UBC Objectives: Women's Heath, UBC Objectives: Care of Men, Priority Topic: Gender Specific Issues & Priority Topic: Ischemic Heart Disease

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Recognize differences between genders with respect to pharmacology, disease prevalence, presentation laboratory screening and epidemiology
  

Gender Specific Issues

Key Feature 5: Interpret and apply research evidence for your patients in light of gender bias present in clinical studies (ex: ASA use in women).
Skill: Clinical Reasoning, Professionalism
Phase: Hypothesis generation

Ischemic Heart Disease

Key Feature 2: In a patient with modifiable risk factors for ischemic heart disease (ex: smoking, diabetes control, obesity), develop a plan in collaboration with the patient to reduce her or his risk of developing the disease.
Skills: Clinical Reasoning
Phase: Treatment

As a future family physician, a significant part of my role in the healthcare system will be to help patients understand the risks associated with cardiovascular disease (morbidity and mortality) and to assist patients to adopt behaviours that promote better health and quality of life. Ischemic heart disease is one of the cardiovascular diseases that has a large negative impact on the health of many, and very significantly so. In terms of mortality alone in developed countries, ischemic heart disease is responsible for at least one-third of the deaths in adults over the age of 35 (UpToDate). So what can be done to reduce one's risk of developing ischemic heart disease? The first part is helping patients understand what they can do to decrease their risk, and the second part is to promote those behaviours. The former is often done by use of a cardiovascular risk calculator if the patient is at least 40 years of age. According to UpToDate, "A number of multivariate risk models have been developed for estimating the risk of initial CVD events in apparently healthy, asymptomatic individuals based upon assessment of multiple variables. The choice of a specific risk model for CVD risk assessment should be individualized based on patient-specific characteristics (eg, age, gender, ethnicity).... While all of the risk models have advantages and disadvantages, no single risk model will be appropriate for all patients. We encourage clinicians to use a CVD risk calculator that has been locally endorsed and that has been validated for their locale and for patient-specific race and ethnic groups."

Much of our strong evidence in medicine, having been studied for many years, was first originally collected on Caucasian males. This is a historical reality. This fact that many of our most "robust" tools and knowledge are not generalisable to every patient in front of us means we have to exercise clinical judgment, recognize the variability among various subsets of the population for different disease processes, different disease presentations, and the need to investigate accordingly. Screening tools still can be very useful to provide guidance, but they are not the be all end all. Ultimately, it is what it is, but it is important to try not to be complacent and really consider whether or not medical algorithms truly fit the individual patient. 

In Canada the most commonly accepted CVD risk calculator for the general population is the Framingham Risk Score (and yes, it is based on a cohort of middle-aged white men). After calculating a patient's risk and presenting them with the information, encouraging the behaviours that decrease their risk of acquiring cardiovascular disease is then as straightforward and as challenging as you'd think.

1. Eat well
2. Be active 
3. Don't smoke
4. Don't engage in heavy alcohol use
5. Maintain optimal control of the following chronic medical conditions: hypertension, dyslipidemia, obesity, and diabetes mellitus

Piece of cake (that you can't eat).