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April 2004 Issue

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High-Risk Heart Conditions Treated Less Aggressively in Women than Men

Published April 2004

According to an analysis of more than 35,000 patients, women entering a hospital with acute coronary syndrome (ACS) were less likely than men to receive many medications that have been shown to improve clinical outcomes and save lives. This analysis, from an ongoing quality improvement initiative known as CRUSADE, identified the existence of this treatment disparity despite data from clinical studies showing that women are at higher risk for cardiac events than men. The findings were presented in March at the American College of Cardiology's Annual Scientific Session by researchers from the UC Medical Center.

The analysis measured adherence to American College of Cardiology and American Heart Association (ACC/AHA) treatment guidelines for patients with cardiac conditions known as non-ST-segment elevation acute coronary syndrome (NSTE ACS), which account for more than 1.4 million hospitalizations each year. Ongoing research shows that patients suffering from NSTE ACS who are treated according to the ACC/AHA guidelines are more likely to survive than those who are not treated according to those guidelines. In the analysis presented, men were more likely than women to receive recommended therapies in the hospital setting, such as heparin or glycoprotein (GP) IIb-IIIa inhibitors. The findings also showed that women are similarly less likely than men to undergo cardiac procedures and receive certain recommended medications upon discharge.

"We found that, despite being at higher risk, women who arrive at the hospital with symptoms of a heart attack were less likely to receive recommended medications and procedures than men," said Andra Blomkalns, MD, assistant professor of emergency medicine at the UC Medical Center, who presented the findings. "Through CRUSADE, we are working to understand the reasons for this disparity so that we can ensure that all patients at risk for a heart attack, female or male, receive care that has been proven to save lives."

The UC Medical Center, with its affiliate The University Hospital, is one of more than 400 sites participating in the nationwide quality improvement initiative known as CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC and AHA guidelines). Led by Duke Clinical Research Institute, CRUSADE has been retrospectively gathering clinical data from U.S. hospitals since 2000. The program provides regular feedback to hospitals with the ultimate goal of improving adherence to treatment guidelines established by the ACC/AHA.

Data Identifies Treatment Gap

In their analysis of the medical data of 35,835 patients (41 percent of whom were female) in the CRUSADE initiative, researchers found that female patients were significantly less likely to receive medications such as heparin (80.0 percent of women, vs. 84.0 percent of men) or GP IIb-IIIa inhibitors (28.7 percent vs. 38.6 percent), even when adjusted for differences in patient and hospital characteristics. Similarly, female patients were less likely to undergo diagnostic catheterization (60.1 percent vs. 71.1 percent) or percutaneous coronary intervention (31.4 percent vs. 40.4 percent).

In the analysis, women had an increased unadjusted in-hospital mortality (5.6 percent of women vs. 4.3 percent of men), and an increase in other health complications as well. The women studied were generally older and more likely to have diabetes or hypertension – characteristics that are associated with a high risk for death or other cardiovascular complications.

"This is one of the paradoxes that we see in medicine, that the patients who are in greatest need of effective therapies are not receiving them," said Judith Hochman, MD, a co-author of the study and the Harold Snyder Family Professor of Cardiology; clinical chief, Leon Charney Division of Cardiology and director, Cardio-vascular Clinical Research, New York University School of Medicine. "CRUSADE is providing us with a more comprehensive understanding of the barriers that keep patients from receiving proper care. Our goal is to remove these barriers so that all ACS patients receive proven treatments."

According to the AHA, 267,000 American women die of heart disease each year, which equates to 32 percent of deaths among women. Unfortunately, according to Dr. Blomkalns, physicians often have greater difficulty identifying serious clinical cardiac symptoms in women, making it more difficult to administer optimal treatment.

"Women are less likely to demonstrate ‘classic' symptoms of ACS, increasing the need for education specific to diagnosing their symptoms," Dr. Blomkalns said. "It is critical that their symptoms are diagnosed quickly and that they are treated aggressively. Using appropriate medications as soon as possible in the emergency room can save lives."


CRUSADE is a quality improvement initiative analyzing treatment patterns for patients with NSTE ACS at hospitals across the United States. Duke Clinical Research Institute has retrospectively collected, aggregated and compared the treatment, procedures and medications received by patients with NSTE ACS to the guidelines, and treatment patterns at comparable regional and national hospitals. The summarized data from each hospital is reported back to the hospital in a "report card" to determine needs to improve patient care. Educational programs and materials are being employed to encourage better guidelines adherence and improve patient care. It is the first program of its type and size to work toward changing practice patterns and improving clinical outcomes. CRUSADE is funded by Millennium Pharmaceuticals Inc., Cambridge, Mass., and Schering-Plough Corp., Kenilworth, N.J. A partnership of Bristol-Myers Squibb, N.Y., and Sanofi Pharmaceuticals, N.Y., provided additional funding.

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