Gulati on Unequal CV Treatment for Women: “There Is a Bias in Our Care”

Women who develop cardiovascular disease are more likely to die than men, and the reasons for this are found throughout the care process—from clinical trial enrollment, to the emergency department, to getting the right medication, said Martha Gulati, MD, MS, the Cedars-Sinai cardiologist who this weekend became president of the American Society for Preventive Cardiology (ASPC).

Gulati is associate director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai and holds the Aveda Dan Friedman Endowed Chair Women’s Cardiovascular Medicine and Research. She presented the troubling facts about how the health system treats women with atherosclerotic cardiovascular disease (ASCVD) to kick off a symposium, “Saving the Hearts of Women Through Prevention,” held ahead of the ASPC 2022 Congress, which took place Friday through Sunday in Louisville, Kentucky.

Since 2011, when Gulati coauthored the book Saving Women’s Hearts on prevention strategies for women, there has been some improvement in enrollment of younger women in clinical trials. But, she said, there are still not enough women over 55 years of age enrolled in studies. “And, of course, it’s at that age—over the age of 55—that most women development cardiovascular disease,” Gulati said.

What’s more, government-sponsored trials in particular seem to enroll fewer women than trials in general, she said.

How does this happen? Gulati said the Emory University cardiologist Nanette Wegner, MD, coined the term the “the bikini approach” when it comes to research priorities for women—most funding and attention goes to diseases of the breast or the reproductive organs, with less focus on other diseases that cause significant mortality in women.

Yet Gulati presented data that show women in the United States face a 10-fold risk of dying from cardiovascular disease than they do from breast cancer. “Even if we talk about prevalence, and the definition of prevalence includes hypertension, it’s 1 in 2 women that are living with some form of cardiovascular disease, or 60.8 million women, compared to 3.8 million women living with breast cancer.”

“It’s not to minimize the effect of breast cancer or its importance, or the need for screening,” Gulati continued. “But what do we do about cardiovascular disease?”

Women, she said, are not screened often enough for cardiovascular disease, and too few are aware of their risk. The inequity doesn’t stop there:

• Women are less likely to receive guideline-directed therapy after a myocardial infarction (MI), and statins remain underutilized in women with acute MI;
• A recent article in the Journal of the American Heart Association (JAHA) found that when women present with chest pain, they are less likely to be triaged as emergent or to undergo electrocardiography;
• The JAHA investigators found that women waited least 10 minutes longer compared with men for an initial evaluation, were less likely to receive an electrocardiogram, and were less likely to be consulted by a cardiologist; and
• Finally, women who experienced an MI were more likely to be readmitted to the hospital, which has been a standard quality measure for a decade.

Said Gulati, “There is a bias in our care.”

She discussed the use of risk assessment tools, noting that some risk factors, such as diabetes, may drive higher cardiovascular risk in women than in men. Certain risk enhancers, such as lupus and rheumatoid arthritis, may not be included in a risk score but are more prevalent in women. The 2018 American College of Cardiology/American Heart Association guideline update for management of blood cholesterol, endorsed by APSC, showed how the ASCVD risk score is a useful tool, but just a starting point.

Gulati then turned to a key area where preventive cardiology can make a difference with young women: in pregnancy. Many women will come up as low risk in the ASCVD score, especially when they are young. However, this “doesn’t take into account many things that you may already know about them—and some of those things are related to pregnancy.”

“Nature’s Free Stress Test”

Pregnancy is called “nature’s free stress test,” because women who experience hypertension or gestational diabetes are those who are likely to have cardiovascular problems in the future—or sooner, if they have complications during or after delivery.

“We know pregnancy-related mortality continues to rise in the United States,” Gulati said. “You can see that it really, for all the Western world, the United States has the highest maternal mortality, and the biggest cause is due to cardiovascular disease.” She highlighted how maternal mortality disproportionately affects women of color, especially Black women.

Most of these events are preventable, Gulati said. “We shouldn't think that it's just inevitable that these people are going to die,” she said. “When we talk about maternal mortality, it's important to understand we're talking about within that first year of after you deliver as well. And most of the deaths, of course, occur post partum.”

Health systems should be able identify women who are at risk early on. “We should also be taking their symptoms seriously post partum as well…We've estimated that 68% of the cardiovascular causes of maternal mortality would actually be preventable.”

Gulati discussed the period after delivery—the “fourth trimester,” which has also been endorsed by the American College of Obstetricians and Gynecologists. Access to care in this period is crucial, and HHS has now created a waiver that lets states extend Medicaid coverage through the first year, even if the state has not endorsed the rest of Medicaid expansion. According to the Kaiser Family Foundation tracker, 23 states have extended coverage, 11 are planning to extend coverage, and 2 states have added limited coverage.

Knowing more about a woman’s history during pregnancy will allow physicians to identify “risk enhancers” that can serve as early warning signals for the future. The key is to identify these women, Gulati said. “So, this is really our challenge,” she said. “We know that women have worse outcomes after acute myocardial infarction—if the only thing we did to close the gap is give women guideline-directed medical therapy, that’s at least one way we can reduce the risk of death for women.”

“I think secondary prevention will always be part of our job,” she concluded. “But of course, if you’re doing a lot of primary prevention—identifying both risk factors that are different between men and women and risk enhancers, and being aggressive at doing risk assessment in women, I think that is also our role.”