A study published in the Canadian Medical Association Journal indicates that, among younger patients with acute coronary syndromes, women are less likely than men to receive care within the benchmark times for ECG or fibrinolysis. Furthermore, feminine personality traits (in both men and women), anxiety (in women only), and no chest pain are all risk factors for poorer access to care.
Study authors Roxanne Pelletier (Division of Clinical Epidemiology, Research Institute of the McGill, University Health Centre, Montreal, Canada) and others write that women with acute coronary syndromes have worse outcomes than men. The authors add that some studies have suggested that women have poorer outcomes because they have poorer access to care compared with men, but say that the effect of gender-related factors on access to care has not been investigated. They explain: “Unlike sex, which is a biological characteristic, gender has a wider scope, incorporating the effects of social norms and expectations for men and women. Gender-related variables include gender identity, social roles, socioeconomic status and interpersonal relationships.” The aim of their study, therefore, was to review both sex-related and gender-related differences in access to care among adults (aged 18–55) with premature acute coronary syndrome; Pelletier et al reviewed younger patients because previous studies reviewing differences in access to care between men and women have looked at relatively old patients.
The outcomes of the prospective GENESIS-PRAXY (Gender and sex determinants of cardiovascular disease: from bench to beyond—Premature acute coronary syndrome) study included door-to-ECG time, door-to-needle time for patients with ST-segment elevation myocardial infarction (STEMI), and door-to-balloon time for STEMI patients undergoing primary percutaneous coronary intervention (PCI). Patients were recruited (from 26 centres across Canada, the USA, and Switzerland). Overall, there were 362 women and 761 men in the study.
The authors found that women were significantly less likely than men to receive timely ECG (≤10 minutes: 29% vs. 38%, respectively; p=0.02) and were also significantly less likely to receive timely fibrinolytic therapy (measuring door-to-needle time, ≤30 minutes: 32% vs 59%; p=0.01). While there were no significant differences between men and women in door-to-balloon time in those undergoing primary PCI, female STEMI patients were less likely to receive reperfusion therapy than men and female non-STEMI and unstable angina patients were less likely to receive non-primary PCI than their male counterparts.
Using multivariate analysis, Pelletier et al found that women with anxiety were less likely to undergo timely ECG than women without anxiety (24% vs 35%; p=0.04) but this difference was not observed in men with anxiety compared with men without anxiety. Furthermore, patients who reported being responsible for housework had lower odds of undergoing catheterisation and receiving non-primary PCI and those with higher Bem femininity scores also had lower odds of undergoing non-primary PCI than patients with lower Bem femininity scores. The authors state: “Our results highlight that young men and women with no chest pain and those with anxiety, several traditional risk factors, and feminine personality traits were at particular increased risk of poor access to care.”
They ad that among older patients, there is a longer delay between chest pain and presentation in women compared with men and this may explain the lower odds of reperfusion observed in older women, but they say that this phenomenon of a longer delay in women was not observed in their study and thus could not explain the differences seen in reperfusion between men and women.
Study author Louise Pilote (Division of Clinical Epidemiology, Research Institute of the McGill, University Health Centre, Montreal, Canada) told Cardiovascular News: “We are not sure why feminine traits and roles prolong delays and make patients less likely to receive invasive procedures. May be these men and women are less assertive, precise, and/or concise when expressing their needs and reporting their symptoms. These gender-related characteristics may influence medical personnel’s perceptions of patients’ state and symptoms.”