Female Veterans Experience Poorer CV Care, Worse Mortality Rates Than Males


New data show female veterans receive poorer secondary prevention care in treating premature and extremely premature atherosclerotic cardiovascular disease, compared to male veterans.

A recent study analyzed data on veterans with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), finding female veterans received poorer secondary prevention cardiovascular (CV) care in comparison with male veterans.

Investigators, led by Salim S. Virani, MD, PhD, of the Health Services Research and Development at the Michael E. DeBakey Veterans Affairs Medical Center, found women with premature ASCVD were also less adherent to statins and have comparatively higher mortality rates than men.

ASCVD is the leading cause of death worldwide, with an event being defined as ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), or peripheral arterial disease (PAD).

For patients with ASCVD, secondary prevention optimization is necessary in reducing disease burden, psychosocial effects and financial costs for the patient.

However, there is a lack of data in comparing secondary prevention between men and women with premature (≤55 years) and extremely premature (≤40 years) ASCVD.

Investigators sought to observe sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

The Study

The team conducted a retrospective cohort study of the national Veterans Affairs (VA) electronic medical record system and clinical data sets during 2015. Patients with ASCVD who received care from at least 1 of 30 VA facilities or an associated outpatient clinic were included in the trial.

Investigators identified 1,248,158 ASCVD patients, aged 18 years or older at the time of assessment. Patients needed at least 2 outpatient diagnoses for ASCVD or 1 procedural code for percutaneous intervention.

The team created the Veterans with Premature Atherosclerosis (VITAL) nationwide registry, to determine age cutoff parameters of premature and extremely premature ASCVD patients.

Investigators created 3 phenotypes for each ASCVD subtype (IHD, ICVD, PAD):

  • IHD included acute coronary syndrome, chronic coronary artery disease, and coronary revascularization.
  • ICVD included transient ischemic attack or stroke, and cerebral revascularization.
  • PAD included intermittent claudication, peripheral arterial occlusion, and peripheral revascularization.

The study defined antiplatelet use as patients with an active prescription of aspirin. They excluded patients prescribed anticoagulants.

HIS therapy referred to 40 mg atorvastatin prescriptions or 20 mg rosuvastatin.

Statin adherence assessed proportion of days covered (PDC) and calculated supply divided by total days in a period.

A multivariable regression associated antiplatelet use, any statin and HIS use, and statin adherence in the comparison of males and females.


The cohort analysis included 147,600 patients of the original patient identification with premature ASCVD (10,413 women and 137,187 men).

Women were younger with a mean age of 48 years and had a higher proportion of African American patients, compared to Asian and White patients.

The study found that women had a higher rate of ICVD at 41.8% (n = 4355) compared to men at 26.2% (n = 35,964), as well as major depressive disorder (MDD) and/or PTSD at 54.8% (n = 5711) versus 38.4% (n = 52,681).

A regression analysis found that women with premature ASCVD had a significantly lower likelihood of receiving antiplatelet treatment compared to men, 61.3% versus 79.2% (95% CI, 0.56 - 0.61).

This lower rate continued with any statin in the study, at 57.5% versus 75.1% (95% CI, 0.56-0.61) and HIS therapy, at 23.5% versus 38.1% (95% CI, 0.60 – 0.67).

Women also received less antiplatelet agents, statins and HIS in patients with premature ICVD and premature PAD.

Investigators identified 9485 patients, including 1340 women and 8145 men, with extremely premature ASCVD. Women were again younger with a mean age of 34.5, with a higher proportion of African American patients compared to White and Asian patients.

The team found that in the extremely premature ASCVD group, women received less antiplatelet treatment at 37.7% versus 56.5% (95% CI, 0.53 - 0.70), statins at 29% versus 52.3% (95% CI, 0.44 - 0.58), and HIS therapy at 10.4% versus 27.2% (95% CI, 0.37 - 0.54) compared to men.


Investigators concluded that women with premature and extremely premature ASCVD have a significantly less likelihood of receiving antiplatelets, statins or HIS therapy in comparison with men. The differences remain after adjusted differences regarding clinician and socioeconomic factors.

The team also observed suboptimal secondary prevention therapy in all patient groups, which they believe may be attributed to clinician’s perception of ASCVD risk groups, especially in women with extremely premature ASCVD.

“Such diagnostic inattentiveness toward young patients may result in higher thresholds to initiate or escalate care, resulting in a phenomenon called clinical therapeutic inertia,” investigators wrote.

Despite the increased attention on women’s CV health in the past 2 decades, the team wrote there are gaps in health care delivery for women, particularly in secondary prevention for ASCVD.

“As exact reasons for sex-based heterogeneity in premature and extremely premature ASCVD remain unclear, further investigation and outcomes research are needed to elucidate potential causes and effective solutions,” investigators wrote.

The study, “Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease,” was published online in JAMA Cardiology.

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