Análisis FODA y Plan de desarrollo futuro del proyecto productivo

Coronary heart disease has long been regarded as primary male disease, even women themselves were long not aware that they are at risk of this disease. In 1993 a study asked women to estimate their risk of coronary heart disease at the age of 70, 73% estimated their risk to be less than one percent and 39% even estimated it to be less than 0.1%.(221) In the UK in 2008, 87,392 women died of circulatory system diseases and 80,846 men.(222) Data from the 2006 Health Survey for England suggest that “more than 1 in 3 men and around 1 in 4 women aged 75 or older live with coronary heart disease”.(223) However, women are on average 10-15 years older than men at their first diagnosis of a coronary heart disease, in men 45 years of age or older is considered as risk factor while in women it is 55 of age or older. (21) We found a higher incidence of myocardial infarction in men, compared to women but the presence of COPD decreased the difference between men and women.

The incidence of stroke is higher in men than in women and women tend to be older than men at their first stroke diagnosis.(163, 164, 224) Women have often more severe strokes than men, they have a higher degree of disability and a higher likelihood to die within 28 days of the stroke diagnosis than men.(163, 164) It is not known why there are gender differences. Smoking, diabetes, hypertension, obesity and reduced mobility are important risk factors in

men and women. It is discussed that differences in smoking and alcohol abuse might explain part of the differences. However, women are thought to have a greater susceptibility to the effects of smoking than men. Hormones have also been discussed as a reason for gender differences as within 10 years after the menopause women have similar rates of stroke than men.(21) Studies on HRT, however, showed inconclusive results.(225) We found a higher incidence of stroke in men compared to women in the COPD-free population, however women were more likely to die within 30 days than men. This gender difference is lost in patients with COPD. While the presence of COPD had no impact on the risk to develop stroke in men, COPD increased the risk of stroke in women by 1.41 (95% CI, 1.06-1.88). The presence of COPD increased the overall mortality, in particular the mortality in men which was as high as the mortality in women with and without COPD.

Whether there is a gender difference in incidence and prevalence of VTE is controversially discussed.(21, 226) A systemic review of studies on the incidence of DVT published in 2003 did not find a difference between men and women.(227) There are, however, sex-specific risk factors for the development of a VTE, which might explain small differences observed at certain age-groups. Pregnancy, use of oral contraceptives and hormone replacement therapy are associated with VTE in women.(226) The incidence rates of pulmonary embolism of men and women were closely similar in the COPD-free group and slightly higher in men with COPD than in women with COPD, also statistically non-significant. The incidence rates of DVT in the COPD-free group were slightly higher in women than in men while they were closely similar in men and women with COPD. Overall the impact of COPD on the incidence of a VTE was more important than a potential gender difference.

Atrial fibrillation is the most common cardiac arrhythmia in developed countries, with a prevalence in a general population of about 0.7%, increasing up to 9% in patients over the age of 80 years. (228, 229) Atrial fibrillation is a major independent risk factor for thromboembolic events, mainly stroke and transient ischemic attacks.(230) The incidence in women is higher than in men but as women outnumber men in the older age-groups the prevalence of atrial fibrillation is almost the same in men and women.(21) We found slightly

higher incidence rates in men than in women in both patients with and without COPD. The incidence of arrhythmia was increased in patients with COPD, however, in an analysis adjusted for other potential risk factors we found only a non-significant association of 1.19 in both men and women. Women, however, tended to be slightly older than men at the diagnosis and patients with COPD, in particular men, tended to be slightly younger at the diagnosis of arrhythmia.

There are tumours which are only found in women or men because they are localized in sex- specific organs such as the ovary, uterus, prostate or penis. Brest cancer is mainly affecting women, but can also affect men. Tobacco-smoke associated tumours, such as lung cancer, oesophagus, kidney and bladder cancer are more often seen in men than in women but women are catching up. Gall bladder and thyroid cancer are more common in women while liver cancer is more common in men. Most other tumours have a similar distribution in men and women.(21) We observed a higher number of cancer cases in men, both with and without COPD when compared to women. COPD, however, seemed to have a greater impact on the risk of a cancer diagnosis in women than in men. For most cancers the risk was materially unchanged except for lung cancer which was materially increased in men and women. This association was even seen in non-smokers. Associations in women were much stronger than in men. In women in addition the risk of urinary and kidney cancers was increased although, results were statistically not significant.

Men have historically higher numbers of peptic ulcer (231, 232) The reason for this gender difference is not clear. It might be due to a different risk factor profile (H.pylori infection, NSAID exposure, smoking status) or sex hormones. Ulcer rates in younger men are declining while they are increasing in the older population, particularly in women. (233) Recent numbers on gender differences are scarce. Men had higher incidence rates of peptic ulcer than women, in both patients with and without COPD. COPD did not have a strong impact on the risk of peptic ulcer.

erosive reflux disease. Non-erosive reflux disease is more commonly observed in women, although part of this difference (if not all) might be attributed to pregnancy. Erosive reflux disease and Barrett’s oesophagus are more common in men.(234) We found slightly higher incidence rates of GORD in women than in men but we could not stratify this analysis into erosive and non-erosive reflux disease. Differences were slightly smaller in COPD patients than in COPD-free patients but neither COPD nor gender had a significant impact in the risk of GORD.

Women are twice as likely to develop depression as men. This difference is strongest in early and middle adulthood, while during childhood and in elderly, men and women are more equally affected by the disease. Explanations for these observed differences are diverse ranging from hormonal or genetic differences, over diagnostic bias to differences in social status. The truth might be a mixture of all of them but it is not clear. This difference is restricted to a first-time diagnosis of depression, recurrence is observed at similar rates in men and women.(21) We observed higher incidence rates of depression in women, in both patients with and without COPD. The impact of COPD on the risk of depression seemed to be slightly higher in men than in women and was highest for patients with severe COPD. In addition the presence of both COPD and depression had a negative impact on survival in men but not in women, a phenomenon which needs further investigation.