Sex Disparities - Cardiac Risk Factors in Type 2 Diabetes
Objective: Diabetes eliminates the protective effect of female sex on the risk of coronary heart disease (CHD). We assessed sex differences in the treatment of CHD risk factors among patients with diabetes.
Research Design and Methods: A cross-sectional analysis included 3,849 patients with diabetes treated in five academic internal medicine practices from 2000 to 2003. Outcomes were stratified by the presence of CHD and included adjusted odds ratios (AORs) that women (relative to men) were treated with hypoglycemic, antihypertensive, lipid-lowering medications or aspirin (if indicated) and AORs of reaching target HbA1c, blood pressure, or lipid levels.
Results: Women were less likely than men to have HbA1c <7% (without CHD: AOR 0.84 [95% CI 0.75-0.95], P = 0.005; with CHD: 0.63 [0.53-0.75], P < 0.0001). Women without CHD were less likely than men to be treated with lipid-lowering medication (0.82 [0.71-0.96], P = 0.01) or, when treated, to have LDL cholesterol levels <100 mg/dl (0.75 [0.62-0.93], P = 0.004) and were less likely than men to be prescribed aspirin (0.63 [0.55-0.72], P < 0.0001). Women with diabetes and CHD were less likely than men to be prescribed aspirin (0.70 [0.60-0.83], P < 0.0001) or, when treated for hypertension or hyperlipidemia, were less likely to have blood pressure levels <130/80 mmHg (0.75 [0.69-0.82], P < 0.0001) or LDL cholesterol levels <100 mg/dl (0.80 [0.68-0.94], P = 0.006).
Conclusions: Women with diabetes received less treatment for many modifiable CHD risk factors than diabetic men. More aggressive treatment of CHD risk factors in this population offers a specific target for improvement in diabetes care.
Diabetes confers a markedly increased risk of coronary heart disease (CHD) events in both women and men and eliminates the protective effect of female sex on the risk of CHD. In women with and without diagnosed heart disease, diabetes raises the relative risk of heart disease mortality 3- to 10-fold relative to that of women without diabetes. Despite declining CHD mortality over the last 30 years in the U.S. population overall and in men with diabetes, women with diabetes appear to have experienced an increase in age-adjusted CHD mortality.
Several pathophysiological mechanisms may contribute to the increased risk of CHD mortality in men and women with diabetes. Patients with type 2 diabetes have an increased incidence of conventional and unconventional CHD risk factors. Women with diabetes may be subject to even more adverse changes in coagulation, vascular function, and CHD risk factor levels than diabetic men.
In addition to sex-based physiologic differences, there may also be differences in treatment of CHD risk factors that contribute to increased risk in women with diabetes. Several studies of patients without diabetes have demonstrated disparities in treatment of heart disease and CHD risk factors among women and men in primary care and hospital settings. Treatment disparities have been shown to be related to differences in patient risk factors and physician behavior. These differences may persist even after a problem is identified: when women receive treatment, they are often treated less aggressively.
Treating modifiable CHD risk factors (such as blood pressure and lipids) and using ACE inhibitors and aspirin reduce mortality in diabetes, which is now considered a CHD equivalent. The Heart Protection Study showed an ~25% reduction in vascular event rates in all subgroups treated with simvastatin, including patients with diabetes and women, regardless of initial levels of LDL and HDL cholesterol. In 2000, the American Diabetes Association (ADA) recommended statin therapy for patients with LDL cholesterol >100 mg/dl if CHD or multiple risk factors were present, as well as prophylactic use of aspirin and blood pressure control with an ACE inhibitor to delay progression to microalbuminuria. Subsequent recommendations are more stringent. The American Heart Association, concordant with the latest ADA guidelines, has endorsed an HDL target of >50 mg/dl and recommends that statins be initiated in women with diabetes, even if LDL is <100 mg/dl.
In light of these recommendations and the possibility of sex disparities in CHD risk factor control in the high-risk diabetic state, we sought to determine whether there were differences in the treatment of CHD risk factors in women compared with men in a large primary care cohort of patients with diabetes, stratified by presence of diagnosed CHD.
Objective: Diabetes eliminates the protective effect of female sex on the risk of coronary heart disease (CHD). We assessed sex differences in the treatment of CHD risk factors among patients with diabetes.
Research Design and Methods: A cross-sectional analysis included 3,849 patients with diabetes treated in five academic internal medicine practices from 2000 to 2003. Outcomes were stratified by the presence of CHD and included adjusted odds ratios (AORs) that women (relative to men) were treated with hypoglycemic, antihypertensive, lipid-lowering medications or aspirin (if indicated) and AORs of reaching target HbA1c, blood pressure, or lipid levels.
Results: Women were less likely than men to have HbA1c <7% (without CHD: AOR 0.84 [95% CI 0.75-0.95], P = 0.005; with CHD: 0.63 [0.53-0.75], P < 0.0001). Women without CHD were less likely than men to be treated with lipid-lowering medication (0.82 [0.71-0.96], P = 0.01) or, when treated, to have LDL cholesterol levels <100 mg/dl (0.75 [0.62-0.93], P = 0.004) and were less likely than men to be prescribed aspirin (0.63 [0.55-0.72], P < 0.0001). Women with diabetes and CHD were less likely than men to be prescribed aspirin (0.70 [0.60-0.83], P < 0.0001) or, when treated for hypertension or hyperlipidemia, were less likely to have blood pressure levels <130/80 mmHg (0.75 [0.69-0.82], P < 0.0001) or LDL cholesterol levels <100 mg/dl (0.80 [0.68-0.94], P = 0.006).
Conclusions: Women with diabetes received less treatment for many modifiable CHD risk factors than diabetic men. More aggressive treatment of CHD risk factors in this population offers a specific target for improvement in diabetes care.
Diabetes confers a markedly increased risk of coronary heart disease (CHD) events in both women and men and eliminates the protective effect of female sex on the risk of CHD. In women with and without diagnosed heart disease, diabetes raises the relative risk of heart disease mortality 3- to 10-fold relative to that of women without diabetes. Despite declining CHD mortality over the last 30 years in the U.S. population overall and in men with diabetes, women with diabetes appear to have experienced an increase in age-adjusted CHD mortality.
Several pathophysiological mechanisms may contribute to the increased risk of CHD mortality in men and women with diabetes. Patients with type 2 diabetes have an increased incidence of conventional and unconventional CHD risk factors. Women with diabetes may be subject to even more adverse changes in coagulation, vascular function, and CHD risk factor levels than diabetic men.
In addition to sex-based physiologic differences, there may also be differences in treatment of CHD risk factors that contribute to increased risk in women with diabetes. Several studies of patients without diabetes have demonstrated disparities in treatment of heart disease and CHD risk factors among women and men in primary care and hospital settings. Treatment disparities have been shown to be related to differences in patient risk factors and physician behavior. These differences may persist even after a problem is identified: when women receive treatment, they are often treated less aggressively.
Treating modifiable CHD risk factors (such as blood pressure and lipids) and using ACE inhibitors and aspirin reduce mortality in diabetes, which is now considered a CHD equivalent. The Heart Protection Study showed an ~25% reduction in vascular event rates in all subgroups treated with simvastatin, including patients with diabetes and women, regardless of initial levels of LDL and HDL cholesterol. In 2000, the American Diabetes Association (ADA) recommended statin therapy for patients with LDL cholesterol >100 mg/dl if CHD or multiple risk factors were present, as well as prophylactic use of aspirin and blood pressure control with an ACE inhibitor to delay progression to microalbuminuria. Subsequent recommendations are more stringent. The American Heart Association, concordant with the latest ADA guidelines, has endorsed an HDL target of >50 mg/dl and recommends that statins be initiated in women with diabetes, even if LDL is <100 mg/dl.
In light of these recommendations and the possibility of sex disparities in CHD risk factor control in the high-risk diabetic state, we sought to determine whether there were differences in the treatment of CHD risk factors in women compared with men in a large primary care cohort of patients with diabetes, stratified by presence of diagnosed CHD.
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