Ischaemic Heart Disease-Implications of Gender

Dr Kaye BirksSchool of Rural Health

Monash University AustraliaGender Competency Training for

Medical Educators Seminar, April 2003

Aims

Describe differences between women and men

• Natural history

• Clinical presentations

• Management

• Outcome

Natural History of IHD

• Cause of death of approximately one third of women

• Greater age dependency

• Clinical onset is about 10-15 years later than for men

Natural History--Risk Factorsyoung women

• Family history maternal IHD

• NIDDM

• Smoking risk for sudden death

• Isolated raised total cholesterol – less risk

• Obesity risk ? explained by co-morbidity

Clinical Presentations

• In women angina common first presentation [54%] v. men [38%]

• Recognised MI [18%] men [30%]

• More atypical symptoms

• Pain free MI in older diabetic women

• More non Q wave infarcts

Clinical Presentations

• Older

• Co-morbidities

• Unstable angina rather than acute MI

• Those with infarction less likely to have ST segment elevation

Outcome differences

• More likely to die

• The younger the women the greater the difference when compared to male cohort

• < 50 years twice as likely to die

• After CABG younger women mortality 3.4% v. men 1.1%

• Over 75 years no difference in mortality

Outcome differences ?why

• Women delay in going to hospital• Missed diagnosis on admission• Less likely to receive thrombolytic therapy• More co morbidities• Less likely to receive established treatments

e.g. betablockers, aspirin• Higher death rates for men before going to

hospital

Outcome differences ?why

• Different pathophysiology in premenopausal women

• Plaque erosions in young women, plaque rupture in men and older women

• Young women have less narrowing of arteries• ?hypercoaguable state or coronary spasm• Transmural MI with normal coronary angiography

Management

• Diagnostic testing less specific in younger women

• Less likely to have coronary angiography

• When performed more likely to have clinically insignificant disease

• Less likely to receive primary preventive treatments

Summary

Differences in

• natural history

• presentation

• management

• outcome

Summary

• Important to highlight these differences in the undergraduate curriculum