European women face the same cardiac gender gap we do

by Carolyn Thomas    @HeartSisters

I’m interested in women’s heart health, and because my Heart Sisters blog readers come from all parts of the world (in 190 countries at last count), that interest isn’t aimed only at women’s shared experiences here in North America where I live. As the World Heart Federation tells us, heart disease is the #1 global health threat to women everywhere on the planet.

Researchers know that the cardiac gender gap we worry about here is distressingly similar to what women around the world face, too. Here’s how one European cardiologist describes how she views this gap for the women where she lives: 

Cardiologist Dr. Vera Regitz-Zagrosek is based in Berlin, and is the founder of the Institute of Gender in Medicine and of the International Society for Gender Medicine. Here’s how she recently explained the differences between men and women heart patients in Europe:

“In most European countries, women experiencing a heart attack come much later to emergency departments than men do. Once in the hospital, they are diagnosed later than men. Diagnosis does not always lead to a positive result, and syndromes specific to women are frequently missed. Women are also treated later than men, they are treated less intensively, and they receive less medication and information when they are sent home. If they do receive drugs, they face a greater chance of having adverse effects and inadequate dosing than men. While the situation has improved over the last few years in most European countries, the problem still persists.”

She has identified six distinct problems preventing women from getting better care and treatment for heart disease. They include:

  • 1. Lack of awareness. Women and their doctors are not well aware that cardiovascular diseases are the most frequent causes of death in women. Women are often not tuned to complain on the same few lead symptoms of heart attack as men. They are often more sensitive and mention many more bodily problems and complaints then men do, and this can confuse the doctors in charge. On the other hand, men underestimate psychosocial causes of disease, such as depression and stress.


  • 2. Lack of knowledge among doctors. Women with an acute coronary syndrome – in men most frequently caused by rupture of plaque in a coronary artery – may have stress-induced heart disease, they may have Spontaneous Coronary Artery Dissections (ruptures in the walls of arteries), they may have functional disorders of the coronary arteries such as spasms or coronary artery disease. This diversity leads to symptoms that deviate from the straightforward picture in men and make diagnosis of the underlying problem difficult.


  • 3. Women’s and men’s specific cardiovascular syndromes are poorly understood. There is a lack of research, a lack of research funding, a lack of animal models and a lack of researchers who understand these problems. Estrogen/estrogen receptors and testosterone in men do their best to drive the cardiovascular system into specific directions in both genders, and make it sensitive to specific risks and stress factors in a gender specific manner. Stress-induced heart disease may occur in women, especially after menopause. Coronary artery dissections may occur because of overstimulation with sex hormones in pregnancy. The functional disorders of the coronary arteries, such as spasms or disturbances of the microcirculation, may be more pronounced in women than in men. Heart failure develops with different clinical characteristics in women and men, with more diastolic failure (defects in relaxation) in women, more systolic failure (defects in pump function) in men. In men, poorly understood syndromes include sudden death in younger athletes (about 90 percent of whom are men).
  • 4. Lack of gender-sensitive diagnosis strategies. Standards of diagnosis are often insufficient in women: coronary artery spasms, for example, are only detected when specific trigger substances (not included in routine diagnosis) are injected, and disorders like coronary microvascular disease need specific imaging approaches. Exercise stress testing is less sensitive in women than in men. The more expensive diagnostic tools are not always available in every hospital, and doctors may not be aware when they need to use them. This may be one of the reasons that standard angiograms lead to much more negative test results in women than in men, best documented in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) study that began in 1989 tracking every heart patient treated in 29 Swedish hospitals.
  • 5. Use of therapies and therapeutic outcomes also differ between genders. Women have a higher mortality after a heart attack than men. They have more bleeding complications after angioplasty/stent. They have a higher mortality after coronary artery bypass surgery. Women have better effects with the more expensive heart rhythm treatments, but these expensive therapies are less frequently used in women.
  • 6. Heart drugs are less well adapted for women than for men, and female-specific drugs may not be detected since more than 80 percent of animal research in cardiology is done in male lab animals. More heart rhythm conditions (e.g Long QT syndrome), more bleeding complications, more adverse effects of cardiac drugs have been reported in female patients. Women also receive less effective drugs after a heart attack. They also receive less counseling in particular for lifestyle, cardiac rehabilitation and resuming sexual activities following a cardiac event.

How can we possibly overcome these six serious problems in women’s cardiology?

Dr. Regitz-Zagrosek warns that it’s crucial to apply a gender-sensitive lens to all medical care.

“Coronary artery disease is just one example. Gender differences impact many other medical areas, including oncology, nephrology and endocrinology. Therefore, we do need gender sensitive lenses in ALL medical disciplines – and we need one discipline that makes and provides the lenses to others.”

Here’s how she believes we can achieve that goal:

  • Use both male and female animals in cardiac research.
  • Analyze the sex differences in animal models and in cell cultures.
  • Provide information on gender sensitive risk factors in humans (e.g. sex hormone status, sexual function, number of children, number of stillbirths, education, socioeconomic status, nutrition, stress, environmental factors, and awareness of major risk factors).
  • Make sure doctors understand gender-sensitive heart disease and symptoms.
  • Develop gender-sensitive diagnostic tools and gender-sensitive treatments.
  • Include sufficient numbers of women and men in clinical studies, and develop tools for gender analysis and study design.


Q: What will it take for modern medicine to embrace Dr. Regitz-Zagrosek’s recommendations?

See also:

8 thoughts on “European women face the same cardiac gender gap we do

  1. I have been reading Heart Sisters for several years, and have hypertrophic cardiomyopathy. Still, I failed to absorb that angiograms and exercise stress tests (both of which I pass with flying colors) often produce false negatives in women.

    Yet another one to pass to my primary care doc and to my cardiologist – both good docs AND women. Yet, my PCP was astonished when told that heart disease is the #1 killer of women. She always thought it was breast cancer. Another consequence of pink washing.

    As a (not breast) cancer survivor, I regularly am aware of another. There is zero breast cancer in my biological family, and already I have had too much radiation for more than a dozen lifetimes. My HMO badgers me to get an annual mammogram with every single contact, but leaves me entirely on my own, or even makes me fight, for tests and checks which are far more important to my particular health.

    Liked by 1 person

    1. Hi Kathleen – you bring up such an interesting issue about tests that indicate negative findings (in doctorspeak, that doesn’t mean negative-bad, it means NOT the diagnosis this particular test is looking for). Just recently, I was reading physician feedback about a study that suggests newer high-sensitivity cardiac enzyme blood tests are good for ER docs because their “primary focus is to rule out myocardial infarction (heart attack) and triage patients out of the hospital.”

      But as a patient whose heart attack was misdiagnosed in the ER as acid reflux (and then was triaged the hell out of that hospital as fast as they could get rid of me!), I would much prefer that docs get excited about developing and using tests that are more accurate in diagnosing women’s cardiac events, not simply ruling-out.

      Your story of being readily prompted to get your mammogram is a indirect result of the lobbying efforts of some in the medical profession, especially those who are writing the clinical guidelines, many of whom may have a financial interest in either the diagnostic technology or the subsequent treatment itself. As the author Elisabeth Rosenthal writes in her excellent new book, “An American Sickness: How Healthcare Became Big Business“: Yearly mammograms in many studies proved no better at predicting significant breast abnormalities than an every-other-year regimen.” So why are so many docs still pushing annual mammograms?


  2. Being sent home with too MUCH medication, and dosing developed on young men, is just as much a problem. And an acknowledgement that things were missed, but that they would be more diligent next time because of that, would have been nice. And help with side effects.

    I keep getting the feeling I’m bothering them.


    1. As Dr. Regitz-Zagrosek says, “women are treated less intensively, and they receive less medication and information when they are sent home” so the problem is actually far more that women tend not to be prescribed even the basic cardiac meds compared to our male counterparts (even including aspirin!) according to existing treatment guidelines. It’s that pervasive gender gap that is glaringly present that concerns us in both Europe and North America.


  3. What will it take for modern medicine to embrace Dr. Regitz-Zagrosek’s recommendations? More women in cardiology, less misogynism among the men. More gender-savvy women lab researchers and more female lab animals. More women knowing what questions to ask and demanding answers to those questions — in English, not medicalese.

    And — it would be helpful if the American Heart Assn were as proactive re women’s heart disease as the cancer people are about women’s cancers.

    Liked by 1 person

    1. All good points, Sandra! Using both male and female lab animals in clinical research is a no-brainer. Can you imagine the outcry from men and their male docs if only female lab mice had been the norm for decades?

      Unlike heart disease, the ‘cancer people’ are able to focus on breast cancer in a way that has spawned countless independent groups devoted to a (largely) women’s cancer. The AHA does support the Go Red For Women campaign which has helped put women’s heart disease awareness on the map (especially their “Just A Little Heart Attack” video which I open every one of my women’s heart health presentations with (see right sidebar for link). Small but important steps, still LOTS more to do…


      1. I know about Go Red, but it just doesn’t energize or inspire women like the breast cancer programs. I wish there were something we could do … but my best efforts so far are to talk up HeartSisters. My PCP, who is female and terrific, wrote down the coordinates and will pass them along.

        Liked by 1 person

        1. The breast cancer movement has also merged inextricably with commercial partners amid the whole ‘pinkification’ explosion. I’m not sure at all if that’s what we want to model, but that kind of massive corporate involvement IS arguably what gets thousands of women out to walk/run/swim/shop “for the cure” and raises millions for breast cancer research. I wrote more about this at What Women With Heart Disease Can Learn From ‘Pinkwashing’

          Thanks, Sandra, for your continuing support of my blog!


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