Yet, women have more complications post-MI, such as heart failure and rupture, as well as readmissions.  Especially troubling is the recognition of racial and ethnic differences noted by Mehta et al. that may be underappreciated and lead to suboptimal care.

This gap can only be closed with continuing education which should start in medical school curricula where the science being taught should be more sex specific.  Education during training must also be inclusive and noted that the faculty teaching house staff should be well versed in sex, racial and ethnic differences in CHD.   This observation extrapolates to the quality of teaching and mentoring itself.  Teachers should be fully acquainted with the literature and evidence-based guidelines and practice. Setting an example to house staff of thoughtful processes of care by faculty will go far to the education of our residents.  Furthermore, CME needs to also incorporate the topic of sex-specific differences in MI presentation and treatment and add this feature to all programs related to MI as an indispensable part of learning.

Quality Reviews

The cardiovascular space is replete with quality measures, whether mandated by CMS, insurers or quality improvement groups, such as AHA’s Get With The Guidelines.  Perhaps measures should be created to review processes of care that are sex specific and imbued with sensitivity to racial and ethnic differences.  Such measures may go a long way to bring clinicians into the reality of sex equality in recognition of CVD and its appropriate approach and care. 

References

  1. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, Lindley KJ, Vaccarino V,  Wang TY, Watson KE, Wenger NK; on behalf of the American Heart Association Cardiovascular  Disease in Women and Special Populations Committee of the Council on Clinical Cardiology,  Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and  Council on Quality of Care and Outcomes Research. Acute myocardial infarction in women: a  scientific statement from the American Heart Association [published online ahead of print  January 25, 2016]. Circulation. doi: 10.1161/CIR.0000000000000351.
  2. Eiser AR, McNamee WB Jr, Miller JY. Integrating quality improvement into continuing medical education activities within a community hospital system. Am J Med Qual. 2013;28:238-242.
  3. Kwolek DS, Donnelly MB, Carr E, Sloan DA, Haist SA.  Need for comprehensive women's health continuing medical education among primary care physicians. J Contin Educ Health Prof. 2000; 20:33-38.
  4. Kwolek DS, Witzke D, Sloan DA. The need for faculty development in women's health among internal medicine and family practice teaching faculty. The Women's Health Education Working Group (WHEWG).  J Women's Health Gend Based Med. 1999;8:1195-1201. 
  5. Spencer AL, Kern LM. Primary care program directors' perceptions of women's health education: a gap in graduate medical education persists. J Women's Health (Larchmt). 2008; 17:549-556.
  6. Pursley HG, Kwolek DS. A women's health track for internal medicine residents using evidence- based medicine. Acad Med. 2002;77:743-744 
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association. --