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Page 8 of 17 Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112

After revascularization, routine statin and anti-platelet therapies prevent cardiovascular disease
[70]
progression . Further anticoagulation may be desired for LV thrombus, AF, and after surgical ventricular
[3]
restoration . HFrEF is managed with foundational quadruple medical therapy of angiotensin-converting
enzyme inhibitor, angiotensin type II receptor blocker, or preferentially angiotensin receptor neprilysin
inhibitor; beta-blocker; mineralocorticoid receptor antagonist; and sodium-glucose co-transporter 2
[71]
inhibitor . Despite a similar predominance of White men in the enrollment of landmark heart failure
trials, equivalent GDMT efficacy in women and men has been shown through meta-analysis .
[72]
Underprescription of GDMT remains an issue, but there may be no significant racial disparity in
prescription patterns; in fact, Black patients are more likely to achieve the target dose due to baseline
hypertension [73,74] . Patients with poor LVEF recovery are followed closely for chronic issues of cardiorenal
syndrome, congestive hepatopathy, pulmonary hypertension, and evaluation of candidacy for advanced
heart failure therapies.

DISPARITIES IN MANAGEMENT AND OUTCOMES OF CAD WITH REDUCED LVEF
There is growing evidence pointing to various psychosocioeconomic disparities that impact the prevalence,
prognosis, access to care, and outcomes of patients with ICM. Social factors that have been associated with
differential prevalence of CAD and resulting outcomes include sex, gender, race, ethnicity, socioeconomic
status, social isolation, and stressful lifestyles [75-78] .

Women with CAD commonly present with atypical symptoms, such as abdominal discomfort and
heartburn, nausea or vomiting, and fatigue or dizziness, while women with acute coronary syndrome (ACS)
tend to present at an older age with more comorbidities, including obesity, smoking, depression,
hypertension, diabetes, and chronic kidney disease, compared to men [79-87] . At hospital presentation, they
[88]
experience delays in diagnostic testing (duration to ECG: 7.5 min vs. 5.7 min in men) , and are less likely
to receive evidence-based treatment, including dual antiplatelet therapy (89% vs. 93.5%; P < 0.001), heparin
(66.7% vs. 71.2%; P < 0.001), or reperfusion therapy with fibrinolysis and/or PCI (50.2% vs. 59.5%; P < 0.001).
Women also experience higher in-hospitality mortality rates than men, even after adjusting for age and
[89]
clinical variables (adjusted OR 1.20 [1.01-1.43]) . According to the Framingham Heart Study, despite
women being associated with fewer diagnoses of obstructive CAD (≥ 50% stenosis), women with obstructive
[90]
CAD are at higher risk for 30-day (RR 1.75 [1.48-2.07]) mortality compared to men . They are also at a
greater risk of developing symptomatic heart failure without an antecedent MI (RR 11.4% [9.6%-13.2%]) for
men and 15.4% [13.5%-17.3%] for women) [87,90] . The incidence of CAD rises in menopausal/post-
menopausal compared to pre-menopausal women (age 45-54 years: OR 2.5; P < 0.01) .
[91]
The incidence of CAD per 1,000-person years is impacted by patients’ race, gender, and comorbidities:
Black women 5.1% [4.2-6.2], Black men 10.6% [8.9-12.7], White women 4.0% [3.5-4.6], and White men
12.5% [11.5-13.7] . Hypertension is significantly associated with CAD in Black women (HR 4.8 [2.5-9.0]),
[92]
[92]
while diabetes mellitus is predictive among White women (HR 3.3 [2.4-4.6]) . Further, racial and/or ethnic
minority patients present with ACS at a younger age (66 years vs. 73 years old; P < 0.001) with multiple
comorbidities including hypertension (66% vs. 54%; P < 0.001), hypercholesterolemia (49% vs. 34%;
P < 0.001), and diabetes (48% vs. 24%; P < 0.001) compared to White patients [93,94] . White patients with ICM
are more likely to get admitted for invasive diagnostic testing compared to Black, Asian, and Indigenous
[95]
patients in the United States (P < 0.01) . Once diagnosed with ICM, the use of implantable cardioverter-
defibrillator among women (3.5% vs. 10.2%; P < 0.001) and Black patients (5.4% vs. 8.1%; P < 0.001) is
significantly lower compared to men and White patients, respectively [96,97] . In addition, while GDMT for
heart failure is underprescribed for all racial and ethnic groups, Black patients with hFrEF are more likely to
get discharged with optimal GDMT , particularly β-blockers (OR 1.45, 95%CI: 1.10-1.90; P = 0.008) and
[98]