Under-treatment of women with acute coronary syndrome appears to be related to unrecognised risk

Abstract

Background: Studies continue to document that, compared to men, women presenting with acute coronary syndromes (ACS) receive fewer guideline-based therapies. This has previously been explained by a greater prevalence of co-morbidities. However whether clinical assessment of risk influences this practice is unknown. Objective: To evaluate if physicians underestimate risk of adverse events following ACS in women as compared to men. Methods: PREDICT was a multi-national, multi-centre, prospective, cross-sectional, non-interventional study. Clinicians completed a perceived risk questionnaire to estimate expected risk of death and recurrent ischaemic events associated with no therapy and each of the guideline-recommended therapies for ACS. This was performed as early as possible, and prior to diagnostic angiography, in ACS patients. Physician estimated risk was contrasted with the GRACE risk score calculated in each patient as an objective measure of risk. Results: The Australian cohort included 828 observations of 419 patients. The median time from graduation of physicians was 9.5 years. The physician predicted risk of death by six months was significantly lower for women than men (12 versus 15%, P = 0.006). The objectively measured GRACE risk score was significantly higher in women than men (132 versus 127, P = 0.043). A regression plot demonstrated a lower physician estimated risk for women than men, across the spectrum of GRACE calculated risks. Conclusions: This is the first study objectively demonstrating the underestimation of risk in women with ACS and may in part explain their under-utilisation of guideline-based therapies. This supports the routine use of formal risk scores in assessing ACS patients.<br />