Systematic Review and Meta-analyses Investigating Whether Risk Stratification Explains Lower Rates of Coronary
Linda Worrall-Carter1, Samantha McEvedy, Lisa Kuhn
1Linda Worrall-Carter, PhD, BEd, Med(Prelim), RN Founder and CEO, Her Heart Ltd; Director, St Vincent's Centre for Nursing Research (SVCNR) and The Cardiovascular Research Centre (CvRC), Australian Catholic University; and St Vincent's Hospital, Melbourne, Australia. Samantha McEvedy, LLB Research Associate, SVCNR, Australian Catholic University, Melbourne, Australia. Lisa Kuhn, PhD, MHSc (Nursing), RN Research Fellow, Deakin University, Melbourne, Australia. Elizabeth Scruth, PhD, MPH, RN Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Andrew MacIsaac, MD, FRACP Director of Cardiology Services and Deputy Chief Medical Officer, St Vincent's Hospital and The University of Melbourne, Melbourne, Australia. Muhammad Aziz Rahman, PhD, MPH, MBBS Senior Research Fellow, SVCNR and CvRC, Australian Catholic University; and The Mary MacKillop Institute for Health Research, Melbourne, Australia.
Background:
Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category.
Objectives:
The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography.
Methods:
PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective.
Results:
Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations.
Conclusions:
Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.
