That women with heart disease generally have worse outcomes than men is well known, but recent research is turning up some unusual and possibly very important new risk factors. Low testosterone levels, ?on-pump? bypass grafts, increased anxiety and under-treatment in secondary prevention may each have an independent, negative impact on women?s outcomes.
Provocative studies, presented during a Sunday news conference, suggest that currently accepted risk factors and scores for women should be reexamined, given that many were developed in an era when women were underrepresented in clinical research, said moderator Ann Bolger, M.D., professor of clinical medicine at the University of California/San Francisco and chair of the American Heart Association Council on Clinical Cardiology.
Testosterone deficiency
Postmenopausal women with low testosterone levels have twice the risk of MI, revascularization surgery and mortality as women with higher levels, said Gail A. Laughlin, Ph.D., assistant adjunct professor of family and preventive medicine at the University of California, San Diego/La Jolla.
The 20-year study of 678 women age 50 to 90 years also found low testosterone levels more common in women who were younger, nonsmokers and those who had undergone hysterectomy or bilateral oophorectomy.
?We are not saying high testosterone levels are protective,? Dr. Laughlin said. ?But even after adjusting for other factors, women with low testosterone had significantly higher risks of pre-existing coronary heart disease, specific coronary events and earlier heart disease death than women with higher levels, independent of other hormone levels, diabetes or ovarian status.?
Outcomes better off-pump
Using ?off-pump? surgery appears to neutralize the disparity in complications and deaths between women and men undergoing bypass graft surgery, said John D. Puskas, M.D., chief of cardiac surgery at Emory Crawford Long Hospital and associate chief of cardiothoracic surgery at Emory University, Atlanta. The retrospective study reviewed risk factors and clinical outcomes after major cardiac events in 11,413 bypass procedures.
?Disproportionately fewer women experienced major cardiac events with off-pump surgery and fewer deaths or strokes ? so much so that the gender disparity with men was neutralized,? Dr. Puskas reported.
Anxiety worsens outcome
A multinational study of 879 patients suggests that anxiety influences the higher post-MI rate of complications in women. Patients all underwent standard anxiety tests within 72 hours of admission.
?Women?s higher anxiety levels were closely associated with both the rate of complications and the difference in complications between genders,? said Debra K. Moser, D.N.Sc., professor of nursing at the University of Kentucky, Lexington.
She said that 30 percent of women experienced post-MI anxiety versus 22 percent of men and that women with anxiety had a hazard ratio for complications 30 percent higher.
?The good news is that anti-anxiety medications reduced complications in both men and women,? she said.
Secondary prevention less aggressive
Women with cardiovascular disease receive less-aggressive secondary prevention therapy than men, including less lipid-lowering therapy (62.6 percent versus 67.1 percent) and antiplatelet therapy (76.6 percent versus 85 percent).
The study of disparities in secondary prevention, led by Leslie Cho, M.D., director of the Women?s Cardiovascular Center and medical director of preventive cardiology and rehabilitation at the Cleveland Clinic Foundation, followed 2,462 men and women for seven years.
Dr. Cho said the data held true even though the women?s median age was higher than the men?s, they were hypertensives, and they had statistically higher baseline levels of c-reactive protein and higher levels of LDL cholesterol and total cholesterol.
Dr. Cho added that both men and women received less therapy than the guidelines recommend.