Yentl Syndrome: cardiology’s gender gap is alive and well

by Carolyn Thomas  ♥ @HeartSisters

There’s a big fat yawning gap between cardiovascular diagnostic tests and resulting medical treatments – depending on whether doctors are looking at a male or a female patient lying there on the gurney. I’ve been saying this out loud ever since I came home from Mayo Clinic, where I first learned about the gender gap from Mayo cardiologists following my own heart attack misdiagnosis.

When asked if we might need to develop a new set of diagnostic/treatment protocol guidelines to specifically address this gap, Dr. Sharonne Hayes (founder of the Mayo Women’s Heart Clinic) responded:

“Part of the problem now is that the clinical practice guidelines are less likely to be applied to women compared to men.

“We know that when hospitals have systems in place to ensure they do provide care according to the guidelines, women’s outcomes improve.”

You may be wondering what it will take to put into place systems and guidelines (already used in male patients) for all patients, including women – in order to finally close that gender gap for good. 

Or must we merely resign ourselves to yet another cardiac study that reports, as my Mayo Clinic heart sister and Spontaneous Coronary Artery Dissection survivor Laura Haywood-Cory describes it in her comment to this 2011 Heart Sisters post called The Sad Reality of Women’s Heart Disease Hits Home:

“Sucks to be female – better luck next life!”

Recent research published in the journal Clinical Chemistry and Laboratory Medicine showed that women heart patients may have to wait longer than we had first hoped for the same quality of care that our male counterparts both expect and get.

Lead researchers Dr. Giovannella Baggio starts off this important Italian study called Gender Medicine: a Task for the Third Millennium(1) by telling us about what doctors now call the Yentl syndrome.

It was the late physician, cardiologist and academic Dr. Bernadine Healy who coined this phrase in 1991, writing in The New England Journal of Medicine:

“Yentl, the 19th-century heroine of Isaac Bashevis Singer’s short story, had to disguise herself as a man to attend school and study the Talmud. Being ‘just like a man’ has historically been a price women have had to pay for equality.

“Being different from men has meant being second-class and less than equal for most of recorded time and throughout most of the world. It may therefore be sad, but not surprising, that women have all too often been treated less than equally in social relations, political endeavors, business, education, research, and in health care.”

This health care inequality includes cardiology. A New England Journal of Medicine editorial in the same issue highlighted this discrimination against women in cardiology, including the reality that women hospitalized for coronary heart diseases underwent both fewer major diagnostic and therapeutic procedures than men did.(2)

But that NEJM editorial was written back in 1991. Surely things have improved for women heart patients since then?  Not so fast . . .

Twenty years after Dr. Healy had first written about the Yentl Syndrome, cardiologist Dr. Noel Bairey Merz of Cedars-Sinai Heart Institute in Los Angeles wrote her own editorial for the European Heart Journal, observing that:

“The Yentl syndrome is alive and well!” 

She cited disturbing results of two cardiac studies:(3)

“Both studies demonstrate medical undertreatment of women, including lower rates of aspirin and ACE inhibitor use in stable women compared with men, and lower rates of ACE inhibitor, beta blocker and statin medication in women with Acute Coronary Syndrome (ACS) compared with men.

“Both studies also show gender differences in use of procedures, where interestingly stable women undergo more repeat angiography, while women with ACS undergo fewer angiograms, revascularization, cardiac catheterizations,  and coronary artery bypass grafts compared with their male counterparts, and with higher death rates than men.

“The adverse outcomes described in these new works are consistent with earlier literature – both studies demonstrate adverse gender differences for women.”

The Italian study confirms this reality once more. Dr. Baggio et al compiled a distressingly long list of  areas in which the cardiac gender gap is still alive and well, observing for example that:

• coronary heart disease (CHD) is widely perceived to be less of a public health problem for women than for men even though CHD is the leading killer of women by 65 years of age;

• mortality for cardiovascular diseases and in particular for CHD has not decreased in the last 30 years in women as it has in men;

• the in-hospital mortality of an acute myocardial infarction (heart attack) is higher in women than in men up to 70 years of age;

• survival after six months of acute myocardial infarction is lower in women;

• clinical trials on prevention and treatment of cardiovascular diseases have been conducted either exclusively in males or in populations with very low numbers of females;

• women are less likely than men to have typical angina and are more likely to have atypical or non-anginal symptoms;

• CHD in women is ever often under-recognized particularly at younger ages or in patients with diabetes, and the disease is more severe and complicated (MI, hearth failure, sudden death);

• compared to men, women are less likely to undergo cardiac monitoring, enzyme measurement, recovery in coronary care unit, coronary angiography, and revascularization;

• coronary angiography in women may show no evidence of atherosclerotic coronary artery disease because of the frequent involvement of microvascular circulation;

• women can have a Tako Tsubo cardiomyopathy or a coronary artery dissection (SCAD):

• women with atrial fibrillation are at higher risk of stroke, and they are less like to receive anti-coagulation and ablation procedures compared to men;

• stroke of any origin is more frequent in women than in men;

• smoking is associated with a 70% increase in CHD mortality, but smoking rates are declining more slowly for women than for men;

• hypertension (high blood pressure) has an age-related increase and is more prominent in women; only systolic blood pressure predicts cardiovascular outcomes in women and isolated systolic hypertension (a marker of loss of large-artery elasticity) is more common in women than in men;

• much of the seminal research on dyslipidemia (high cholesterol) and CHD has involved middle-aged men and none or very few women;

• Type 2 diabetes is a potent coronary risk factor in women, increasing their risk of developing or dying from CHD by 3-7 fold, as compared with a 2-3 fold risk increase in men; adverse cardiovascular profiles are more common among diabetic women than among men;

• psychosocial factors such as depression, anxiety, and chronic psychosocial stress have greater adverse effects on women’s heart rate, blood pressure, visceral obesity, endothelial dysfunction, inflammatory activation and likely raise CHD risk;

• side effects of statin drugs to treat cholesterol are frequently associated with a variety of skeletal muscle complaints in women including myalgia, cramps and weakness;

• side effects of ACE inhibitor drugs (such as severe coughing) are reported significantly more frequently in women than in men;

• Beta blocker drugs like propranolol and metoprolol reach higher plasma concentrations in women than in men that could lead to frequent reports of greater drug toxicity in women;

• the effect of increasing age on discontinuing medication therapy is greater for women than men;

• several studies on men have found that daily low-dose aspirin therapy was associated with a significant 32% reduction in the risk of heart attack in men;  but studies on women have found that among women under age 65 years, there was no heart attack prevention benefit, and only a small benefit in the reduction of stroke risk

IMPORTANT UPDATE:

January 31, 2016:   The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be undertreated“, and including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”

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