10.4081/btvb.2023.87
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2785-5309
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Rosanna Abbate
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Bleeding, Thrombosis and Vascular Biology
thrombosis
What is the gender of thrombosis? A natural model of precision medicine
Text.Serial.Journal
https://www.btvb.org/btvb
2
Letters
2023-08-03
2023-06-07
2023-07-31
2023-08-03
Bleed Thromb Vascul Biol
Rosanna Abbate
2023/08/03
10.4081/btvb.2023.87
Department of Clinical and Experimental Medicine, University of Florence
2785-5309
3
thrombosis
en
What is the gender of thrombosis? A natural model of precision medicine
https://www.btvb.org/btvb/article/download/87/78
2
                                                                                                LETTER TO THE EDITOR

What is the gender of thrombosis? A natural model of precision medicine
                                                                        It is more important to know what kind of person has a disease
                                                                                       than to know what kind of disease a person has
                                                                                                    (Hippocrates of Kos, 460-377 BC)


Dear Editor,                                                                Finally, antithrombotic therapies have different safety and ef-
                                                                        ficacy profiles among women: this is clear even if the data we ac-
     We have undoubtedly and definitely entered the season of per-      quire from drug intervention trials mostly involve men. Several
sonalized or precision medicine. Thrombosis offers a natural field      data show higher platelet reactivity in females and a higher preva-
of application of this approach. We are talking about a patho-          lence of high platelet reactivity on aspirin and clopidogrel therapy.
genetic mechanism in which the cause of the diseases most rep-          In primary prevention, the use of aspirin is associated with a
resented in the Western world (and rapidly growing in emerging          higher reduction of risk for ischemic stroke in females and for
countries) is recognized.                                               myocardial infarction in males. In the context of acute coronary
     The mechanisms that regulate the activation of platelets and       syndrome, females have a significantly higher risk of bleeding.
coagulation leading to the inappropriate formation of a clot at a
venous or arterial level are responsible for several diseases ranging        From now on, prevention is becoming the watchword.
from venous thromboembolism to myocardial infarction, the so-                And prevention must be accompanied by the concept of risk
called atherothrombotic diseases. In each of these clinical mani-       awareness and by the perception of one's health. Even in this con-




                                                                                                    ly
festations, it is possible to recognize a prevalence of the female      text, the female sex shows important differences. Only 13 out of
sex, even in those diseases – such as ischemic heart disease – in       100 women consider thrombosis diseases as an enemy to fight.




                                                                                           on
which, historically, men were the main protagonists.                         But thrombosis is the most serious threat to the quality and
     Therefore, studying and recognizing in detail how much gen-        duration of their future life. By believing they are protected,
der affects the pathophysiological mechanisms allows us to better       women do less physical activity, do not control their level of cho-




                                                                                     e
treat patients and truly apply the principles of precision medicine.    lesterol (40% of women over 55 have hypercholesterolemia), nor
     Let's start with venous thromboembolism: exposure to the risk
of this disease is peculiar to women and accompanies them in all
moments of their life. From adolescence – a stage in life in which
                                                                              us
                                                                        do they keep their blood pressure in check (only 50% of women
                                                                        over 45 have acceptable blood pressure values), they smoke and
                                                                        they do not want to quit, they are overweight, they have diabetes
                                                                        al
they often come into contact with estro-progestinic therapy – to        and are unaware of it.
pregnancy, natural or induced by assisted procreation techniques,            Women are traditionally caregivers in our society, and as such
                                                             ci

to the possible use of hormone replacement therapy in menopause.        they tend to underestimate their own thrombotic risk and neglect
Different risks, in relation to different ages and procedures, but      healthy lifestyles more than men. Not to mention the exposure to
                                                           er


always peculiar to being a woman.                                       thrombotic risk factors – such as smoking – which is dangerously
     The clinical setting of arterial thrombosis, historically a pre-   increasing in young women, consequences of which will only
                                                          m




rogative of the male sex, is also showing and confirming the affin-     emerge in the next decades.
ity of thrombosis for the female sex. Women affected by heart
                                               om




attack or stroke die more than men: partially due to a delay in di-          All this considered, it is necessary to commit ourselves on
agnosis and therefore in treatment, linked to the widespread and        several fronts:
erroneous belief that these diseases are less likely to occur in        i. clinically, we must apply tailored gender diagnosis and ther-
                                         -c




women. In Europe, 55 out of 100 women die from vascular dis-                 apy schemes. We can imagine dedicated treatment settings or
eases, against the 40 out of 100 men: stroke is the third leading            different modules according to gender, in order to recognize
                                 on




cause of death in men, the second in women.                                  the peculiar elements of women and allow a more appropriate
     Sex-based disparities in the evaluation and management of               diagnosis and treatment.
                            N




acute coronary syndrome are also pervasive. Women with ST-el-           ii. scientifically, we must promote all efforts aimed at analyzing
evation myocardial infarction tend to request medical intervention           pathophysiological mechanisms from a gender perspective.
later after symptom onset than men. Among patients who have             iii. institutionally, we must organize programs suitable to reach
sought medical attention for symptoms before acute coronary syn-             the female population and modeled on gender.
drome, it’s more likely for women to have been reassured that the
symptoms were not cardiac in nature. For these reasons, women                Scientific societies, such as the Italian Society for the Study
with acute coronary syndrome are less likely than men to undergo        of Haemostasis and Thrombosis, will have to promote the culture
revascularization. When percutaneous coronary intervention is           of gender difference in the field of thrombosis: a culture that must
performed for acute coronary syndrome, radial access is less com-       train, in their own context, all younger generations of doctors (in-
monly used in women, and older women have higher rates of sig-          creasingly women), each of whom must act as a spokesperson of
nificant post-procedural bleeding than older men. In terms of           this modern reading of medicine.
secondary prevention, women are less likely to receive statins, an-
giotensin converting enzyme inhibitors, or angiotensin receptor             Medicine should be precise not only in curing the patient, but
blockers at the time of discharge than men.                             also in how it is studied and taught.
     These differences in secondary prevention regimens might                                       Rossella Marcucci, Rosanna Abbate
contribute to the lesser observed reductions in recurrent myocar-                   Department of Clinical and Experimental Medicine,
dial infarction rates over time in women than in men.                                                         University of Florence, Italy




                                          Bleeding, Thrombosis and Vascular Biology 2023; 2:87
