HEALTH / Second Opinion

THE MEDICAL treatment of a sore throat or a sprained ankle is just the same whether the patient is a man or a woman. Heart disease may be another matter. In the past year or two, doctors have been accused of being less willing to offer high-technology investigations and treatments to women with coronary heart disease than to men.

Studies in the United States and Britain have shown that four times as many men as women have measurements of the blood flow in their coronary arteries, and that many more men have coronary bypass operations. Most of the research on heart disease has been carried out on men.

Of course, the simple answer is that middle-aged men are much more prone to heart disease than women. In Glasgow, for example, the death rate for men aged 35-64 from coronary heart disease is 12.4 per 1,000 whereas in women it is only four per 1,000.

But even when this is taken into account, differences persist; analysis of the treatment given in hospital to men and women admitted after having had heart attacks shows higher rates of surgery for men.

So do women have less severe heart disease? Apparently not, or at least not those admitted to hospital - they have a higher mortality rate than men. In one study, the mortality rate within one year of admission for a heart attack was 25 per cent for men and 32 per cent for women. According to the British Heart Journal, this is partly because men are more likely to die within an hour or so of the start of their chest pain and so more die before they reach hospital, whereas more women die after admission.

Outside hospital, many more women than men seem to have relatively mild forms of heart disease such as angina (pain in the chest on exertion), but fewer have heart attacks from blood clots in the coronary arteries.

In full-scale investigations of men and women with heart disease, the coronary arteries are reported as normal more often in women: in one study half the women but only 17 per cent of the men had arteries described as normal. On the other hand, the smaller proportion of women who do have heart attacks tend to have bad ones with a high mortality rate.

Until fairly recently, the medical response to people with angina but normal arteries was the unhelpful: 'The test results are normal, so you have nothing to worry about.' An effective treatment has now been found, but the bad news is that it involves the antidepressant drug, imipramine.

A report in the New England Journal of Medicine described a clinical trial of 60 patients, two-thirds of them women, who had been investigated for coronary heart disease and found to have normal arteries. Treatment with imipramine substantially reduced the frequency of attacks of chest pain. The authors rejected the explanation that their patients' chest pain was due to some psychiatric disturbance, preferring instead the possibility that the drug has a direct pain- relieving action on the heart.

Ultimately, the most important message from recent research is less to do with gender differences than that heart disease in men and women takes several forms, each probably requiring different treatment.-