A professor’s take on women’s heart disease

by Carolyn Thomas     @HeartSisters 

The ominous title of this 2019 report,Cardiovascular Disease and the Female Disadvantage makes it fascinating reading for all women, but potentially repellent for the minority of physicians who still dismiss the entire notion of a gender gap in cardiology(1)sadly, the ones least likely to read it. Yet I know they are out there, because some of them openly call me names on Twitter whenever I cover a scientific paper on this topic.

Luckily for the rest of us, however, the expert writing this report is the very credible Professor Mark Woodward at the University of Oxford (who also teaches at Australia’s University of New South Wales, and at Johns Hopkins University in the U.S.)        

Let’s Start With our PERCEPTION of Heart Disease:

Professor Woodward cites a national survey of women undertaken at the Ottawa Heart Institute that focused on our knowledge and perceptions about our own heart health.(2)  Researchers found that most women “lack knowledge of heart disease symptoms and risk factors, and significant proportions are unaware of their own risk status.”  He added:

“Despite observations that women’s magazines and social media include much about healthy lifestyles, many women still may be unsure of issues regarding their cardiovascular disease risk.”

Women, he warns, may also be more likely to put their own needs behind  family and other priorities than men are, which – as I’ve written about here and heremay actually compromise our own health.  See also: Are You A Priority In Your Own Life?

The Ottawa researchers found that:

  • fewer than half of the women surveyed knew that smoking is a cardiac risk factor

  • fewer than 1/4 named high blood pressure or cholesterol as risk factors

  • fewer than 1/3 could identify four common symptoms of a heart attack in women

  • of those at high risk (based on medical history and risk factors), 62 per cent rated their risk as low to moderate

  • 65 per cent claimed they had the most influence on their family’s health

I believe that the last point could well be the key to changing the face of heart disease (future researchers, take note!)  If we can significantly improve women’s awareness of cardiac risk factors and convince them of the need to address these risk factors, can we by extension improve the health of our children and families?

But women aren’t the only ones who currently have unrealistic perceptions about women’s heart disease. Professor Woodward reminds us:

“Just like the general public, medical practitioners are prone to the misconception of cardiovascular disease as being a predominantly male problem.”

When I read this part of the report, I wondered how I must have appeared to the first Emergency physician I encountered back in the spring of 2008.

I had walked calmly through the doors of the Emergency Department at that first visit, on my own steam.  I could walk, talk, think, drive my car – did I look like that stereotypical old white guy clutching his chest in agony during a “real” heart attack?  (And despite my severe symptoms of central chest pain, nausea, sweating and pain down my left arm – and not unlike what happens to many other women – all of my first diagnostic test results came back “normal”).

So I was promptly sent home, misdiagnosed with acid reflux.

Higher MISDIAGNOSIS Rates:

Professor Woodward points out that the odds of a woman having an incorrect initial cardiac diagnosis on admission to hospital are higher for women than men among all heart attack patients.(3)  Women who had a final diagnosis of STEMI* (the most serious type of heart attack) had a 59% greater chance of a misdiagnosis compared with men, while women who had a final diagnosis of NSTEMI* (a slightly less serious heart attack) had a 41% greater chance of a misdiagnosis when compared with men. And Professor Woodward added:

“Since those with an incorrect initial diagnosis were more likely to die within 12 months than were those with a correct initial diagnosis, this suggests that misdiagnosis is an extremely important problem, and more so in women.”

Worse SURVIVAL rates:

It’s important to point out here that Professor Woodward’s international reputation is based on his expertise in statistical methods in medical research. This makes his paper a rich and yet surprisingly accessible read if you’re a woman living with heart disease. It’s particularly true of his analyses of women’s cardiac outcomes.

The figure below features data from another 2018 study, involving over half a million admissions to Emergency Departments throughout Florida.(4)  This study showed that survival rates were two to three times higher for female patients treated by female physicians in Emergency compared with female patients treated by male physicians.

And this was not the first study to report that female physicians tend to perform better than male physicians across a wide variety of ailments. Previous studies called this phenomenon “in-group bias”. As Professor Woodward describes it:

“Regardless of the sex of the cardiologist attending, after allowing for several confounding factors, survival was worse for women than for men. A striking feature of these data is that, although female physicians appear to have similar results for female and male patients, amongst patients treated by men, female patients survive their treatment less often than do male patients.

Although the differences in probabilities in Figure 4 are small, this issue if widespread is of immense importance in terms of female lives that might be saved, and is also compounded by the relative lack of female cardiologists in many settings.

To me, one of the most striking findings of this research was that male physicians who had “more exposure to female patients and female physician colleagues” had more success treating female patients. As the study’s conclusions suggested:

“We found that male physicians are more effective at treating female heart attack patients when they work with more female colleagues, and when they have treated more female patients in the past.

“Given the cost of male physicians’ learning on the job, it may be more effective to increase the presence of female physicians within the Emergency Department. This corroborates prior work of researchers studying racial concordance in medicine, who have consistently concluded that increasing the presence of minority physicians in the hospital is critical. It also underscores the need to update the training that physicians receive to ensure that heart disease is not simply cast as a ‘male’ condition, an observation underscored in the media.”

When this study was first published by the National Academy of Science in August 2018, I vividly remember that the online response to its findings on social media were swift and predictable.

Female physicians seemed far more likely to welcome the study’s recommendations, while a surprising number of male physicians (particularly those working in Emergency medicine) generally attacked the study on all fronts as yet another example of “doctor-bashing”, a blanket dismissal that I too face with alarming regularity every time I write – or even link to studies – about female heart patients being underdiagnosed or undertreated compared to our male counterparts.

Before I even signed my book contract with Johns Hopkins University Press, for example, the (anonymous) cardiologist who had reviewed my 10-chapter draft outline in advance of the contract issued a one-line warning about Chapter 3 (all about diagnosis and misdiagnosis of women’s heart disease):

“Seems like doctor-bashing to me.”

And this was in response to merely a 4-line bulleted list of proposed topics for that chapter.

Apparently, even using the word “misdiagnosis” qualifies as doctor-bashing.

That publishing debate ultimately had a happy ending. As I argued with my editors, “It would be a great disservice to all women reading this book if, given the growing body of research on this important topic, my chapter on diagnosis and misdiagnosis was forced out.”

They agreed.

It stayed.

(So did Chapter 7, by the way, despite the same reviewing cardiologist’s assessment that this chapter was “irrelevant to female heart patients”, and should be removed). I don’t think the reviewing cardiologist quite grasped the irony at the time of a cardiologist telling a female heart patient what is or is not relevant to female heart patients. . .

Now Back To Our Topic. . . 

Professor Woodward didn’t stop at simply describing the extent of the known historical bias in cardiology. A specific call to action, I have noticed, is often remarkably absent across medical research: academics study a specific subject, publish a paper describing the extent of the bad news, and move on to the next paper with the requisite disclaimer“more study is required. . .”

But for Professor Woodward, seven months after his “Female Disadvantage” report came out, his template for actually improving this reality (“Rationale and Tutorial for Analysing and Reporting Sex Differences in Cardiovascular Associations) was published in the cardiology journal, Heart.(5)  

In his template, he not only confirms what he calls “the historical bias toward the male model of cardiovascular disease”, but also goes on to suggest to his cardiac research colleagues 15 key recommendations to address that gender bias. (NOTE: it’s written in dense medical-ese, but of interest to those of you with a keen grasp on statistical concepts like “inverse variance weighted pooled relative risks.”) 

Finally, Professor Woodward warns that such improvements MUST become the norm in cardiovascular disease research “for both humanitarian and clinical reasons”.

Image based on original from Gerd Altmann, Pixabay

1. Woodward, Mark. “Cardiovascular Disease and the Female Disadvantage.” International Journal of Environmental Research and Public Health” Apr. 2019. Vol. 16,7 1165. 1

2. MacDonnell et al. “Perceived vs Actual Knowledge and Risk of Heart Disease in Women: Findings from a Canadian Survey on Heart Health Awareness, Attitudes, and Lifestyle.” Canadian Journal of Cardiology. 2014 Jul;30(7):827-34.

3. Wu J. et al. “Impact of Initial Hospital Diagnosis on Mortality for Acute Myocardial Infarction: A national cohort study.” Eur. Heart J. Acute Cardiovasc. Care. 2018; 7:139–148.

4. Greenwood BN et al. “Patient-Physician Gender Concordance and Increased Mortality Among Female Heart Attack Patients.”  Proc Natl Acad Sci USA. 2018 Aug 21; 115(34): 8569-8574.

5. Woodward M.  “Rationale and Tutorial for Analysing and Reporting Sex Differences in Cardiovascular Associations.” Heart (British Cardiac Society), 105(22), 2019. 1701–1708.

*DEFINITIONS (see more in my Patient-Friendly, Jargon-Free Glossary of Cardiology Terms)

 

Q:  How important is it that experts like Professor Woodward continue to try convincing researchers to address this gender gap?

.

See also:

The book Invisible Women: Data Bias in a World Designed for Men by Caroline Criado Perez, winner of the 2019 Royal Society Science Book Prize.

-My review of Maya Dusenbery’s book Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and SickWARNING: Do NOT open this book before you have taken your blood pressure meds!

-My own book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017), in which I wrote much more about the cardiology gender gap;  order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press. Use their code HTWN to save 20% off the list price when you order.

Is it enough to have “enough” women in cardiac studies?

This is NOT what a woman’s heart attack looks like

-But what about the men?

-Women’s cardiac care: how do you think we’re doing?

-A Typical Heart” – this documentary film pulls no punches

-Yentl’s bikini: Dr. Martha Gulati on women’s most deadly heart attacks

-Skin in the game: taking women’s cardiac misdiagnosis seriously

-How implicit bias in medicine hurts women and minorities

-Cardiac gender bias: we need less TALK and more WALK

11 thoughts on “A professor’s take on women’s heart disease

  1. Pingback: Clinical Hearts
  2. Thank you for another excellent post , I’ll be sharing it elsewhere – but I take issue with the terms “STEMI* (the most serious type of heart attack) …..NSTEMI* (a slightly less serious heart attack) “ – was it men who decided the degrees of seriousness?

    Both types have a serious impact on our lives and how we live them – there are all sorts of reasons for questioning the type of evaluation of gravity starting with the data on outcomes, which is by no means accurate _ we need to keep challenging these assumptions – in the same way that we are finally challenging views on period pain (often due to endometriosis) which is only experienced by women and dismissed by medics everywhere as trivial!!!!!!!

    Liked by 1 person

    1. Hi Eva – your comment is so timely.

      Just this weekend, a tragic heart attack death in the U.S. has been discussed by physicians and paramedics on social media. I want to explain this case because I think it proves your point nicely.

      The case involves a 70 yr old woman who went to her local hospital’s ER reporting that she’d had chest pain for approximately one week, then profuse sweating and extreme fatigue.

      The cath lab was activated, but then the interventional cardiologists (the ones who implant stents) insisted that the woman’s ECG “did not meet STEMI criteria” and cancelled the cath lab activation.

      The Emergency physicians believed that this ECG did meet STEMI criteria. This debate was happening 90 minutes after she had arrived in Emergency.

      What this means is that the difference between a STEMI and NSTEMI is basically determined based on what’s seen on the ECG test, and more importantly, on who is interpreting that test.

      According to these established diagnostic criteria, certain electrical waves on the test result show which area of the heart muscle is in trouble. STEMI (in which the S and the T waves are affected, as shown on the ECG) means higher risk that more heart muscle is being affected. In NSTEMI, those ECG changes are not seen, suggesting a lower risk that heart muscle is in danger. Think of it as an aid to emergency triage: which patient needs priority care first?

      However, in this woman’s case, she was clearly in trouble and getting worse while the experts debated whether she was sick enough to go upstairs to the cath lab. She had to be resuscitated. Her blood pressure dropped dangerously. She was intubated and a transvenous pacemaker was implanted. Her cardiac enzyme (troponin) test was positive (a marker for heart attack).

      She died 2 1/2 hours after she had arrived at that hospital, before the cardiac catheterization could be performed.

      I asked the senior paramedic who told me this story (and who was upset by this woman’s outcome) how this tragedy could have happened.

      Would this woman’s case be discussed at Grand Rounds? Taught at medical school to warn of the dangers of this kind of clinical disagreement? And what on earth had the Emergency team told this woman’s family? (“She died because we didn’t take her seriously?!?”)

      His response: “I guarantee this will NOT be considered a missed STEMI, and will NOT be included in official first medical contact or door-to-balloon statistics. The system is broken and needs to be fixed. Her official diagnosis was likely NSTEMI (non-ST elevation myocardial infarction). No one will learn anything, and they will rinse and repeat.”

      In answer to your question about ‘was it men who decided the degree of seriousness’? – I would say OF COURSE – because for decades we have had only men in senior cardiology positions and guideline writing roles. Women still make up less than 13 per cent of cardiologists, and only 4 per cent of practicing interventional cardiologists.

      Perhaps things will change as more women enter cardiology as a field. There are already a number of vocal leaders emerging – very promising news.

      Meanwhile, read this 2012 post I wrote that confirms your own opinion: “No Such Thing As a ‘Small’ Heart Attack” which includes more on this STEMI vs NSTEMI debate that some doctors are having while women are dying in front of them.

      Thanks for weighing in here, Eva…

      Like

      1. And to add to the dilemma, some people, like me, have a Left Bundle Branch Block on their EKG. Which makes their EKG always look like a STEMI. My EKG can never be used to rule out or in an MI so the docs scratch their heads and have to use other criteria.

        Liked by 1 person

        1. I sure hope you’re wearing a clearly visible medical I.D. that says that specifically in case you are ever in the unfortunate position of being found unconscious or unable to speak for yourself, Jill.

          It’s increasingly recommended, as this article on Medical I.D. reminds us, to note what is NOT the issue. For example, the paramedic I interviewed describes how his stepdaughter (with a history of brain tumours/seizures) wears 24/7 medical alert tags that let first responders know that hemianopsia (decreased vision or blindness in half the visual field of one or both eyes) is a “normal” finding for her.

          The ability to interpret EKGs is tricky (often an issue even in heart patients who don’t have LBBB or other conditions that may appear confusing). I follow a number of first responders online whose shared hobby (some might say “obsession”!) is to challenge each other to figure out the diagnosis based on minimal de-identified patient demographics (age, sex, history, early symptoms) along with a screenshot of that recent patient’s EKG.

          It is astonishing to me how often dozens of these “votes” (all from Emerg physicians and paramedics who do this for a living) support a variety of (incorrect) diagnoses! There are some rumblings out there among some docs/first responders to do away with the whole STEMI/NSTEMI classification formats. Stay tuned…

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  3. I look forward to your emails every week! I have a BIG problem with blood pressure that got so bad I felt pressure in my chest and neck. But because it was hours on end and I was still standing, I thought it was no big deal. Until I had a ambulatory blood pressure test over the course of 24 hours.

    Now I am on higher powered meds and they have helped even with my heavy feeling legs. I ran across this article today and know how much it plays into heart disease. Keep on keeping on Carolyn!

    Liked by 1 person

    1. Hello Lynda – so glad that your high blood pressure is being taken seriously now. High blood pressure typically has few if any symptoms (which is why it’s hard to convince people to keep taking their blood pressure meds (unlike pain meds for example where there’s a clear ‘before and after’ effect when taking medications). Thanks so much for sending me the link to this NYT article. The idea that high blood pressure happens so much earlier in women compared to men (even in the 3rd decade of life) is an important change in thinking about hypertension!

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  4. This is so important, Carolyn.

    I was very fortunate in 2017, when I went to Emergency with shortness of breath and dizziness. I remember, as I was asked about whether I had had many other symptoms, that it was possible I had had a heart attack. That women with heart attacks could have different symptoms than men and it was sometimes hard to diagnose.

    I was diagnosed with Prinzmetal or Cardiac Microvascular Disease, after a week of daily physical tests and bloodwork.

    Liked by 1 person

    1. Hi Jenn – you’re describing the dream hospital experience for all people with non-obstructive heart disease: a trip to Emergency that included staff who seemed well-informed about this diagnosis, and indeed, even acknowledged that this can be “hard to diagnose”. (Much better than hearing “It’s not your heart!”) If only all clinicians were as educated as your team was…

      Like

  5. As always thank you for this posting. I have been recently diagnosed with Microvascular Disease approximately 18 months after a quadruple bypass and a month after an angiogram that resulted in a stent.

    Usually I blame myself for not being clear enough with my doctors (all male) about my symptoms, downplaying them, trying to sound normal because I think I am exaggerating. It has been hard to convince my caretakers that I can have heart disease when I am not overweight, have no high blood pressure or high cholesterol, and I exercise daily. It’s my genes, mother, father, brother, etc.

    This posting helps me be more confident in how I present myself when I am describing my symptoms to my doctors. I wish there was a support group just for MVD patients on Vancouver Island. Thank you

    Liked by 1 person

    1. Hello Ann and thanks for sharing your unique perspective. I hope you’ve now reached your maximum lifestyle quota of invasive cardiac procedures, and that this most recent diagnosis will be the last one you have to adjust to! I’m not aware of a support group for those of us with MVD here on the Island (although you might want to visit the online WomenHeart group for MVD patients if you haven’t done so already.)

      Also, have you watched the 2019 INOCA “Meeting of Minds” conference videos? This was a medical conference held in London, England last summer, including the Who’s Who of MVD experts; many keynote speakers were filmed. You can watch the videos here (just scroll all the way down the page until you see the video on Patient Voices, which I think you’ll find really interesting.

      Also check out the videos on the same site of clinical presentations, too: there are some interesting studies discussed on lasting after-effects of invasive cardiac procedures themselves that can damage coronary arteries (post-stent, for example).

      You make such an important point for ALL women when you stress being confident in describing our symptoms!!! Thank you Ann for that reminder.

      Like

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