1. Ischaemic Heart Disease- Implications of Gender Dr Kaye Birks School of Rural Health Monash University Australia Gender Competency Training for Medical Educators Seminar, April 2003

2. Aims Describe differences between women and men Natural history Clinical presentations Management Outcome

3. Natural History of IHD Cause of death of approximately one third of women Greater age dependency Clinical onset is about 10-15 years later than for men

4. Natural History--Risk Factors young women Family history maternal IHD NIDDM Smoking risk for sudden death Isolated raised total cholesterol – less risk Obesity risk ? explained by co-morbidity

5. Clinical Presentations In women angina common first presentation [54%] v. men [38%] Recognised MI [18%] men [30%] More atypical symptoms Pain free MI in older diabetic women More non Q wave infarcts

6. Clinical Presentations Older Co-morbidities Unstable angina rather than acute MI Those with infarction less likely to have ST segment elevation

7. Outcome differences More likely to die The younger the women the greater the difference when compared to male cohort < 50 years twice as likely to die After CABG younger women mortality 3.4% v. men 1.1% Over 75 years no difference in mortality

8. Outcome differences ?why Women delay in going to hospital Missed diagnosis on admission Less likely to receive thrombolytic therapy More co morbidities Less likely to receive established treatments e.g. betablockers, aspirin Higher death rates for men before going to hospital

9. Outcome differences ?why Different pathophysiology in premenopausal women Plaque erosions in young women, plaque rupture in men and older women Young women have less narrowing of arteries ?hypercoaguable state or coronary spasm Transmural MI with normal coronary angiography

10. Management Diagnostic testing less specific in younger women Less likely to have coronary angiography When performed more likely to have clinically insignificant disease Less likely to receive primary preventive treatments

11. Summary Differences in natural history presentation management outcome

12. Summary Important to highlight these differences in the undergraduate curriculum