My interest in women’s misdiagnosed heart attacks began after my own misdiagnosed heart attack. Despite textbook cardiac symptoms of central chest pain, nausea, profuse sweating and pain down my left arm, I was confidently told: “You’re in the right demographic for acid reflux!” – and sent home from the Emergency Department.
I know that, had I been appropriately diagnosed and treated on that fateful day, I’d have little interest in this topic. But I wasn’t. So I do. . .
Yet emerging studies continue to look the same: Different researchers, different dates, different academic institutions – but basically, the study conclusions I write about are the same, best summed up by my irreverent heart sister Laura Haywood-Cory (a survivor of a SCAD heart attack at age 40 and, like me, a graduate of the WomenHeart Science & Leadership training at Mayo Clinic), who bluntly translates them like this:
“Sucks to be female – better luck next life!”
“This research clearly shows that women are at a higher risk of being misdiagnosed following a heart attack than men.”
I want this to stop.
But alas, no sign of stopping any time soon. Here’s the latest evidence, this time from Spain.(2) Lead author Dr. Gemma Martinez-Nadal reported that physicians were significantly more likely to consider heart disease as the cause of chest pain in men, compared to women. This gender bias was maintained “regardless of the number of risk factors or the presence of typical chest pain in women.”
Physicians in this study were asked a simple question (the same question that your physician faces if you report chest pain): was this chest pain due to either “a coronary cause or another cause such as anxiety or a musculo-skeletal complaint?”
The answer to such a simple question could be called the rate-determining step, as explained by my late ex-husband (a chemical oceanographer and researcher).*
In other words, the answer physicians give to this question will determine whether your cardiac symptoms will be taken seriously.
The answer physicians give to this question will determine whether you’ll be referred for further cardiac diagnostic tests in case your initial tests come back “normal” – as so often happens to women even in mid-heart attack – because cardiac diagnostic tools have been, until recently, designed/developed/researched in (white middle-aged) men.
The answer physicians give to this question will determine whether you’ll be referred to a cardiologist.
But once a physician has locked onto anxiety or any other psychological reasons for your symptoms, you can essentially kiss a cardiac diagnosis goodbye. See also: “When Your Doctor Mislabels You As An “Anxious Female”
That’s the rate-determining step. This kind of diagnostic error is often based on what social scientists who teach critical thinking skills call an anchoring bias – “locking on to a diagnosis too early” (and pronouncing, for example: “You’re in the right demographic for acid reflux!”)
This new Spanish research seems alarmingly similar to Dr. Gabrielle Chiaramonte’s 2008 Cornell University study.(3) I described her research like this:
“Some of the patient reports listed a “recent psychological stressor” in the patient’s life.
“When physicians reviewed charts in which heart disease symptoms were presented in the context of a psychological stressor, fewer women received coronary heart disease diagnoses than men did (15% vs 56%), or cardiologist referrals (30% vs 62%), or prescriptions of cardiac medication (13% vs 47%).
“Researchers found that just the mention of recent stress shifted the interpretation of women’s symptoms so that these were thought to have a psychological origin.
“By contrast, men’s comparable symptoms were perceived as cardiac whether or not psychological stressors were present.”
While not all worrisome chest pain symptoms are due to a heart attack, the increasing weight of research on gender bias in cardiology does not lie. See also: “There Is No Gender Bias in Medicine. Because I Said So…”
Meanwhile, here’s how Dr. Martinez-Nadal presented her research results this month to her colleagues attending the European Society of Cardiology’s Acute Cardiovascular Care Congress:(2)
“Heart attack has traditionally been considered a male disease, and has been under-studied, under-diagnosed, and under-treated in women.
“Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being under-estimated in women. Chest pain was misdiagnosed in women more frequently than in men. This low suspicion of heart attack occurs in both women themselves and in physicians, leading to higher risks of late diagnosis and misdiagnosis.”
One of these studies dates back to 2008, one from three years ago, and another (all with essentially identical conclusions) dates from last week. So you tell me: are men’s cardiac symptoms still taken more seriously than women’s?
And what can women do when they truly believe the diagnosis doesn’t match their symptoms? Dr. Jerome Groopman, in his must-read book “How Doctors Think” , suggests that you ask these three questions of your doctor before you leave:
- “What else could it be?” The cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
- “Is there anything that doesn’t fit?” This follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
- “Is it possible I have more than one problem?” Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, to order more tests that might not have seemed necessary based on initial impressions.”
This problem of cardiac misdiagnosis in women must be addressed in medical school training, in physicians’ ongoing professional development, and, most importantly, in mandatory reporting of diagnostic error. The field of medicine, in fact, is alone among all professional workplaces in that, when something goes wrong for the client, the official kneejerk response is to refuse to talk about it. We can’t fix something that physicians refuse to even measure. See also: Mandatory Reporting of Diagnostic Errors: Not the Right Time?
Sadly, I’m thinking that Laura Haywood-Cory’s conclusion is still correct.
PLEASE don’t leave a comment here detailing any symptoms you may be experiencing. I’m not a physician so am not qualified to advise you. Please see a physician to ask specific medical questions.
* Rate-determining step: “In a sequence of elementary steps by which a chemical reaction occurs, the slowest step in a chemical reaction mechanism is known as the rate-determining step. The rate-determining step limits the overall rate and therefore determines the rate law for the overall reaction.”
1. Wu, J., Gale, C., et al. “Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study.” European Heart Journal: Acute Cardiovascular Care, 7(2), 139–148. 2018
2. Gemma Martinez-Nadal, “An analysis based on sex & gender in the chest pain unit of an emergency department during the last 12 years”; results presented at the the European Society of Cardiology’s Acute Cardiovascular Care Congress, March 12, 2021.
3. Gabrielle Chiaramonte, Cardiovascular Research Foundation. “Signs Of Heart Disease Are Attributed To Stress More Frequently In Women Than Men.” 14 October 2008.
Image: Annalise Batista, Pixabay
Q: Despite all of these studies, why are women’s cardiac symptoms still taken less seriously than men’s?
NOTE FROM CAROLYN: I wrote more about this and other diagnostic issues affecting female heart patients in my book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, 2017). 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 Johns Hopkins University Press (and use their code HTWN to save 20% off the list price).