Gender bias in the clinical management of women with angina: another look at the Yentl syndrome.

BACKGROUND: Woman with heart disease may receive lower levels of clinical care than men. We assessed whether the Yentl syndrome (women receive equivalent care to men only when they demonstrate that they are like men by having a heart attack) operates in the management of angina pectoris in primary care. METHODS: The study design is a cross-sectional survey of 1162 angina patients (552 women) managed in eight sentinel centers serving 15% of the population of Liverpool. Data were extracted by specially trained data managers. Analysis included directly age-standardized proportions and male/female adjusted odds ratios (AOR), adjusted for age, disease duration, physician consultation rate, and age at diagnosis. RESULTS: All aspects of care were higher for men with angina-previous myocardial infarction (MI) than for women with angina-previous MI. Risk factor recording was an absolute 8% higher (95% CI 1%-17%), secondary prevention 9% higher (95% CI 1%-17%), cardiac investigation 10% higher (95% CI 1%-20%), and revascularization 13% higher (95% CI 4%-22%). Men with angina-previous MI consistently received the highest level and women with angina the lowest level of risk factor recording (AOR 1.79, 95% CI 1.21-2.66), secondary prevention (AOR 2.24, 95% CI 1.47-3.40), cardiac investigation (AOR 2.21, 95% CI 1.56-3.13), and revascularization (AOR 4.67, 95% CI 3.03-7.18). The provision of care to men with angina alone and women with angina-previous MI fell between these two extremes. CONCLUSIONS: A gender-based clinical hierarchy operates in the clinical management of angina pectoris in primary care. The Yentl syndrome did not apply, however, as women with angina received less intensive clinical care than similar men irrespective of prior MI.

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care.

BACKGROUND: Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care. METHODS: A cross-sectional survey undertaken in 8 sentinel centres serving 63,724 individuals in the city of Liverpool (15% of the city population). Aspects of clinical care assessed included: risk factor recording (smoking, cholesterol, blood pressure, body mass index); secondary prevention (aspirin, beta-blocker, statin); cardiac investigation (exercise ECG, perfusion scanning, angiography); and revascularisation (percutaneous coronary intervention, coronary artery bypass grafting). Male-to-female adjusted odds ratios (AOR) were calculated (adjusted for age, angina duration, age at diagnosis and previous MI) using logistic regression. RESULTS: 1,162 patients (610 men; 552 women) with angina were identified. Women were older than men (71 vs 67 years), with a shorter duration of angina (6 vs 7 years), and a lower prevalence of previous MI (25% vs 43%). Men were significantly more likely than women to undergo detailed risk factor assessment (AOR = 1.35, 95%CI 1.06 to 1.73); receive 'triple' secondary prevention with aspirin, beta-blockers and statins (AOR = 1.47, 95%CI 1.07 to 2.02); access exercise ECG testing (AOR = 1.31, 95%CI 1.02 to 1.68); angiography (AOR = 1.61, 95%CI 1.23 to 2.12); and undergo coronary revascularisation (AOR = 1.93, 95%CI 1.39 to 2.68). CONCLUSION: Systematic gender differences exist in the comprehensive clinical management of patients with angina in primary care.