Is there a sex bias in implantable cardioverter-defibrillator referral and prescription? | Heart

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Is there a sex bias in implantable cardioverter-defibrillator referral and prescription?

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Implantable cardioverter defibrillators - are women getting a RAW deal (refused arrhythmic work-up)?
Lokpal Bhatia
Published on: 23 July 2004

Published on: 23 July 2004
Implantable cardioverter defibrillators - are women getting a RAW deal (refused arrhythmic work-up)?
- Lokpal Bhatia, Cardiology Research Fellow
Dear Editor,
Staniforth et al provide interesting data relating to a sex bias in favour of men with regard to implantable cardioverter defibrillator (ICD) use,[1] concluding that the reason for this discrepancy is unclear.
Previous work has suggested that women are less likely to be referred for ICD implantation, even when clinically appropriate.[2] This is surprising given that survival rates in w...
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Dear Editor,
Staniforth et al provide interesting data relating to a sex bias in favour of men with regard to implantable cardioverter defibrillator (ICD) use,[1] concluding that the reason for this discrepancy is unclear.
Previous work has suggested that women are less likely to be referred for ICD implantation, even when clinically appropriate.[2] This is surprising given that survival rates in women after ICD use are similar to their male counterparts.[3] The long-held notion of male gender as a risk factor in patients with coronary artery disease probably favours more male referrals, which mirrors the TIMI III Registry findings,[4] where women were less likely to undergo coronary angiography as well as referral for revascularisation after acute coronary syndromes.
In addition, a large cross-sectional study across 91 intensive care units in Great Britain showed that there was inequity of female referrals to such units after sustaining a myocardial infarct compared to age-adjusted males.[5] Can this gender disparity in ICD take-up be explained by greater co-morbidity in females, bearing in mind they present at a slightly older age compared to men, as the authors postulate? This is unlikely, as evidenced by large studies where even after adjustment for comorbid conditions, female sex remained an independent predictor of reduced cardiac interventions in coronary artery disease.[6,7] All these findings imply we are adopting a less aggressive approach in our treatment of females with coronary artery disease, despite mortality risks being broadly similar to that of males.
What about gender differences in survival outcomes in patients at risk of sudden cardiac death? Perers et al reported that female gender was associated with a higher chance of reaching hospital alive after suffering an out of hospital cardiac arrest.[8] Herlitz et al also showed that females were more likely to survive to hospital discharge following an in- hospital cardiac arrest.[9] However, the aetiology of the cardiac arrest in less than half of these patients was specifically due to coronary ischaemia, so one cannot argue that women are less deserving of an ICD.
If one of the reasons for this gender discrepancy turns out that women are indeed declining the procedure more often, then we need to focus our attention on how to better educate them as to the risks and benefits of intervening. As for physicians’ preferences in referral rates, we need to re-evaluate our practice and keep in mind that Venus is not so far away from Mars after all.
References
(1). Staniforth AD, Sporton SC, Robinson NM, et al. Is there a sex bias in implantable cardioverter-defibrillator referral and prescription? Heart 2004;90:937-8.
(2). Beauregard LA. Incidence and management of arrhythmias in women. J Gend Specif Med 2002;5:38-48.
(3). Pires LA, Sethuraman B, Guduguntla VD, et al. Outcome of women versus men with ventricular tachyarrhythmias treated with the implantable cardioverter defibrillator. J Cardiovasc Electrophysiol 2002;13:563-8.
(4). Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: The TIMI III registry. Jama 1996;275:1104-12.
(5). Raine R, Goldfrad C, Rowan K, et al. Influence of patient gender on admission to intensive care. J Epidemiol Community Health 2002;56:418- 23.
(6). Bearden D, Allman R, McDonald R, et al. Age, race, and gender variation in the utilization of coronary artery bypass surgery and angioplasty in SHEP. SHEP Cooperative Research Group. Systolic Hypertension in the Elderly Program. J Am Geriatr Soc 1994;42:1143-9.
(7). Raine RA, Crayford TJ, Chan KL, et al. Gender differences in the treatment of patients with acute myocardial ischemia and infarction in England. Int J Technol Assess Health Care 1999;15:136-46.
(8). Perers E, Abrahamsson P, Bang A, et al. There is a difference in characteristics and outcome between women and men who suffer out of hospital cardiac arrest. Resuscitation 1999;40:133-40.
(9). Herlitz J, Rundqvist S, Bang A, et al. Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest? Resuscitation 2001;49:15-23.
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Conflict of Interest:
None declared.
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