Cardiac gender bias: we need less TALK and more WALK

23 Mar

by Carolyn Thomas  @HeartSisters

News flash! Yet another new cardiac study from yet another group of respected researchers has been published in yet another medical journal suggesting that (…wait for it!) women receive poorer care during a heart attack compared to our male counterparts.(1)

As my irreverent Mayo Clinic heart sister and heart attack survivor Laura Haywood-Cory from North Carolina once observed in response to a 2011 Heart Sisters post:

“We really don’t need yet another study that basically comes down to: Sucks to be female. Better luck next life!’, do we?”

Well, Laura - apparently we do.  Because those studies just keep on coming.

At what point, by the way, do agencies that issue grants to support cardiac research stop spending millions of dollars on “discovering” what Laura and I and countless other female heart attack survivors already know?  I’ve been writing about research like this for years, and I’m quite frankly tired of continuing to cover the bleedin’ obvious.

A former study published in the New England Journal of Medicine back in 2000, for example, found that women are seven times more likely to be misdiagnosed in mid-heart attack compared to men.(2)  For real-life examples of these misdiagnoses, see: Stupid Things Cardiologist Say to Heart Patients

When will some gutsy cardiologist or Emergency Department or med school out there finally be willing to actually step up to the plate to change the way medicine is practiced so that women who come into Emerg with cardiac symptoms are treated the way men are?

In this new study of 1,100 heart attack patients admitted to 24 hospitals in Canada, U.S. and Europe (median age: 50), Montréal researchers found that women experiencing heart attack are slower than men to have an EKG done, or to receive life-saving clot-busting drugs, or to undergo artery-opening revascularization procedures.

The study’s authors posed this rationale to help explain why men receive faster appropriate treatments in Emergency compared to men:

“Clinical determinants of poorer access to care included anxiety, increased number of risk factors, and absence of chest pain.”

In other words, researchers are suggesting that Emergency physicians are less likely to believe women are having a genuine cardiac event if patients seem anxious. The more anxious a woman appears to the Emergency physician, the harder it is to be taken seriously. This may be because doctors see lots of  non-cardiac patients suffering with genuine anxiety who often present to Emergency with heart attack-like symptoms such as chest pain. Do docs simply get used to sending these patients home with a little “It’s not your heart” reassurance?

Medicine does have a bias, as Emergency physician Dr. Brian Goldman of Toronto recently confirmed when he described doctors’ responses to the anxious patient in the ER:

“There’s either something really wrong with you, or you’re just anxious.”

But take it from me: few things in life are more anxiety-producing than being in the middle of a heart attack.

Secondly, doctors are less likely to believe women are having a genuine cardiac event if you have an increased number of risk factors. This may seem counter-intuitive: shouldn’t doctors be more suspicious of heart attack if they know you are actually at higher risk for heart attack?  But if you present with what doctors call co-morbidities like diabetes or high blood pressure, this study suggests that your cardiac issues may be lost in the shuffle.

Thirdly, docs are less likely to believe women are having a genuine cardiac event if they are not having chest painBut since up to 40% of women experience no chest symptoms at all during a heart attack, this leaves a whole whack of women at risk for not being taken seriously compared to patients who do have chest pain. I hasten to add here, however, that I was misdiagnosed with indigestion and sent home from Emergency in mid-heart attack despite presenting with textbook heart attack symptoms of central chest pain, nausea, sweating and pain radiating down my left arm. Even a simple Google search at that time would have clearly confirmed the only possible correct diagnosis which was, of course, myocardial infarction (heart attack). 

But the Montréal researchers offered up a most puzzling rationale for what they described as this “significant gender bias against women with heart disease”:

“Gender-related determinants included feminine traits of personality and responsibility for housework.”

The study participants were asked to complete a survey with questions about “feminine personality traits” (like being unassertive) and perceived social standing, as well as who in their household was responsible for “housework”Yes. You read that right. Housework.

The researchers’ take on the results: these feminine personality traits and housework habits (observed in both men and women in Emergency) are associated with inferior cardiac care.

Memo to Montréal researchers: since women still average 14 hours per week of unpaid domestic housework compared to men’s eight hours, it appears that asking subjects this question is a bit like asking: “Who wears a bra in your family?” – and then concluding that wearing a bra is associated with poor cardiac care. What was the purpose of including  the housework question in the first place – unless it is to scare men off from pitching in around the house to ensure better care when they show up one day at Emerg? And what are women supposed to do now with this housework theory?

There may indeed be a correlation between those feminine humans who do housework and their subsequent poor heart disease treatment – but as my scientist friends like to remind me:

“Correlation does not equal causation.”

In other words, it’s also possible that subjects who experienced the gender bias shown in this study ate pickles on Tuesdays. So if we all stopped eating pickles on Tuesdays, would Emergency physicians start treating male and female heart patients equally? Now there’s a future study topic for you . . .

Let’s consider the Montréal study’s results only, unembroidered by any fanciful theories of feminine traits or vacuuming skills.

Dr. Goldman, host of the weekly radio show called White Coat, Black Art, bluntly told a CBC interviewer in response to this study:

“This is very significant. Gender bias is at play here.

“Women do wait longer than men for treatment – if they get diagnosed at all. There’s a saying about heart attacks: ‘Time is muscle’. The longer it takes to unblock a blocked coronary artery, the more heart muscle dies.

“We’re talking here about people under age 55 – in the prime of life. Delays in treatment can mean many, many years of living with a chronic disability that maybe could have been avoided.

Emergency personnel like me tend to dismiss women who complain of chest pain as just being ‘anxious’. And since women are less likely to have chest pain than men during heart attack, we need to rewrite standard medical textbooks.

“It’s time to examine the appropriateness of the care given to younger heart patients, especially women.”

It’s what some in medicine call the “Yentl Syndrome”, as described by the late cardiologist Dr. Bernadine Healy who coined this phrase back 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.

“”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. An editorial in the same journal issue (again, remember that this was back in 1991)  highlighted this discrimination against women in cardiology, including the reality that women hospitalized for coronary heart disease underwent both fewer major diagnostic and therapeutic procedures than men did.(3)

Meanwhile, how many more studies like the new Montréal paper do we need to read before this long-established gender gap in cardiac care is ultimately addressed?

And finally, consider this story shared with me by a woman attending one of my heart health presentations. While lying on a gurney in the Emergency Department, she overheard this conversation between a physician and one of his (male) patients beyond the curtain separating her from the next bed. The doctor told the (male) patient:

“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.

So a male patient is thus kept in hospital for observation in spite of his ‘normal’ cardiac test results. But I and countless other females in mid-heart attack are being sent home from Emergency mistakenly diagnosed with indigestion or anxiety or menopause or a dog’s breakfast of many other misdiagnosis options available. 

We know this gender bias is happening. We don’t need yet another study to tell us so. The real question now is when are those who have the power and the will to influence change going to start actually changing it?    

Researchers, let me interrupt your grant funding applications and save you time and effort by telling you what you’re going to find out in any future studies you’re planning on gender bias in cardiology:

“Women heart patients are under-diagnosed and under-treated even when appropriately diagnosed compared to our male counterparts.”

Now can we start walking the talk to do something that finally addresses this disturbing reality?

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(1)  Pelletier R et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. 10.1503/cmaj.131450 CMAJ March 17, 2014 cmaj.131450.
(2)  Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
(3)  Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med 1991;325:2221–5.

Q: What will it take to finally change the way women heart patients are diagnosed/treated?

See also:

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11 Responses to “Cardiac gender bias: we need less TALK and more WALK”

  1. CJ McKinney March 26, 2014 at 3:38 pm #

    We have such a protocol here in Central Florida and I’m certain it saved my life last October.

    Despite classic heart attack symptoms–crushing chest pain, shortness of breath, left arm, jaw and back pain– he was convinced it was an esophageal spasm. Thankfully, I was required to stay overnight for more enzyme tests. I’d had a “widowmaker” heart attack and required a stent.

    Keep preaching it, Heart Sister!

    Liked by 1 person

    • Carolyn Thomas March 26, 2014 at 4:57 pm #

      Yoiks! Thank goodness for that protocol that FORCED the ER staff to keep you for observation. So glad you made it through that frightening event. My Emerg clearly does not follow that same protocol (for women anyway)…

      Like

  2. Marilyn Edmonds March 23, 2014 at 2:48 pm #

    Carolyn, I wish you would address your remarks to more than just heart attack. How about heart disease? Or heart failure? I went into the ER in a small resort town hospital gasping for breath. The ER doc told the local ambulance driver to standby for possible transport (to a major city hospital). Turned out to be heart failure, not heart attack.

    So, are women better treated with heart failure? Or was I simply lucky to stumble into good care (regardless of sex) in the middle of the night?
    Marilyn

    Liked by 1 person

    • Carolyn Thomas March 23, 2014 at 4:43 pm #

      Hello Marilyn – sounds like you had fast and appropriate treatment for your heart failure diagnosis. I addressed heart attack here because the Montréal study focused only on heart attack survivors. If you browse my site, you’ll find that I have also covered other forms of heart disease as well.

      But because coronary artery disease/heart attack affects far more of us (three times more than heart failure or stroke, and 13 times more than congenital heart conditions) that’s what I tend to focus on. And because I was misdiagnosed and sent home from the ER during a heart attack, I’m especially interested in this particular subject.

      Like

  3. HibernationNow March 23, 2014 at 2:14 pm #

    Reblogged this on HibernationNow's Blog and commented:
    Really important, please read and pass along. Thanks.

    Liked by 1 person

  4. Lauren March 23, 2014 at 8:34 am #

    Grrrrrrrr!! I heard this study being discussed on a CBC lunchtime show while in the grocery store and the pontificating medical professional sounded happy to cite all the excuses including the housework allocation. I had to leave before I exploded so missed the end, but somehow his tone of voice did not lead me to believe that he would be changing his attitude.

    And I had the same experience while lying on the gurney that your friend did; I went on to have open heart surgery, am being treated for microvascular dysfunction, and am getting a pacemaker next month.

    Nothing wrong with my heart! :-)

    Liked by 1 person

    • Carolyn Thomas March 23, 2014 at 9:04 am #

      Hi Lauren – yes, that “housework” non sequitur seems so irrelevant in this study. Personally, I prefer the “pickles on Tuesdays” explanation for women’s inferior cardiac care compared to men . . .

      Like

  5. Sunny March 23, 2014 at 7:21 am #

    This is the true “war on women”, the phrase that is so ballyhooed about here in the States; and no focus on that frustrating patronization of women by cardiologists and other health care workers.

    Too bad some of that energy isn’t directed into an arena that has been studied to death with proof of the disparity and seemingly, nothing is being done about it.

    I agree, Carolyn…. more action and less talk.

    Liked by 1 person

    • Carolyn Thomas March 23, 2014 at 7:27 am #

      Thanks for your comment, Sunny. I can’t help but wonder if the medical profession would be as complacent if years of studies reported that men are dangerously under-diagnosed and under-treated compared to women? Somehow, I just can’t imagine that…

      Like

  6. Dr. Anne Stohrer March 23, 2014 at 4:45 am #

    Shout it out again! Change the textbooks! Change the ER protocols! Educate the ER providers!

    Shout it out again! Women are dying here, sisters.

    Liked by 1 person

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