In Western countries, cardiovascular disease is the leading cause of death for women. Research has highlighted important gender differences in the prevention, diagnosis and treatment of these diseases. Diversity due not only to biological, but also social and cultural factors, which worsened during the Covid-19 pandemic. On the occasion of International Women’s Rights Day, Daiichi Sankyo Italia e Wave-Observatory Foundation National Women’s Health and Gender Healthcare initiative support the initiative ‘Female cardiology’: due training courses for doctors held by some of the most famous Italian cardiologists.
Scheduled in webinar format today March 8 and Wednesday 24, the two courses aim to “offer an in-depth study on the topic with a focus on the post-menopausal phase, on the incidence of thromboembolic stroke in women and the difference in the response to therapies – reads a note – also in relation to Covid-19 infection, for which heart disease itself represents one of the main risk factors “. The scientific reports are followed by a round table for women, for” a comparison on gender balance in the health sector, now considered a matter of health policy “.
Significant gender differences are known for numerous diseases from different specialist branches. In particular, however, “women have a particularly low perception of cardiovascular risk and they tend to underestimate the symptoms “, remind the promoters of the initiative. In addition”they often have clinical manifestations that are difficult to diagnose, tend to have greater complications and therefore worse prognosis, and use drugs studied on predominantly male samples, since especially in the development phase of a drug, reproductive life and comorbidities must be taken into account that make the woman a more problematic subject in the experimentation “.
The problem of gender differences in medicine it also concerns Covid-19. “They emerged from the early stages of the epidemic – he says Nicoletta Orthmann, medical-scientific coordinator of Fondazione Onda – Although the data on the ‘sindrome Long Covid’, the persistence of symptoms following the disease, are still small, already show that women are twice as likely to develop this complication. Several factors are called into question: not only hormonal and biological, but also socio-cultural, on which numerous studies are being conducted with the aim of identifying specific preventive and therapeutic strategies for men and women. Without forgetting that the social consequences of the pandemic in terms of unemployment, poverty and violence have hit women much harder “.
Going into the specifics of cardiovascular diseases, gender differences begin with risk factors. “The excess of risk produced by smoking, for example, in women is 2 to 4 times greater than that observed in men – it is highlighted in the note – and it has been shown that the strong association between arterial hypertension, early mortality and the onset of coronary heart disease is greater than in males and there is no threshold value below which the risk disappears “. of pathology and outcome, “men have about double the total incidence of morbidity and mortality compared to women among subjects aged 35 to 84, but the advantage is mitigated by a mortality rate from coronary attacks which exceeds the male one (32% vs 27%) “.
Yet, “it is more likely that myocardial infarction is not recognized in women than in men (34% vs 27%) “. Because” the differences are associated with the diagnostic difficulties often linked to the different clinical presentation of cardiovascular diseases in women – observes Battistina Castiglioni, director of the Cardiovascular Department and director of SC Cardiology – unit of Tradate, Asst Sette Laghi (Varese) – in addition to the lack of awareness by both doctors and patients of the specificity of cardiovascular disease in women “. Cinzia Valenti, head of the Cardiology Service of the Beato Matteo Clinical Institute (Vigevano, Pavia), “to consider a gender-specific diagnostic approach in cardiology is of primary importance, taking into account that cardiovascular diseases are among the main causes of death in women. Therefore, knowledge and awareness of cardiovascular disease in women and correct risk stratification are fundamental “.
Another “serious and long-neglected problem” in women is stroke, “although acute cerebrovascular disease represents the third cause of death in women (in men it is the fifth) – continues the note – and one in 5 women will experience a stroke in the course of her life, so much so that it is expected that in 2050, mortality from stroke will be 30% higher in females, due to their greater longevity. Female sex modifies epidemiology, expression of risk factors, clinical and prognostic characteristics of stroke that are modulated by changes in life The incidence of stroke is higher in women up to 30-34 years (+ 26%), lower in the intermediate age group (55-64 years, -60%), and then presents a progressive increase after menopause and get to be significantly higher after 75 years (75 years, + 50%) “.
“The increase in incidence in young women – the experts analyze – is due to peculiar or specific risk factors such as migraine with aura, estrogen-progestogen therapy and pregnancy. Furthermore, due to the greater frequency of atypical and rare onset symptoms, and for the lack of knowledge of the gender peculiarities of cerebrovascular manifestations both in doctors and in patients themselves women are at increased risk of misdiagnosis and delayed / missed recognition of stroke symptoms, which reduces the probability of using systemic and / or endovascular recanalization interventions capable of significantly and positively modifying the prognosis “.
“Unfortunately an important barrier still exists in understanding stroke in women, its effects and possible therapeutic interventions both in the acute and chronic phase, the cause of which is to be found in the lack of representation of women in clinical studies, but also for cultural and psychological reasons – reflects Anna Cavallini, Director of the Complex Unit of Emergency Neurology and Stroke Unit, Irccs Fondazione Mondino Pavia – Stroke in women is, however, an ‘impending epidemic’, and in the near future, priority must be given to research on stroke in to contain the socio-economic impact of this disease “.
The latest study proposed by the promoters of ‘Female Cardiology’ concerns gender differences in anticoagulation. “Atrial fibrillation – continues the note – is the major modifiable risk factor for stroke, cardiovascular disease and mortality. The risk of stroke in fibrillation, however, is heterogeneous between men and women; in fact, several studies have shown that women have an increased risk of stroke and a particularly high risk of bleeding compared to men, even during treatment with vitamin K antagonists. The use of new oral anticoagulant drugs, which compared to vitamin K antagonists are associated with a reduced incidence of intracranial haemorrhages, has been shown to be particularly safe and beneficial in women “.
“This is demonstrated, for example, by a pre-specified analysis of Engage Af-Timi 48, which – it continues – was aimed at evaluating the efficacy and safety profile of the direct oral anticoagulant edoxaban in women compared to men. 21,105 patients enrolled patients, of which 8,040 were women; compared to men, women were older, had lower body weight, were more likely to have hypertension and kidney dysfunction, but less likely to smoke, drink alcohol, have diabetes or coronary heart disease . Despite many differences in baseline characteristics between women and men, edoxaban at the recommended dosage has shown similar efficacy to warfarin between genders and a reduction in the risk of bleeding with an amplified benefit in women compared to men. “
“Understanding the gender differences in anticoagulation of patients with atrial fibrillation is important in establishing long-term preventative measures and guide the choice of the most effective and safe anticoagulant treatment, with a fundamental impact on early diagnosis and access to therapies, so as to improve clinical outcome “, concludes Piera Angelica Merlini, director of cardiologist Asst Grande metropolitan hospital Niguarda, Milan.