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Original Investigation
April 21, 2021

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

Author Affiliations
  • 1Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
  • 2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 3Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 4Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
  • 5Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
  • 6Department of Medicine, The Aga Khan University, Karachi, Pakistan
  • 7Department of Medicine, Cardiology Division, Hoag Memorial Hospital, University of California at Irvine
  • 8Department of Medicine, West Virginia University, Morgantown
  • 9Division of Cardiovascular Medicine, University of Florida, Gainesville
  • 10Department of Veterans Affairs Medical Center, Gainesville, Florida
  • 11Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
JAMA Cardiol. 2021;6(7):782-790. doi:10.1001/jamacardio.2021.0683
Key Points

Question  In young patients with premature atherosclerotic cardiovascular disease (ASCVD), how are sex-based differences associated with use of antiplatelets and statins?

Findings  In this cross-sectional study, women veterans with premature ASCVD (≤55 years) and extremely premature ASCVD (≤40 years) were less likely to receive antiplatelet agents or statins than men. Additionally, women with premature ischemic heart disease were comparatively less statin adherent.

Meaning  In this study, women veterans with premature and extremely premature ASCVD received poorer secondary prevention care; hence, a systematic approach toward health care delivery improvement and patient education is necessary to narrow this health care disparity for women.


Importance  There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.

Objective  To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

Design, Setting, and Participants  This was a cross-sectional, multicenter, nationwide VA health care system–based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).

Exposures  Women vs men with premature and extremely premature ASCVD.

Main Outcomes and Measures  Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8).

Results  We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: −0.02; 95% CI, −0.03 to −0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD.

Conclusions and Relevance  This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.

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    1 Comment for this article
    Sex or Gender?
    J David Spence |
    Surely these are gender differences, not sex differences. They may relate to the gender of the prescribing physicians vs. the patients, or to the gender of the patient, or both - but they are unlikely to be sex differences.

    WHO definitions: http://www.who.int/gender/whatisgender/en/
    "Sex" refers to the biological and physiological characteristics that define men and women.
    "Gender" refers to the socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women.

    NIH definitions: https://orwh.od.nih.gov/sex-gender
    “"Sex" refers to biological differences between females and males, including chromosomes, sex organs, and endogenous hormonal
    profiles. "Gender" refers to socially constructed and enacted roles and behaviors which occur in a historical and cultural context and vary across societies and over time. All individuals act in many ways that fulfill the gender expectations of their society. With continuous interaction between sex and gender, health is determined by both biology and the expression of gender.”