Women Have Poorer Survival Than Men in Years After First Heart Attack
Here's a good reason for women to take a heart attack more seriously than they might: A new study shows that women are more likely to develop heart failure or die within five years of their first severe heart attack than men are.
Though the gender gap was narrower for a less severe type of heart attack, that wasn't true with a more severe type, according to Canadian researchers who discovered women have a 20% greater risk of developing heart failure or dying within five years.
The study found a few clues: Women were generally older at the time of their heart attacks and had more risk factors that could have increased their heart failure risk, but they also were seen less frequently by a cardiovascular specialist, were not as likely to have been prescribed heart medications, and had slightly lower rates of certain surgical procedures.
Women tend to be about 10 years older than men when they first have heart attacks and there may be some barriers that can be resolved by improving elder care, said study co-author Dr. Justin Ezekowitz. He's a cardiologist and co-director of the Canadian VIGOUR Centre at the University of Alberta, in Edmonton.
"I think still there is a gap that needs to be better understood. I think we do need to understand whether or not there are also different risks that women may have," Ezekowitz said. "And we tried to identify a few of those, but we didn't come up with one single factor. I think it's a constellation of factors that makes it more difficult to understand."
For the study, the researchers analyzed data on more than 45,000 patients who were hospitalized for their first heart attack between 2002 and 2016 in Alberta, Canada. Nearly 31% of those patients were women.
The investigators focused on two types of heart attacks: the severe, life-threatening ST-elevation myocardial infarction (STEMI); and the less severe NSTEMI, which is more common. The study followed the patients for an average of six years.
Women were more likely to develop heart failure in the hospital or after discharge for both types of heart attack when no adjustments were made for variables, but the gap was considerably narrower for the NSTEMI patients after those adjustments, according to the study authors.
Women were an average age of 72, compared to 61 for men at the time of their first heart attacks. They also tended to have more complicated medical histories at the time of their heart attacks, including high blood pressure, diabetes, atrial fibrillation and chronic obstructive pulmonary disease (COPD). These are risk factors that contribute to heart failure.
Nearly 73% of women were seen by a cardiovascular specialist, compared to 84% of men. Women were also less likely to receive heart medicines like beta blockers or cholesterol-lowering statins, and slightly less likely to receive certain procedures to restore blood flow, such as surgical angioplasty.
The study was published online Nov. 30 in the journal Circulation.
Among the potential solutions to close the gap could be more accommodations for patients' preferences when delivering care, Ezekowitz said.
"For the longest time we've offered cardiac rehabilitation in fixed buildings. It may be more difficult for somebody who's older to attend cardiac rehabilitation than somebody who's younger because of mobility or they can't get transportation," Ezekowitz explained. "We can start to offer that in a much more bespoke model as in 'this person has these types of issues, therefore we need to offer this different type of model for them.' I think that will help more people access care and get high-quality care."
If a woman is older at the time of her heart attack, there may be some intrinsic biases by providers that certain therapies don't work as well in older people, and so some of that care may be held back, he added.
"We've got to recognize some of the gaps can be filled in by providing elder-friendly care, care that's appropriate for different ages but also making people more aware that many of our therapies work equally well in young and old people," Ezekowitz said. "We need to be very careful not to limit their therapy based on age alone."
Critically important is increasing efforts to prevent these types of heart attacks in the first place, said Dr. Gregg Fonarow, a cardiologist at the University of California, Los Angeles. This includes reducing cholesterol, controlling blood pressure, increasing exercise, stopping smoking and eating a healthy diet.
Even after a heart attack occurs, there are therapies that can lower the risk of developing heart failure or mortality after that heart attack that are cardioprotective, Fonarow added. These include ACE inhibitor and beta blocker drugs, as well as high-intensity statins.
"These therapies tend to be underutilized in women relative to men," Fonarow said. "So, there's more work that needs to be done to provide higher quality and equitable care to women in a way that will decrease their risk of complications and recurrent events, heart failure and premature cardiovascular death after an acute coronary event."
The U.S. Centers for Disease Control and Prevention offers more information on heart failure.
SOURCES: Justin Ezekowitz, MD, cardiologist, Mazankowski Alberta Heart Institute, co-director, Canadian VIGOUR Centre, professor, department of medicine, division of cardiology, University of Alberta, Edmonton, Alberta, Canada; Gregg Fonarow, MD, chief, division of cardiology, University of California, Los Angeles; Circulation, Nov. 30, 2020, online
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