Orlando， FL –治疗充血性心力衰竭（CHF）-心脏不能有效将血泵入身体其他器官的状态-其治疗效果不仅仅与病人的性别有关系，研究发现与治疗的医生的性别也有关系。来自2009年ACC会议的心血管用药分会上，报道了有关心血管病医生和心血管病专家的最新发现。

    尽管先前有很多关于性别对心血管疾病的药物治疗和存活率方面的研究，但是这是第一次证实医生性别对治疗决定的影响的研究。总的来说，女医生对CHF患者的用药对指南的遵循较好。无论患者是男性还是女性，女医生在决定给药的种类和剂量上没有偏倚；但是，男医生则不然，他们倾向于使用较少的药物，尤其对于女患者，他们倾向于应用低于理想剂量的药物。
“我们发现医生性别的不同，可产生对充血性心力衰竭治疗上的较小但是却又显著性差异的区别。医生们应当了解并注意到这种性别相关的治疗偏倚，”来自德国洪堡Saarland大学医院的Magnus Baumhakel医生认为，“所有的患者均应当受到最好的治疗，而不应当有性别上的差异。但是不幸的是，循证医学的用药似乎对男性患者有益，尤其是ACEI类和β-受体阻滞剂的合理应用。”

    大量证据表明女性患者的治疗较男性患者不足。与同等病情的男患者相比，女性患者的治疗不仅仅是剂量较小，而且最佳的药物治疗也显不足，例如ACEI和β-受体阻滞剂的使用。一个男医生对女患者应用ACEI和β-受体阻滞剂的使用率较男医生或者女医生对一个男患者的使用率显著降低。无论男医生，还是女医生，对于一个男患者的β-受体阻滞剂的剂量应用没有差异，但是男医生给女患者的β-受体阻滞剂的剂量却显著降低。

    该研究纳入德国的一些研究中心的1857例连续的CHF患者。患者的并存疾病、纽约心功能分级、目前用药以及ACEI和β-受体阻滞剂的应用剂量是可比的。治疗记录里包括829名医生，分析他们按照循证医学用药的情况。所有医生的专业男女之间没有统计学差异(63.2%男医生 vs. 68.0%女医生 全科医生， 29.0%男医生 vs. 25.7%女医生 内科医生， 7.8%男医生vs. 6.2%女医生 心脏病学医生， p=0.105)，其从事医疗行业的时间男女医生也无显著性差异(男医生：23.9±9.1年， 女医生：23.5±8.8年)。仅全科医生和专科医生有较小的差别。

    尽管所有的治疗均较好—大部分患者接受了ACEI和β-受体阻滞剂治疗，处方剂量均尚不足。大约有一半的患者ACEI类药物的应用剂量是指南推荐剂量的75%，而仅有25%的患者β-受体阻滞剂的应用剂量可达到指南推荐剂量的75%以上。

    “我们知道，更高的剂量对于改善症状和降低患者死亡率是有好处的，” Baumhakel说，“因为目前的治疗效果还是很好的，我们并不赞成患者更换他们的医生。只是，需要提醒所有的临床医生，尤其是男医生，应当提高对循证医学的遵循程度。”

（张丽洁 吕树铮 首都医科大学附属北京安贞医院）
 

英文原文：

INEQUITIES IN TREATMENT OF HEART FAILURE BASED ON GENDER
Clinician’s Gender Plays Important Role in Drug Therapy Selection

Orlando， FL – Treatment of chronic heart failure (CHF) – a condition in which the heart can’t pump enough blood to other organs in the body – appears to be influenced not only by a patient’s gender， but also by that of the treating physician， according to research presented today at the American College of Cardiology’s 58th Annual Scientific Session. ACC.09 is the premier cardiovascular medical meeting， connecting cardiologists and cardiovascular specialists to the latest and most innovative findings in cardiovascular science.

While a number of studies have examined the impact of gender on the provision of medical care for and survival of heart disease， this is the first to show that a physician’s gender may sway treatment decisions. Overall， female doctors are better at recommending guideline-recommended drug therapy when taking care of patients with CHF. Female physicians do not differentiate whether their patients are male or female when determining the type of drug therapy or dosages， whereas male physicians tended to use less medication overall and recommended lower than ideal doses in female patients. 

 “We found a small， but statistically significant difference in treatment of chronic heart failure with regard to physician gender. Physicians should be aware of possible gender-related treatment biases，” said Magnus Baumhakel， M.D.， of the University Hospital of the Saarland， Homburg， Germany. “All patients should receive the best treatment for their disease and symptoms irrespective of gender. Unfortunately， the use of evidence-based drug treatments among these patients appears to favor men， especially when it comes to the appropriate use of ACE inhibitors and dosage of beta-blockers.”

The data provide mounting evidence that women tend to be treated less intensively than men. Not only were doses lower among females patients， but these patients were also less likely to receive optimal drug therapy， such as angiotensin-converting enzyme (ACE) inhibitors or beta-blockers， compared to their male counterparts. The use of ACE inhibitors or beta-blockers was significantly lower in female patients treated by a male physician than in male patients treated by either a female or male physician. Dosage of beta-blockers was comparable in male patients irrespective of the physician’s gender， whereas female patients treated by a male physician received the lowest doses.

The study involved 1，857 consecutive patients with CHF treated at the centers in Germany. Patients were found to be comparable based on an evaluation of comorbidities， the New York Heart Association international classification of heart failure symptoms， current medical treatment， as well as specific dosages of ACE inhibitors and beta-blockers. Treatment records involving 829 physicians were analyzed with regard to use of evidence-based drug treatments and dosages proven to improve survival. Treating physicians did not differ by specialization (63.2 percent male vs. 68.0 percent female general practitioners， 29.0 percent male vs. 25.7 percent female internists， 7.8 percent male vs. 6.2 percent female cardiologists， p=0.105) and duration since medical examination (male: 23.9±9.1 years， female 23.5±8.8 years). There were only small differences in treatment by general practitioners and specialists.

Even though overall treatment was good – with most patients receiving ACE-inhibitors and beta-blockers， which are known to improve survival – the prescribed dosage was too low across both genders. About half of patients received at least 75 percent of the recommended ACE-inhibitor-dosages， and only 25 percent received at least 75 percent of recommended beta-blocker dosages. 

 “This is concerning because we know that higher dosages are better for improvement of mortality and symptoms，” Baumhakel said. “We are not advising patients to change their treating physicians due to the results of our study because treatment was very good overall. Still， all clinicians， especially males， could improve treatment by their use of evidenced-based practices.”