Young Women with Premature ASCVD are at Risk for Worse Outcomes

Young Women with Premature ASCVD are at Risk for Worse Outcomes
Debesai Hailemicael, PharmD, Minnesota Community Care

Background:  New evidence suggests that sex-based healthcare disparities exist among patients with premature atherosclerotic cardiovascular disease (ASCVD), defined as having an initial ASCVD event at age <55 years for men and <65 years for women.  Women tend to bear a higher risk burden and mortality rate of ASCVD due to multiple factors including socioeconomic barriers, inferior secondary preventative care, and an underestimation of cardiovascular risk factors. According to a 2019 study by Vikulova et al, over the last two decades a decline in cardiovascular events and mortality rate did not occur for young women despite a decline in the general population. This worrisome finding indicates that more work and education is needed to reverse this disparity. Dismantling sex-based health disparities requires multidisciplinary and patient-centered interventions. This article aims to increase awareness among the medical community and provide recommendations to narrow the gap. 

Evidence:  Three recent articles highlight the existence of sex-based healthcare disparities in patients with premature ASCVD. 

Jain V et al. looked at 748,090 patients aged 18-55 years enrolled in the US Behavioral Risk Factor Surveillance System (BRFSS) survey. The authors conducted a retrospective analysis to evaluate sex-based difference in physical and mental health and health access in adults with premature ASCVD. The primary outcomes and measures of the study were self-reported physical and mental health, healthcare access, and medical adherence. Self-reported ASCVD was defined as having a history of coronary artery disease, myocardial infarction (MI), or stroke. Out of the enrolled patients, 28,522 had self-reported premature ASCVD, and about 47% were women. The study reported that women were significantly more likely to report poor physical health (OR 1.39 [95% CI 1.09-1.78]), clinical depression (OR 1.73 [95% CI 1.41-2.14]), medical nonadherence (OR 1.42 [95% CI 1.11-1.82]), and inability to access a physician (OR 4.52 [95% CI 2.24-9.13]) due to cost barriers. These disparities were observed despite women having a higher rate of health care coverage and established primary care physicians than men. The study's strengths include having a large sample size with high representation of women and measuring multiple outcomes to assess the impact of disparities. The study's weaknesses include low internal validity as a retrospective cohort study, risk of response and recall bias in utilizing self-reported outcomes, and selection bias in gathering data from a voluntary survey. Moreover, the authors failed to determine if worsening physical and mental health outcomes occurred before or after the ASCVD diagnosis. 

Another study by Michelle T. Lee et al. examined sex-based differences in cardiovascular care in premature ASCVD. The study enrolled 147,600 veterans with premature ASCVD identified from the VITAL (Veterans with Premature Atherosclerosis) nationwide Veterans Affairs (VA) healthcare registry. Enrolled patients had at least one primary care visit at the VA from October 2014 to October 2015. Out of all the subjects, 7.1% were women with premature ASCVD. The researchers found that women with premature ASCVD were less adherent to statin therapy (β coefficient −0.01; [95% CI 0.02 to −0.01]) than men and less likely to receive antiplatelets (OR 0.59 [95% CI 0.56-0.61]), statins (OR 0.66 [95% CI 0.63-0.69]), and high-intensity statin therapy (OR 0.64 [95% CI 0.60-0.67]).  Authors also observed other disparities in this cohort based on  race with a higher incidence of women with premature ASCVD were Black than White or Asian. However, the study failed to report why these differences may exist.

The VIRGO study was a prospective observational study designed to examine sex differences in the presentation, treatment, and outcomes of young patients with acute MI. The study enrolled 3,501 patients aged 18-55 years. The researchers found that women were less likely than men to be informed that they were at risk of cardiovascular disease (1039/2349 [45.1%] versus 554/1152 [49.2%) and have a physician discuss risk modification before an MI. Per patients' reports, providers correctly identified more heart problems in men than women (87% versus 76%, p<0.01), and more men considered themselves at risk of heart disease compared to women (642/1152 [55%] versus 1221/2349 [52.2%]. 

Clinical Impact and Discussion: Current data suggests that age and gender biases have contributed to young women having worse cardiovascular disease outcomes compared to any other age and sex-based group. Multidisciplinary and patient-centered interventions are needed to improve these outcomes. Since women of childbearing age were previously excluded from medication trials, representation of young women in ASCVD clinical trials should be increased. Creating a nationwide or individual state based campaigns aimed to improve ASCVD risk awareness, especially in Latinx and Black communities, would draw attention to these groups who are often underrepresented. Policy-level interventions to address prohibitive out-of-pocket costs would also improve young women's access to physicians and other beneficial health services aimed at reducing their cardiovascular risks. Lastly, treatment guidelines must be updated to incorporate age- and sex-based distinctions and risks. The implementation of the above recommendations would help foster equitable care and assist with reducing sex-based healthcare disparities.

References:

  1. Jain V, Al Rifai M, Turpin R, et al. Evaluation of factors underlying sex-based disparities in cardiovascular care in adults with self-reported premature atherosclerotic cardiovascular disease [published online Jan 5, 2022]. JAMA Cardiol. 2022;e215430. doi:10.1001/jamacardio.2021.5430.
  2. Lee MT, Mahtta D, Ramsey DJ, et al. Sex-related disparities in cardiovascular health care among patients with premature atherosclerotic cardiovascular disease. JAMA Cardiol. 2021;6(7):782-790. doi:10.1001/jamacardio.2021.0683.
  3. Vikulova DN, Grubisic M, Zhao Y, et al. Premature atherosclerotic cardiovascular disease: Trends in incidence, risk factors, and sex-related differences, 2000 to 2016. J Am Heart Assoc.
  4. Leifheit-Limson EC, D'Onofrio G, Daneshvar M, et al. Sex differences in cardiac fisk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: The VIRGO Study. J Am Coll Cardiol. 2015;66(18):1949-1957. doi: 10.1016/j.jacc.2015.08.859.