A woman attending one of my heart health presentations told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between the (male) doctor and the (male) patient in the bed next door beyond the curtain:
“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”.
A male patient is thus admitted to hospital for observation in spite of ‘normal’ cardiac test results – as current treatment guidelines require. But I and countless other females in mid-heart attack are being sent home from Emergency following ‘normal’ test results like his, and with misdiagnoses ranging from indigestion to anxiety or menopause. Why is this?
Women (especially younger women) with heart disease are far more likely than men to be misdiagnosed. Research on cardiac misdiagnoses reported in the New England Journal of Medicine looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with chest pain or other heart attack symptoms. Investigators found that women younger than 55 were seven times more likely to be misdiagnosed than their male counterparts. The consequences of this were enormous: being sent away from the hospital doubled the risk of dying.(1)
UPDATE: The 2018 Heart and Stroke Foundation Report called Ms. Understood concluded that women’s hearts are victims of a broken system that is ill-equipped to diagnose, treat and support them. Other alarming findings:
- early heart attack signs are missed in 78% of women
- five times more women die from heart disease than from breast cancer
- two-thirds of all heart disease clinical research focuses only on men
- even the laboratory mice, rats and rabbits used in early studies are male animals
Dr. Jerome Groopman‘s book, How Doctors Think, helps to explain why misdiagnoses happen in the first place:
“Specialists in particular, are known to demonstrate unwarranted clinical certainty. They have trained for so long that they begin too easily to rely on their vast knowledge and overlook the variability in human biology.”
This so-called “disregard for uncertainty” was what I faced with that Emergency Department physician in 2008 who sent me home from hospital with a misdiagnosis of GERD (gastroesophageal reflux disease), despite the fact that I’d just presented with textbook heart attack symptoms like chest pain, nausea, sweating, and pain radiating down my left arm. His emphatic but unwarranted clinical certainty:
“You are in the right demographic to be having acid reflux!”
A PERSONAL ASIDE: as if being misdiagnosed in mid-heart attack wasn’t bad enough, the ER nurse that fateful morning came up to my bedside at one point after the physician had moved on to the next patient, and warned me sternly that I’d have to stop asking questions of the doctor, adding:
“He is a very good doctor, and he does NOT like to be questioned.”
The question that I’d just had the temerity to ask him?
“But doctor, what about this pain down my left arm?”
The medical error of a misdiagnosis like mine can include:
- a complete failure to diagnose (totally missing the disease)
- wrong diagnosis (for example, diagnosing acid reflux instead of a heart attack)
- partial misdiagnosis (diagnosing the wrong subtype of heart disease or the wrong cause of the disease or its complications)
- delayed diagnosis (when a doctor does not recognize a disease until long after it should have been identified)
There is also still, amazingly, a persistent myth that heart disease is a man’s disease.
Even the name of the type of heart attack I survived (the so-called “widowmaker”) tells you that semantics reflect the medical profession’s historical assumption that this kind of myocardial infarction hits men, not women. It’s not, after all, called the “widowermaker”, is it?
Doctors may actually be reluctant to consider heart disease when a woman has cardiac symptoms, and instead will look for other causes. An American Heart Association study showed, in fact, that only 8% of family physicians and 17% of cardiologists were aware that heart disease kills more women than men each year.
UPDATE – June 22, 2016: A study published in the Journal of the American Heart Association reported: “Women presenting with cardiac arrest are less likely than male patients to undergo therapeutic procedures, including coronary angiography, percutaneous coronary interventions and targeted temperature management. Despite trends in improving survival after cardiac arrest over 10 years, women continue to have higher in‐hospital mortality when compared with men.”(2)
Women themselves are less likely than men to realize how vulnerable they are to heart disease.
A number of studies report that women are more likely to delay seeking emergency treatment even when they experience serious cardiac symptoms. One survey, for example, suggests that only half of women indicated they would call 911 if they thought they were having a heart attack (and that’s down from 80% just five years earlier!). Few were even aware of women’s most common heart attack symptoms.
And those symptoms can be more vague and atypical compared to men’s ‘Hollywood Heart Attack‘ symptoms. For many women in mid-heart attack, the words “chest pain” would not even be the ones they’d choose to describe their symptoms – instead, words like full, heavy, burning, pressure or aching might be more accurate descriptors.
And remember that 8-40% (depending on which of many studies you read) of women experience no chest symptoms at all during a heart attack.(3) See also: How women can tell if they’re headed for a heart attack
It’s astonishing to me that even first-responders like ambulance paramedics are less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to their male counterparts, according to the disturbing results of a study at the University of Pennsylvania. See also: Fewer Lights/Sirens When a Woman Heart Patient is in the Ambulance
Researchers found significant differences in both aspirin and nitroglycerin therapy offered to women vs. men. In fact, this study showed that of the women transported to hospital by ambulance who were suffering from heart attacks, not one was given aspirin by paramedics en route.
Once women do arrive at hospital, both nurses and physicians working in Emergency Departments report a bias towards looking for heart attack pain symptoms, even though a majority acknowledge that women often present with vague, non-chest pain symptoms during a cardiac event. Again, between 10-40% do not have ANY chest symptoms at all. See also: How Can We Get Heart Patients Past the E.R. Gatekeepers?
Why don’t diagnostic tests pick these up? Women are less likely than men to receive some cardiac diagnostic tests in the first place, and some tests don’t work as well in women. In fact, most tests for diagnosing heart disease have been fine-tuned in studies focused on (white, middle-aged) men.
The treadmill stress test, for example, has been found to be less accurate in women than in men, and particularly for identifying single vessel or non-obstructive heart disease – which are both more common in women.
Even the standard EKG (or ECG – electrocardiogram) can be problematic – especially when it’s not offered to female patients in a timely manner. A Montreal study, for example, found that women were significantly less likely than men to receive an electrocardiogram within the recommended 10 minutes of arriving in hospital with suspected cardiac symptoms.(4) And even when we do finally get hooked up to a 12-lead EKG in a hospital’s Emergency Department, the doctors there may not be able to correctly interpret the “significant EKG changes” that identify heart disease. Previous research has reported a disturbing reality about diagnostic EKGs, which is the likelihood that high-risk EKG abnormalities may NOT be detected by physicians working in Emergency Medicine.(5) See also: When Your “Significant EKG Changes” are Missed
The gold standard test for diagnosing coronary artery disease in both men and women is the angiogram, but studies also show that women are less likely than men to be referred for angiography. And some types of non-obstructive heart disease like Coronary Microvascular Disease (small vessel disease) or Prinzmetal’s Angina (a spasm disorder), do not show up during angiography unless the spasm happens to occur during the procedure. See also: Misdiagnosed: Women’s Coronary Microvascular and Spasm Pain
UPDATE January 31, 2016: We’ve been waiting 92 years for this announcement, ladies. The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be under-treated”, 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.”
How to help yourself get an accurate diagnosis:
- Know your symptoms
- Know your facts
- Ask clarifying questions if you don’t understand what you’re being told
- Be specific
- Be objective
- Get results
What to do if you think you’ve been misdiagnosed:
- Do not feel embarrassed to speak up/ask clarifying questions
- Get more tests/ask for repeat tests
- Get a second opinion
- Keep going back until you are diagnosed accurately!
Dr. Jerome Groopman further recommends that you ask these critically important questions of your doctor:
- “What else could it be?” The cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
- “Is there anything that doesn’t fit?” This follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
- “Is it possible I have more than one problem?” Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, to order more tests that might not have seemed necessary based on initial impressions.
© Carolyn Thomas www.myheartsisters.org
(1) 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.
(2) L Kim et al. Sex‐Based Disparities in Incidence, Treatment, and Outcomes of Cardiac Arrest in the United States, 2003–2012. J Am Heart Assoc. 2016; 5: e003704
(3) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart 2009;95:1 20–26.
(4) Roxanne Pelletier et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. Canadian Medical Association Journal. March 17, 2014. cmaj.131450 10.1503/cmaj.131450
(5) Frederick A. Masoudi et al. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the emergency department quality in myocardial infarction (EDQMI) study. Circulation. 2006; 114: 1565-1571
NOTE FROM CAROLYN: I wrote much more about cardiac diagnosis and misdiagnosis in my book “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).
- Skin in the Game: taking women’s cardiac misdiagnosis seriously
- Cardiac Gender Bias: We Need Less TALK and More WALK
- The Sad Reality of Women’s Heart Disease Hits Home
- Misdiagnosis: the Perils of “Unwarranted Certainty”
- Seven Ways To Misdiagnose a Heart Attack
- The ’18 Second Rule’: Why Your Doctor Missed Your Heart Attack Diagnosis
- Six Rules for Navigating Your Next Doctor’s Appointment
- Things Your Doctor May Not Know
- Experts: Why So Wrong So Often?
- How to Be a Good Patient
- Seven Ways to Misdiagnose a Heart Attack
- What Doctors Really Think About Women Who Are ‘Medical Googlers’
- Women’s Cardiac Care: is it Gender Difference – or Gender Bias?
ANOTHER NOTE from CAROLYN: I am not a physician. Information on this site is not meant as a substitute for medical advice. If you are experiencing symptoms that are distressing enough to ask me about them, please see your doctor. Do NOT leave a comment here describing your symptoms.