Biology or bias? Women twice as likely to die after heart attack

woman heart tattoo Image.0.0.1

The CBC (our Canadian Broadcasting Corporation) did a report this week about women and heart disease that included an interview with Dr. Beth Abramson, a Toronto cardiologist and spokesperson for the Heart and Stroke Foundation.  She was responding to results of a new study reported in the Journal of the American Medical Association that suggests women are almost twice as likely to die within 30 days of a heart attack compared with men. Dr. Abramson said:

“It’s sometimes hard to sort out if there is a difference in biology between men and women, or if there is a gender bias.

The study’s lead author, Dr. Jeffrey Berger of New York University Medical Center, votes for biology.   He says that women with acute coronary syndrome (heart attacks caused when the heart muscle doesn’t get enough oxygen) tend to:

  • be older than men when they have their first cardiac event
  • have a greater incidence of high blood pressure, high cholesterol and diabetes than men
  • have more single-vessel heart disease than men
  • have more non-obstructive artery blockages (ACS may be caused by coronary artery spasms instead)

This makes sense. Let’s say an elderly woman with serious cardiac risk factors like high blood pressure, high cholesterol and diabetes (referred to as co-morbidities by our docs) shows up in her local hospital’s Emergency Department with heart attack symptoms. If what she has is a single-vessel coronary spasm causing her heart attack, she already has two strikes against her: these unique characteristics can make this particular cardiac event difficult to accurately detect using current diagnostic tools, thus difficult to appropriately treat, thus causing deadly delays in obtaining timely treatment.

A treadmill stress test, for example, already considered less accurate for female heart patients, can miss single-vessel disease entirely, and the invasive angiogram test, while highly effective for identifying blockages located within coronary arteries, is less effective for identifying painful spasms occurring outside the arteries. No wonder women fare worse given these factors.

The NYU study also shows why it’s so important for women to pay attention to cardiac risk factors like high blood pressure, high cholesterol and diabetes. Women may also experience more subtle symptoms such as shortness of breath, fatigue and tightness in the chest, back, neck, or jaw compared with those of men, and some standard cardiac treatments are less effective and riskier in women.

On the other hand, study co-author Dr. Paul Armstrong of the University of Alberta in Edmonton blames women’s poorer outcomes on medical bias, which he calls:

“…a legitimate misinterpretation because of a failure to understand that women present (with heart attack symptoms) differently.”

The American Heart Association explains:

  • Many of the major cardiovascular research studies have been conducted on men only. Results of current clinical studies may help clarify the gender differences that affect pathophysiology, diagnosis and treatment of women with heart disease.
  • Clinicians and patients often attribute chest pains in women to non-cardiac causes, leading to misinterpretation of their condition.
  • Both women and men may present “classic” chest pain that grips the chest and spreads to the shoulders, neck or arms. But women may have a greater tendency than men to have atypical chest pain or to complain of abdominal pain, difficulty breathing (dyspnea), nausea and unexplained fatigue.
  • Women may avoid or delay seeking medical care, perhaps partly due to denial or their lack of awareness of both typical and atypical heart attack symptoms. (See Knowing & Going below)


Read the CBC coverage of this study.

See also:

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