I’d love to believe that if both a man and a woman suffering the same type of serious heart attack showed up together at the same Emergency Department, their treatments and outcomes would be the same. I wish I could believe that, but as cardiologist Dr. Martha Gulati wrote recently(1):
“Despite progress, gaps still persist in how we treat women, and the impact on outcomes. Decades of tracking outcomes continue to show gaps in the treatment of women, and similar findings have been replicated throughout the world.” .
Dr. Gulati is known internationally as a champion for women’s heart health. She’s the Chief of Cardiology at the University of Arizona in Phoenix, Executive Editor of the American College of Cardiology’s CardioSmart, a prolific researcher, and author of the best-selling book, Saving Women’s Hearts.
Most importantly to me, of course: she’s also the person who very generously agreed when I asked her to write the foreword to my own book, “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017). You can read her beautiful foreword here.
On May 21, 2019, the Journal of the American Heart Association published an article by Dr. Gulati in response to a new Australian study that evaluated the gender gap in women’s cardiac treatment and outcomes during a serious heart attack.(1)
The news is not good.
The intriguing title of her article (“Yentl’s Bikini: Sex Differences in STEMI“) first needs three translations.
1. The word “Yentl”, she reminds us, is the heroine of the Isaac Bashevis Singer story, who had to disguise herself as a man in order to study the Talmud because women at the time weren’t allowed to do so. In cardiology, using the word Yentl to describe female heart patients who are underdiagnosed or undertreated compared to men was first coined by cardiologist Dr. Bernadine Healy almost three decades ago.(2)
2. The word “bikini” refers here to the areas of a woman’s body that are most commonly studied by medical researchers (i.e. the breasts and reproductive areas that would be covered up if you’re wearing a bikini).
3. The acronym “STEMI”, as I described in my patient-friendly, jargon free glossary, stands for ST-Elevation Myocardial Infarction(heart attack). This is the most severe form of heart attack, in which an artery that feeds the heart muscle can become fully blocked, cutting off blood flow to that muscle. So opening up that blood supply as quickly as possible (what our doctors call“revascularization”) can be lifesaving.
In Dr. Gulati’s article, she notes that back in 1991, Dr. Healy concluded that, “in cardiovascular disease, women remained second‐class citizens in terms of equity of treatment and outcomes of the disease that was most likely to kill them.”
A number of important changes have been implemented by the cardiology community since 1991 to help improve cardiac prevention, treatment and outcomes of women.
Over time, these changes led to the following improvements:
- ♥ release of cardiac treatment guidelines that were specific to women(3)
- ♥ increased research on sex differences in heart disease
- ♥ initiated awareness campaigns targeted at women (like the American Heart Association’s Go Red campaign).
But as Dr. Gulati herself wrote in 2017 in the cardiac journal, Circulation:(4)
“Gaps still persist in how we treat women and the impact on outcomes, particularly in women with STEMI.”
In the new Australian study she writes about this month, for example, researchers led by cardiologist Dr. Julia Stehli are reporting disturbingly similar findings. (5)
Specifically, this study showed two types of significant treatment delays that are happening more often in women than in men:
- Symptoms-to-Door (STD) time for women with STEMI: this is the time it takes a woman in mid-heart attack to decide that something is very wrong and to seek urgent medical help, the time from the onset of serious symptoms to arrival at the door of the hospital.
- Door‐to‐balloon (DTB) time for women with STEMI: this is the length of time for a woman in mid-heart attack between arriving at the door of the Emergency Department and having the blocked coronary artery revascularized with balloon angioplasty and an implanted stent.
The Australian study found that women having a serious heart attack are more likely to wait longer in Emergency before being taken to the cardiac unit for urgent treatment (DTB) compared to our male counterparts, and are also significantly more likely to wait longer before deciding to go to Emergency in the first place (STD).
It’s that second disturbing finding that occupies much of my angst these days.
Dr. Gulati explains why the phrase “time is muscle” is so often heard in cardiology circles, especially since we know that “there’s a significant increase in 30‐day mortality in women with STEMI compared with men.”
“The importance of early revascularization is well established for STEMI, and a key component to improving outcomes. Rapid DTB times save lives.
“Yet this study demonstrates the STD times are significantly longer in women with STEMI than in men.”
Women’s Door-To-Balloon (DTB) times have in fact improved “but persistent sex differences remain in timeliness of care with women of all ages being less aggressively treated when compared with men.”
Even more disturbing: “These unnecessary delays in seeking treatment have not improved, and that ultimately the greatest delay to starting lifesaving treatment hinges on the Symptoms-To-Door time” – the time during which women are deciding whether or not to go for help.
Why aren’t women getting to Emergency faster?
At least four possible obstacles are offered by Dr. Gulati:
1. Cardiovascular risk is underappreciated in women. Dr. Gulati quotes a Women’s Heart Alliance survey, with only 45% of women recognizing cardiovascular disease as the number 1 killer of women. “Current public awareness strategies have NOT reached a significant portion of the population, and there should be a public health effort made to reach women, particularly minority women, to a greater extent than what has been achieved thus far.”
2. Only a minority of primary care physicians feel comfortable even assessing cardiovascular disease risk, making preventive discussions (and therefore awareness) of risk less likely to happen in a physician’s office.
3. Effective public awareness campaigns and education are needed to help women understand their own heart disease risk, and especially the need for timely care so that they’ll survive a heart attack. UPDATE: The 2019 American Heart Association’s National Survey revealed that, despite a decade of awareness-raising initiatives like Go Red For Women or the Red Dress campaign, women’s awareness of heart disease is actually LOWER than it had been 10 years earlier.
4. Education of the healthcare community is desperately needed to better serve female patients.
NOTE FROM CAROLYN: I’d add two more obstacles here:
1. First, the skewed priorities often observed in women who are socialized to put their own needs last – yes, even during a heart attack! (See also: “Are You a Priority in Your Own Life?”) A
2. The male stereotype that so many women mistakenly hold that “real” heart attacks happen to (old, fat) men who clutch their chests in agony and fall down unconscious. If our symptoms don’t match that (male) stereotype being relentlessly portrayed in the media, it’s easier to minimize them as not being heart-related.
Dr. Gulati proposes a number of specific steps to help improve cardiac outcomes for women with STEMI:
1. Public awareness and education of women
2. Education of healthcare providers: Understanding sex differences in cardiovascular disease and recognizing gaps in the care of women must be mandatory in the medical education of physicians, but urgently needs to be expanded beyond just medical students. The gaps in education exist in a significant portion of healthcare practitioners who care for women.
3. Protocol‐driven STEMI care: Doctors must provide guideline‐recommended treatment to women with STEMI, just as they do in men.
4. Use of artificial intelligence in STEMI management: Artificial intelligence and machine learning may be future considerations in addressing implicit bias in the care of women.
5. Increased research on sex disparities in STEMI and ongoing reporting of STEMI care by sex: Ongoing research into factors that impact sex differences in cardiovascular disease care and outcomes is needed.
She sums up her article like this:
“Cardiovascular disease remains the Number 1 killer of women, but disparities in care contribute to this excess mortality.
“We can do better. We must do better. For women, health care needs to be more than bikini medicine.”
1. Martha Gulati, “Yentl’s Bikini: Sex Differences in STEMI“. Journal Article, Journal of the American Heart Association, Volume 8, May 21, 2019.
2. Healy B. “The Yentl syndrome.” New England Journal of Medicine, 1991; 325:274–276.
3. Mosca L et al, “Effectiveness‐based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association.” Circulation. 2011; 123:1243–1262.
4. Gulati M. “Improving the cardiovascular health of women in the nation: moving beyond the bikini boundaries.” Circulation. 2017; 135:495–498.
5. Stehli J et al. “Sex differences persist in time to presentation, revascularization and mortality in myocardial infarction treated with percutaneous coronary intervention.” Journal of the American Heart Association. 2019; 8:e012161.
NOTE FROM CAROLYN: I wrote much more about these issues in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, 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 20% off the list price).
Q: What do you make of these “Yentl’s Bikini” sex differences in serious heart attacks?
Same heart attack, same misdiagnosis – but one big difference (for those physicians who continue to reassure me that what happened to me in 2008 could never happen now because of advancements in diagnostic tools and improved physician awareness)