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November 25, 2003
News this month Researchers have found that women with heart arrhythmias are referred for radiofrequency (RF) catheter ablation therapy significantly later than male patients. Women…were referred an average
of 28 months later than men for the treatment.
With a success rate exceeding 90 percent, ablation therapy has become the standard treatment for a variety of arrhythmias. The procedure entails having catheters threaded through veins or arteries to the site of the abnormal electrical pathway responsible for the arrhythmia. The catheter emits high frequency radio waves that burn or sever the source of abnormal heart rhythms. The study, published in the Journal of the American College of Cardiology, reports that women with the same or more severe symptoms as men were referred an average of 28 months later than men for the treatment. Study author Nikolaos Dagres, a cardiologist practicing in Muenster, Germany, and his colleagues looked at 894 patients, 418 men and 476 women, who had the treatment at the Hospital of the Westfaelische Wilhelms-University during a 43-month period. In addition to being referred later, women patients had been given more anti-arrhythmic drugs and at the time of referral, women were more symptomatic with a higher number of patients (80 percent of women compared to 70 percent of men) experiencing frequent tachycardia episodes, more than once a month. Gender did not affect the procedure’s success (93 percent for the men and 95 percent for the women); significant complication rates (1.1 percent for both men and women); or recurrence rates (10 percent for men and 7.3 percent for women). No procedure-related deaths occurred in either group. Why the difference? Gender did not affect the procedure's
success; significant complication rates; or recurrence rates.
This premise is supported by the findings of the comparisons between male and female patients based on their electrocardiogram (ECG) results. In cases where patients had abnormal ECGs, there was no time-to-referral difference between genders. In cases where patients had normal ECGs, men were much more likely to be referred for ablation therapy sooner than women. Many patients with intermittent arrhythmias can have normal ECGs. When people have abnormal ECGs, the possibility for physician bias is reduced, but in the absence of an abnormal ECG, physicians may have considered symptoms to be psychosomatic in origin. The authors also speculated that women may delay having medical procedures for other reasons such as concerns about safety and child care, a predisposition to tolerate symptoms more than men or because they consider themselves less important than men consider themselves. Other gender differences exist in heart care Also women with heart attacks have a longer prehospital delay
and undergo less noninvasive and invasive procedures than men. 
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RF ablation is treatment of choice, regardless of gender Radiofrequency catheter ablation treatment has been available for more than a decade, and it has proven to be a very safe, very effective therapy for people with cardiac rhythm disturbances. “Radiofrequency catheter ablation.
. .has proven to be a very safe, very effective therapy for people
with cardiac rhythm disturbances.”
Prior to its introduction, medications and open-heart surgery were the only alternatives. Surgery represented a major step in our understanding of arrhythmias, and it offered the potential of a cure to patients, but physicians were justifiably conservative in referring patients—often very young patients—for major surgery with its attendant risks. Opting for RF ablation For patients with potentially fatal disorders such as Wolff-Parkinson-White Syndrome, choosing ablation therapy is a relatively clear decision. Other patients, such as those with AV nodal reentrant tachycardia, who are able to control infrequent symptoms, may opt not to undergo the procedure. Many of these patients are able to control episodes of rapid heartbeat with Vagal maneuvers, such as coughing or bearing down, which stimulate the vagus nerve, resulting in slowed conduction of electrical impulses through the AV node of the heart. The German study How do we explain the difference in those cases? As the study authors say, there may be several forces at work.
I suspect there are many factors at work that result in less aggressive care for women. Diagnosing tachycardia “Symptoms of tachycardia include
palpitations, shortness of breath, dizziness and feelings of anxiety.”
Symptoms of tachycardia include palpitations, shortness of breath, dizziness and feelings of anxiety. Individuals have differing sensitivities to what’s going on with their heart. Some people are very clear and can describe their experience in detail. For example, one patient may report when he’s sitting watching television, his heart beat may suddenly race up to 150 beats per minute. Others might describe the same situation as having occasional heart flutters. In the absence of an abnormal electrocardiogram (ECG), it takes some detective work to determine if a patient's symptoms are related to an arrhythmia. The more specific an individual can be in describing his/her experience, the less likely the symptoms will be dismissed as anxiety. Patients may not experience symptoms during an ECG and may have no symptoms during a 24-hour holter monitor test. We are more likely to use an event monitor, which patients keep for a month or longer to record symptoms when they have them. The longer the sampling time, the more likely an event will be recorded. Risks and benefits The risks are small but they exist. There are some risks of bleeding and infection at the catheter insertion site or of damage to the vein or artery. There is a small risk of puncturing the heart or nicking the lung, and there’s a small risk of blood clots and stroke. There’s also a chance—if the normal and abnormal electrical pathways are close together—of damaging the normal pathway. In this case, a pacemaker would be needed. The most significant finding from this study is that the outcomes
for people treated with RF ablation are the same for both men
and women. It is a very effective, safe therapy and it should
be recommended for both men and women. Dr. Rosenfeld is an attending electrophysiologist at Yale-New Haven Hospital and an associate professor of medicine and pediatrics at the Yale University School of Medicine. |
