Nov 18, 2019
Show Notes for Episode Twelve of seX & whY: Sex and
Gender Differences in CPR Part 3
Host: Jeannette Wolfe
Guest: Dr Justin Morgenstern
Here is a link to Justin Morgenstern’s awesome
First10EM blog site where you can find an excellent review of
the two papers that we discussed today: Perman’s DNR paper and
Huded’s
Cleveland Clinic Study on gender gaps in 30 day survival after
ST elevation myocardial infarctions.
Here are some take home points for this podcast:
- We don’t know what we don’t study and when we don’t consider
sex and gender as legitimate variables, we can inadvertently miss
opportunities to improve the health of all of our patients.
- There appears to be lots of sex-based
differences in cardiac
electrophysiology
- females are more prone to AV nodal re-entrant arrhythmias, sick
sinus syndrome, prolonged QTc and postural orthostatic tachycardia
syndrome
- males are more prone to AV block, early repolarization,
Brugada’s syndrome, accessory pathway-mediated arrythmias,
idiopathy ventricular arrhythmias and dangerous arrythmias
associated with arrhythmogenic right ventricular
cardiomyopathies
- In many ways, biological sex represents a much
“cleaner” variable to study in that most of us have a sex specific
chromosomal pairing and hormonal cocktail that allows us to be more
easily placed into a binary male or female category.
- Biological sex differences are often detected and treated by
tweaking technology- adjusting the results of a blood test or using
a different type of imaging modality to account for sex based
physiologically differences.
- Biological sex is akin to the variable of age- its importance
is related to context. Although a 15 year and 50-year-old may get
the same evaluation for an ankle sprain they should not get the
same evaluation for chest pain. Similarly, how females and males
react to any particular treatment may or may not be associated with
a clinically important difference.
- As the science of earnestly studying males and females side by
side is still so new, we are just beginning to understand where
differences actually exist and in what contexts they are clinically
relevant.
- As the influence of gender can be quite subtle and often
involves many touchpoints, recognizing and fixing gender-based
differences can be challenging. For example, here is how an
individual’s gender might influence what happens to them if they
have a heart attack.
- Whether they live alone
- If and when they call an ambulance
- If they come in by car, how quickly they are triaged
- Where they are geographically placed in the department
- How they describe their symptoms
- How their symptoms are perceived by providers (which in turn
may be confounded by provider gender)
- How quickly an EKG is done
- How comfortable they are with procedural consent
- How quickly they go to the cath lab
- When and what type of medications they are prescribed
- Who they are referred to for follow up
- Whether they are compliant with their new meds or
appointments
- Whether they are referred to and participate in cardiac
rehab
- Currently, I suspect that most of us in medicine would likely
acknowledge that there are some legitimate examples out there of
gender and race- based health inequities. The next step, however,
requires an acknowledgement that those inequities are not just
happening somewhere else, but that they have also likely
creeped into our own practices. This can be difficult because it
directly threatens our explicit belief that we deliver “the same”
excellent care to all of our patients.
- Recognizing and mitigating gender disparities, especially those
related to implicit bias, requires deep self-reflection along with
an individual and organizational commitment to actually want things
to change.
- Solutions include wide-spread “no-blame” educational forums and
the development of technical safeguards to help reduce
unintentional bias. For example, the creation of default “opt in”
disease specific order sets and operational checklists.
Here is a table that shows outcome data from Bosson’s
JAHA paper from LA County data base that we briefly mentioned on
the podcast.
| |
Men
|
Women
|
|
CPR
|
41%
|
39%
|
|
shockable
|
35%
|
22%
|
|
STEMI
|
32%
|
23%
|
|
Cath
|
25%
|
11%
|
|
TTM
|
40%
|
33%
|
|
Survival/CPC 1-2
|
24%
|
16%
|
Other studies discussed.
European
study that examined sex-differences in atrial fibrillation
study
Danish
study on cardiac arrests in people less than 35 with 2 to one
ratio of men to women
Korean eunuch study suggesting that a historical lineage of
castrated males outlived several socioeconomically matched peers,
supporting the concept of a disposable soma theory.
Cleveland Clinic informational sheet on arrhythmias in
women
Study that suggests more women than men die or go to hospice
after an intracranial hemorrhage and brings up idea of gender-based
differences in “social capital” contributing to this difference
EOL choices in advanced cancer patients showing gender
differences in palliative care and DNR preferences