Excuse me while I bang my head against this wall…

by Carolyn Thomas   ♥   @HeartSisters

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Last week, the disturbing results of a study on women and heart disease were released, attracting media headlines like Women and Heart Disease: New Data Reaffirms Lack of Awareness By Women and Physicians. I had to go have a wee lie-down after I read this paper in the Journal of the American College of Cardiology.(1)

The study’s lead author, cardiologist Dr. Noel Bairey Merz, of Cedars Sinai Heart Institute in Los Angeles, announced that “increasing awareness of cardiovascular disease in women has stalled with no major progress in almost 10 years”, and (far more intensely disturbing, in my opinion): “Little progress has been made in the last decade in increasing physician awareness or use of evidence-based guidelines to care for female heart patients.”

No wonder I had to lie down. But taking to one’s bed in response to yet another discouraging study about cardiology’s gender gap is no longer enough. Perhaps it’s time for female heart patients like me to simply throw our collective hands in the air while banging our heads against the nearest wall.

The study’s grim conclusions felt distressingly familiar because I and many others have been writing about serial bad news on women’s heart health for years. Researchers have been essentially repeating “More studies are required” as their concluding disclaimer.

So that’s what we get: more studies saying more of the same. But although some role models of care are emerging (consider for example the growth of distinct women‘s heart clinics in many teaching hospitals), I’m wondering when we’re going to see boots-on-the-ground changes in diagnostics and treatment, not just more studies.

My heart sister (and SCAD heart attack survivor) Laura Haywood-Corey has a pithy way to sum up studies like this recent one:

“Sucks to be female. Better luck next life.”

I used to suspect that lack of research focused specifically on women’s heart health was the key culprit behind the cardiology gender gap. We know that this reality has in fact been true for decades. Just one chilling example: when I covered the 2011 Canadian Cardiovascular Congress in Vancouver to interview researchers working on women’s heart disease issues, I was stunned to learn that out of over 700 scientific papers presented at this medical conference, I could count on one hand how many had anything even remotely to do with women’s heart health. See also: The Sad Reality of Women’s Heart Health Hits Home

We’re getting vaguely used to researchers blaming women for our lack of awareness of cardiac symptoms, or for our dangerous treatment-seeking delay behaviour. And many studies suggest that physicians are significantly more likely to misdiagnose female heart patients compared to our male counterparts.

But this study goes beyond even those sorry conclusions, now questioning the ability of some doctors to discuss risk factors.  It found, for example, that only 22 percent of primary care physicians and only 42 percent of cardiologists felt “prepared to assess cardiovascular risk in women”, which of course begs the question:

If the majority of physicians – including cardiologists! – feel unprepared to appropriately assess women’s risk factors for developing heart disease, who exactly IS able to do this?

In case you too need a wee lie-down (or a good head-banging), here’s just a smattering of the range of work over the past decade that seem to confirm Laura’s summary:

♥  Gender differences in diagnosis and management of heart disease reported that the reasons for the significant under-use of standard heart attack treatments in women and higher in‐hospital mortality “need to be investigated further”. Heart, 2007.

♥  Prevention of coronary heart disease in women: a Chicago study determined that misdiagnoses result in higher coronary heart disease mortality rates in women than in men. Therapeutic Advances in Cardiovascular Disease, 2008.

♥  Women wait longer for emergency angioplasty during heart attacks was the conclusion of this Yale University-based study, adding that “time to treatment should be as short as possible”. BMJ, 2009.

♥  Many healthcare providers fail to recognize heart disease in women, and diagnosis and treatments are often delayed due to misdiagnosis. These delays can result in increased morbidity and mortality in women. National Center for Health Statistics, Circulation, 2009

♥  Gender equity in treatment for cardiac heart disease: Women receive notably fewer procedures during heart attack compared to male counterparts, women are significantly more likely to die during hospitalization even with equal treatment, gender differences against women are higher for emergency admissions, and women are more often admitted to cardiology through emergency departments. Social Science and Medicine, 2010.

♥  New guidelines warn of link between pregnancy complications and heart disease. The American Heart Association’s effectiveness-based guidelines recommend that healthcare professionals who meet women for the first time later in their lives should take a careful and detailed history of pregnancy complications, with focused questions about a history of gestational diabetes, preeclampsia, preterm birth, or having a low birth weight/full-term baby. Circulation, 2011.

  ♥ Bridging the gender gap: sex-related differences in the treatment and outcomes of patients with acute coronary syndromes. A Canadian study found that women with acute coronary syndrome are still more likely to be treated conservatively due to underestimation of patient risk, and to have worse in-hospital outcomes. American Heart Journal, 2012.

♥  Women fare worse than men after a heart attack, with longer hospital stays and a greater likelihood of dying in the hospital afterward. Journal of the American College of Cardiology, 2014.

♥  Sex bias in referral of women to cardiac rehabilitation: Research suggests that “women are significantly underrepresented in cardiac rehabilitation, programs which are shown to reduce recurrent cardiac events and related premature death.” European Journal of Preventive Cardiology, 2014.

♥  Female cardiologists are rare, and earn less than men. “Women make up over half of medical school classes, yet gender differences in compensation cannot be explained by differences in workplace performance.” Journal of the American College of Cardiology, 2015.

♥  Women’s heart attacks are under-diagnosed and under-treated even when appropriately diagnosed compared to our male counterparts. First ever scientific statement on women and heart attacks in the 92-year history of the American Heart Association, 2016.

♥  Focused cardiovascular care for women: “The public health cost of misdiagnosed or undiagnosed cardiac disease in women is significant.” This study warned that recognition of women who are at high risk of heart disease is not only important in providing appropriate care, but can avoid reflexively blaming women’s symptoms on non-cardiac causes. Mayo Clinic Proceedings, 2016.

♥  Gender Differences in Coronary Heart Disease – U.K. cardiologist Dr. Ramzi Khamis’ comprehensive look at the areas in cardiovascular disease where women are still either underdiagnosed, undertreated even when appropriately diagnosed, or both – published in the British Medical Journal Heart, 2016.  See image below:

♥ Sex Differences in Young Patients with Acute Myocardial Infarction – Researchers in the U.S. and Spain report that young women (under age 55) with AMI represent a distinct, higher-risk population that is different from young male counterparts. This includes lower quality of life, more co-morbidities, higher clinical risk scores, less likely to undergo revascularization procedures like stents during hospitalization, and more delays in seeking emergency medical help. European Heart Journal: Acute Cardiovascular Care, 2016.

♥  Low income heart attack survivors fare worse, especially women: Women often have lower income and less complete medical coverage than men, and care for multiple generations of family, and that this may in part explain why young poor women have worse outcomes following a heart attack compared with similarly aged men. Journal of the American Heart Association, 2016.

♥ Women fare worse than men after heart attack – Australian researchers found that characteristics of coronary artery plaque varied significantly between the sexes. Plaque in women, for example, was more evenly distributed through the arteries and contained less cholesterol — a major risk factor for heart disease.  Circulation: Cardiovascular Imaging, 2016.

♥  Gender bias in how female physicians are introduced by their male colleagues at Internal Medicine Grand Rounds (less likely to be addressed as “Doctor” than are men introduced by men). Journal of Women’s Health, 2017.

♥ Women and heart disease: new data reaffirms lack of awareness by women and physicians – While 74% of women reported having at least one risk factor for heart disease, just 16% were told by their doctor that they were at risk. Journal of the American College of Cardiology, 2017.

♥ Women’s hearts are victims of a broken system that is ill-equipped to diagnose, treat and support them – Disturbing update from Canada’s Heart and Stroke Foundation’s 2018 Heart Report called Ms. Understood, including: early heart attack signs 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. February 2018.

♥ Fewer lights and sirens when a female heart patient is in the back of the ambulance – This study found that after calling 911, female heart patients were not only less likely than male counterparts to have flashing lights/sirens turned on in the ambulance, but were also less likely than men to receive recommended treatments (including even the minimal basics such as aspirin or cardiac monitoring). December 2018.

(1) C. Noel Bairey Merz, Holly Andersen, Emily Sprague, Adam Burns, Mark Keida, Mary Norine Walsh, Phyllis Greenberger, Susan Campbell, Irene Pollin, Cassandra McCullough, Nancy Brown, Marjorie Jenkins, Rita Redberg, Paula Johnson, British Robinson. “Knowledge, Attitudes, and Beliefs Regarding Cardiovascular Disease in Women”, Journal of the American College of Cardiology, June 2017, 23751.

NOTE FROM CAROLYN:  I had lots of opportunities to bang my head against a wall while writing  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: Why has more heart research not yet translated into better treatment and outcomes for women?

See also:

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

The “Heart Attack Myth”: Revisiting the Controversial Canadian Study

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

Women Heart Attack Survivors Know Their Place