Cardiac gender bias: we need less TALK and more WALK

by Carolyn Thomas  ♥  @HeartSisters

News flash! Yet another new cardiac study from yet another group of respected Montréal 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 Laura Haywood-Cory (who survived a heart attack at age 40 caused by Spontaneous Coronary Artery Dissection) 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.         .

I’m wondering why agencies that issue grants to support cardiac research spend 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 tired of continuing to cover the bleedin’ obvious.

One such study published in the New England Journal of Medicine, for example, found that women in their 50s and younger are seven times more likely to be misdiagnosed in mid-heart attack compared to men.(2) 

When will some gutsy cardiologist or Emergency Department head or med school out there actually step up to the plate to change the way medicine is practiced and cardiac research is conducted and medical students are taught so that women who come into Emerg with cardiac symptoms are treated the way men are?

Consider this story shared with me by a woman attending one of my Heart-Smart Women 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. 

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 lifesaving 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.”

Let’s review that problematic conclusion:

1. 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 dismissive little “It’s not your heart” pat on the head?

But take it from me:

Few things in life are more anxiety-producing than being in the middle of a frickety-frackin’ heart attack.

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

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

2.  Physicians are less likely to believe women are having a genuine cardiac event if you have an increased number of risk factors. This seems 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 get lost in the shuffle.

3.  Doctors are less likely to believe women are having a genuine cardiac event if they are not having chest pain.  But since at least 10 per cent of women experience no chest symptoms at all during a heart attack (could be up to 42 per cent, depending on which of the many studies on this issue you find), this leaves a whole whack of women at risk for not being taken seriously compared to patients who do have chest pain.(3)

I hasten to add here, however, that I was misdiagnosed with acid reflux 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.

I was also scolded sternly by the ER nurse, who told me:

  “You’ll have to stop asking questions of the doctor. He is a very good doctor, and he does NOT like to be questioned!”

The question I had dared to ask this very good doctor?

“But doc, what about this pain down my left arm?”

If only that very good doctor had bothered to consult Dr. Google at that time, he could have clearly confirmed the only possible correct diagnosis which was, of course, myocardial infarction (heart attack). 

But the Montréal researchers also 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.

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.

Will this theory on the cardiac dangers of doing housework scare men off from pitching in around the house to ensure better care when they show up one day at Emerg?   More importantly, what exactly are women supposed to do now with this housework theory? Let’s consider the Montréal study’s results only, unembroidered by feminine traits or vacuuming skills.

As Dr. Goldman 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.(4)

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

IMPORTANT UPDATES:

♥ January 2016:    The American Heart Association released its first ever scientific statement on women’s heart attacks (that’s ‘first’ as in the first one in its entire 92-year history!) confirming that “compared to men, women tend to be undertreated“, including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to experience other symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”   (I don’t know what upset me more: the findings of this scientific statement, or the fact that it took the American Heart Association NINETY-TWO YEARS to come up with it).

♥ February 2016: Focused Cardiovascular Care for Women: The Need and Role in Clinical Practice, a report published in the journal, Mayo Clinic Proceedings on why we need Women’s Heart Clinics that can specifically address the many unique considerations of women’s heart disease, concluding: “The public health cost of misdiagnosed or undiagnosed cardiac disease in women is significant.”

We know this gender bias is happening.

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 warning you right now 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.”

We know this already.  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)  Canto JG, Rogers WJ, Goldberg RJ, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307(8):813-822.

(4)  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.

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NOTE FROM CAROLYN:  I wrote more about cardiology’s known gender gap in my book  “A Woman’s Guide to Living with Heart Disease“.  You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

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

See also:

When Your “Significant EKG Changes” are Missed

Yentl Syndrome: Cardiology’s Gender Gap is Alive and Well

How Does It Really Feel to Have a Heart Attack? Women Survivors Tell Their Stories

Diagnosis – and Misdiagnosis – of Women’s Heart Disease

14 Reasons To Be Glad You’re A Man When You’re Having a Heart Attack

His and Hers Heart Attacks

Heart Attack – or an Attack of Heartburn?

Is it a Heart Attack – or a Panic Attack?

What is Causing my Chest Pain?

When Your Doctor Mislabels You As an “Anxious Female”

Heart Disease: Not Just A Man’s Disease Anymore

How Doctors Discovered That Women Have Heart Disease, Too

Gender Differences in Heart Attack Treatment Contribute To Women’s Higher Death Rates

How a Woman’s Heart Attack is Different From A Man’s

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