The Gender Gap

KentuckyOne Health Cardiac Surgeon Kendra Grubb, MD, discusses when and how gender matters in the treatment of cardiovascular disease

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LOUISVILLE “What should I be doing about my heart?” It’s a simple question, but one Kendra Grubb, MD, MHA, director of Minimally Invasive Cardiac Surgery for the University of Louisville (U of L) and Jewish Hospital, part of KentuckyOne Health, says is pivotal in turning the tide against heart disease as the number one killer of women (and men) in the United States.

Historically, heart disease has been mistakenly thought of as a disease of men. While the prevalence of cardiovascular disease may be higher in men, the American Heart Association (AHA) reports that, in 2013, women accounted for 49.7 percent of all deaths from cardiovascular disease.1 “As a nation, we have done a very good job of raising awareness of breast cancer. But the reality is all cancers combined are not going to take as many women’s lives in a year as heart disease does,” says Grubb. In 2013, one in 4.7 women in the US died of cancer, whereas one in 3.2 women died of cardiovascular disease.i

As deadly as heart disease is, Grubb says 80 percent is preventable with behavior modification. “Part of the battle is just getting women to start the conversation with their doctors,” she says. Simply asking, “What should I be doing about my heart?” jumpstarts discussions about healthy lifestyle choices such as not smoking and getting the proper diet and exercise.

The other part of the equation is the role primary care physicians play in monitoring heart health, particularly in Kentucky where risk factors are abundant. “We need to put the heart higher on our differential as physicians and not discount the possibility just because the patient is female,” says Grubb.

Her advice to physicians is twofold: 1) Discuss heart health with every adult patient at every visit, and 2) Ask the right questions. “If you ask women if they’re having chest pains, they may say no,” says Grubb. “But they may notice when they get stressed or increase their activity, they have abdominal pain. That can be their heart, and it’s just presenting differently.” Women also have a tendency to respond to symptoms of heart failure by decreasing activity. So, a woman may say she does not get short of breath. But the better question is – are you able to do the same level of activity you were doing a year ago? And if not, why?

The Gender Difference

Heart disease does not discriminate based on gender. The disease process is the same in women and men and diagnosis is essentially the same, once the heart is identified as a potential problem.

The difference is in the presentation of symptoms and the response to treatment. Men often suffer from classic, crushing chest pain, what Grubb refers to as the “Hollywood heart attack,” while women’s symptoms may present more subtly. It’s those subtle symptoms that physicians may attribute to some other cause, leading to a delayed diagnosis.

Data has long shown that women’s outcomes for cardiovascular procedures, including stents and open heart surgery, are worse than those of men. “We don’t necessarily understand why women do not respond to treatment as well as men do. Some of it stems from early research,” says Grubb. In early high blood pressure studies for example, the participants were almost exclusively male, yet those results were extrapolated to the entire population. Additionally, Grubb believes outcomes in women have been lower because, historically, women have been diagnosed and treated later in the disease process than men.

The tide is slowing changing. Of promise are improved treatment responses and outcomes for women with new minimally invasive cardiac procedures. “In some cases, like that of the transcatheter aortic valve replacement (TAVR), one of the procedures I do at Jewish Hospital with the team, women actually do much better compared to their male counterparts and certainly do much better than high risk patients when compared to open surgery,” says Grubb. She attributes this in part to better representation of the entire population in clinical trials for these newer modalities and to better timing, as women are beginning to be diagnosed, treated, and followed in a timelier manner.

The TAVR program at Jewish Hospital continues to grow. Physicians there have performed over 300 such procedures and now perform TAVR with the patient completely awake, so they go home the next day. Indications for TAVR are expanding to not only very high risk and inoperable patients, but also intermediate risk patients as part of a registry, and Jewish Hospital has recently begun enrolling low-risk patients in a TAVR trial. While open heart aortic valve surgery is still the most proven, durable treatment for younger patients (65 and under), Grubb has begun recommending transcatheter approaches to patients 80 and up because her results have shown better outcomes and quicker recoveries in this population, particularly for women.

The truth is gender does matter when it comes to heart disease. While physicians need to be equally as active in monitoring the symptoms and heart health of male and female patients, all symptoms and treatments are not created equal. Thankfully new technologies with better outcomes for women and educational efforts to increase awareness of gender differences can enable physicians to tailor treatments in the best interests of each patient, and, hopefully, one day close the heart health gender gap.

1 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després J-P, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER III, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner Mb; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2016 update: a report from the American Heart Association. Circulation. 2016; 133 (4):e38–e360.

HEART DISEASE DOES NOT DISCRIMINATE BASED ON GENDER. THE DISEASE PROCESS IS THE SAME IN WOMEN AND MEN AND DIAGNOSIS IS ESSENTIALLY THE SAME, ONCE THE HEART IS IDENTIFIED AS A POTENTIAL PROBLEM.

3RD ANNUAL LOUISVILLE SYMPOSIUM ON HEART DISEASE IN WOMEN

Three years ago, Grubb began the Louisville Symposium on Heart Disease in Women to help educate practitioners on new guidelines and thinking in women’s heart disease. One of her goals has been to increase access to the technology and services available in Louisville and provide practitioners in smaller communities with resources and people they can contact when they have a challenging case or need modalities not available in smaller communities.

This year the symposium will be held on June 25 at the Muhammad Ali Center in downtown Louisville. The theme will focus on innovative procedures, devices, and state-of-the art care, many of which are research efforts coming out of U of L and Jewish Hospital in regards to stem cell therapy, transplantation, and device and medication advancements.

The symposium is a CME accredited event for physicians and nurses, although the public is welcome to attend. For more information, visit louisvilleheartdiseasewomen.com.