Young Women Left Behind in Secondary Prevention of ASCVD

Among patients with premature atherosclerotic cardiovascular disease (ASCVD), women were less likely to receive key secondary prevention therapies, a VA healthcare system-based study showed.

Of those with ischemic heart disease, ischemic cerebrovascular disease, or peripheral arterial disease by age 55, it was found that women were less likely to receive antiplatelets, any statins, and high-intensity statins, revealing sex disparities in cardiovascular care within the VA system.

Additionally, women with premature ischemic heart disease were particularly less adherent to their statins compared with men, whereas there were no sex-associated differences in statin adherence among other ASCVD groups, reported Salim Virani, MD, PhD, of the Michael E. DeBakey Veterans Affairs Medical Center in Houston, and colleagues in findings published in JAMA Cardiology.

These findings persisted after adjustment for clinical, socioeconomic, and clinician factors. Results were similar among people with extremely premature ASCVD — those who had experienced an event by age 40.

“Despite established benefits of secondary ASCVD prophylaxis, women receive comparatively less aggressive therapy than men,” Virani’s group concluded. “Complacency in secondary cardiovascular prophylaxis in this young cohort can result in devastating long-term consequences with poorer quality of life,” they warned.

Clinician unawareness and bias are probably at least partly to blame for young women not getting guideline-directed statin therapy, the authors said. “It is well-established that women with ASCVD, particularly IHD [ischemic heart disease], often present with atypical symptoms. However, under-recognition of ASCVD in women still persists today.”

The study’s main findings are “quite interesting because many have postulated that women might not be prescribed these therapies because they are more elderly or have more relative contraindications. To some extent, looking at a younger population evens the playing field in that regard,” said Michelle O’Donoghue, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, who was not involved with the study.

“Although likely multifactorial, given the vulnerable population at greatest risk, [the disparity is] likely centered on social determinants of health along with a degree of implicit bias,” suggested Rachel Bond, MD, of Dignity Health in Phoenix, Arizona.

“This study highlights the pivotal role of patient-provider communication, and the need for close, multidisciplinary collaborations,” Bond told MedPage Today in an email sent through a Dignity Health representative.

Virani and colleagues conducted their retrospective cohort study using VA electronic medical records and included patients who had at least one primary care visit in the VA healthcare system in 2014-2015.

The study identified 147,600 veterans with premature ASCVD (7.1% women), of whom 9,485 were deemed as having extremely premature ASCVD (14.1% women).

Overall, both men and women received suboptimal aspirin and statin therapy and had poor statin adherence, the investigators reported.

Compared with men, women with premature ASCVD were more likely to be African American. However, there was no clear direction of association between Black race and female sex on the outcomes: Black women were less likely to receive some therapies (e.g., statins) but also more likely to receive others, Virani’s group reported.

Nevertheless, Bond observed that younger African-American women were the least aggressively treated across the board.

Chief among the study’s limitations were its observational nature and reliance on a database that lacked variables such as statin or aspirin contraindications and certain socioeconomic factors.

“From the clinician’s standpoint, increasing awareness and incorporating a tailored discussion regarding secondary prevention therapies for women of child-bearing age should be emphasized,” Virani’s team wrote.

“Of note, women in this younger age group continue to be underrepresented in clinical trials, so further work should be done to better evaluate whether there is any differential efficacy or safety of cardiovascular drugs in a younger patient population,” said O’Donoghue.

“In the interim, it would be preferred that hospitals and clinics construct more rigorous medication pathways and checklists to help guide clinicians and to help minimize the disparities that currently exist,” she added.

Last Updated April 21, 2021