While the treatment of heart failure has improved over the past two decades, a new study reported in the European Journal of Heart Failure finds that "the use of evidence-based treatments appears to be imbalanced according to the gender of the patient".
In particular, the study found:
- that female patients were less frequently treated with guideline-recommended medications (such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers ARBs) or beta-blockers)
- and that doses were lower in female than in male patients.
However, the patient's gender was not the only influence on treatment; so was the gender of the physician. For example, the study demonstrated for the first time that drug treatment is more complete when female physicians are taking care of the patient. Thus, the use of ACE inhibitors or ARBs was significantly lower in female patients treated by a male physician than in male patients treated by either a female or male physician.
Similarly, the dose of ACE inhibitors and ARBs was highest in male patients treated by female physicians and was significantly different from the reverse combination (female patient, male physician). Dosage of beta-blockers was comparable in male patients irrespective of the physician's gender, whereas female patients treated by a male physician received the lowest doses.
The investigators thus concluded that "male patients with chronic heart failure are more likely to receive evidence-based drug treatment than female", particular so for the prescription of ACE inhibitors and dosage of beta-blockers.
The study was an evaluation of 1857 consecutive patients treated at the centres in Germany; treatment records involving 829 physicians (65 per cent general practitioners, 27 per cent internists, and 7 per cent cardiologists) were analysed with regard to evidence-based drug treatments to improve survival. Assessment of dosages was calculated as a percentage of averages documented in treatment guidelines for heart failure.
Commenting on the results, the study's first author Dr Magnus Baumhakel from the University Hospital of the Saarland, Homburg, Germany, said: "The use of evidence-based treatments as described in the latest guidelines has undoubtedly improved the treatment of chronic heart failure. But there is still evidence of a gender imbalance in both patients and physicians. From our results it seems fair to say that the gender of the physician plays an important role in adherence to drug treatment recommendations in chronic heart failure."
This is one of several recent studies to find gender differences in medical care (and survival) in cardiovascular disease. Many have found that women are treated less intensively than men, especially in the acute phase of the disease.
Heart failure is by far the single biggest reason for acute hospital admission. Around 30 million people in Europe have heart failure and its incidence is still increasing: more cases are being identified, more people are living to an old age, and more are surviving a heart attack but with damage to the heart muscle. According to one study, the reported prevalence among those aged 65-74 years is one in 35, and among the over-85s one in seven.
Heart failure is a cluster of symptoms resulting from the heart's inability to pump blood as required by the body. This is usually because of previous damage to the heart muscle, following a heart attack, coronary disease or hypertension. The resulting symptoms of heart failure are breathlessness, exercise intolerance, and a build-up of fluid in the lungs and abdomen.
New ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure simplify the definitions of new, transient and chronic disease. According to the latest guidelines, published in 2008:
- an ACE inhibitor and beta-blocker are recommended in all patients with symptomatic heart failure; both "improve ventricular function and patient well-being, reduce hospital admission for worsening heart failure, and increases survival"
- an angiotensin receptor blocker (ARB) is recommended in all patients who remain symptomatic despite optimal treatment with an ACE inhibitor and beta blocker.
The 2008 ESC Guidelines can be seen in various formats at http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/acute-chronic-heart-failure.aspx
A statement issued by the ESC in December 2008 on gender differences in the treatment of heart attack said that definitive answers about optimal treatment will only be derived from studies powered to draw significant conclusions in both men and women in the same prospective cohort: "The optimal treatment recommendations for men and women respectively will only be resolved by inclusion of sufficient numbers of both women and men in future clinical trials." It is not clear if men and women should be treated to the same extent but, until we have further information, this is assumed to be the case in heart failure.
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