When male and female heart patients play the same game, but with different rules

                                   .        Notice anything unusual about this group of doctors?

by Carolyn Thomas    ♥   @HeartSisters

She introduced herself to me as she took her seat – although she, of course, needed NO introduction. I was utterly star-struck to realize that THE Nanette Wenger had just sat down beside me in the Mayo Clinic auditorium hosting our conference on women and heart disease. Between the onstage presentations, she chatted amiably, graciously curious about me, a heart patient/panelist on that day’s conference schedule.  I asked about her early days as a female cardiologist in such a steeply male-dominated field. My take-away from that memorable autumn afternoon:  when a noted medical pioneer who has been a practicing cardiologist for 70 years speaks, you listen!

Here’s what Dr. Wenger recently had to say about a Yale University study – in her no-nonsense editorial published in the cardiac journal Circulation – Sauce for the Goose vs. Sauce for the Gander:  Should Men and Women Play the Same Game But With Different Rules?”          .     

Yale researchers led by Dr. Judith Lichtman had studied over 2,000 women aged 18-55 who had survived a heart attack, part of the VIRGO data on how our gender affects cardiac outcomes.  (Any woman under age 55 is considered “young” among heart patients, by the way – women seem to be far more at risk of heart attack post-menopause, but remember that heart disease is 20-30 years in the making). Among several conclusions published: when women sought medical help for their heart attack symptoms, 53% reported that their physicians did not believe their cardiac symptoms were heart-related.  The Lichtman study also found that, compared with men, both physicians and women themselves were more likely to perceive women’s cardiac symptoms as stress or anxiety.

Dr. Wenger’s editorial warnings to her cardiologist colleagues were blunt. For example:

“Because most of the young patients in this study had more than one traditional cardiac risk factor, physicians should be attuned to consider the diagnosis of coronary heart disease in young women who even mention chest pain, pressure, tightness, or discomfort in their presenting history – but in particular, those with multiple cardiac risk factors.”

These cardiac risk factors, of course, include not only those common to both men and women (e.g. a family history of heart disease, smoking, high blood pressure, high cholesterol, diabetes, etc.) but uniquely female factors such as pregnancy complications.  Every pregnant woman who has experienced such complications should now know that her risk of a subsequent heart attack has just been increased 2-3 fold compared to women who have never had such complications. For a list of several types of dangerous pregnancy complications, see:  Pregnancy complications strongly linked to heart disease)

Dr. Wenger adds in her editorial that although chest pain was the predominant cardiac symptom noted for both sexes, the younger women in the Yale study had presented with a greater array of non-chest pain warning symptoms, and independent of chest pain symptoms (e.g. indigestion, heart palpitations, pain/discomfort in the jaw, fatigue, nausea, shortness of breath).  Yet awareness that these symptoms were heart-related was lower for younger than for older women – and even among their physicians:

“Among the patients who sought care for their symptoms before hospitalization, both the women and the physicians who assessed them were less likely to attribute these early warning symptoms to heart disease.

“Physicians must appreciate the importance of the mention of chest pain in the context of a greater number of non-chest pain symptoms among women. In this scenario of multiple symptoms, the prompt recognition of acute myocardial infarction (heart attack) may be delayed with adverse consequences.”

In fact, Dr. Wenger noted that a greater proportion of the women studied had sought medical care because of concern about another non-cardiac health problem – such as diabetes – rather than their heart disease:

“Again, although the women sought care more frequently in the week before hospitalization than did the men, they were less likely to be told that their presenting symptoms related to cardiovascular disease.”

As you might expect from women under 55, the Yale study identified lack of awareness of their own personal cardiac risk factors as common among these women, as Dr. Wenger pointed out:

“Perception of risk may be particularly important in this relatively young population, in that over 40 per cent of these  heart patients reported that they did NOT consider themselves at risk for heart disease before their myocardial infarction (heart attack) – despite a substantial burden of cardiac risk factors.”

That observation, incidentally, reminded me of the infamous Lipstick Study.  This survey reported that only 10% of women over age 40 knew their personal cardiac risk factors –  vs. 64% of them who knew how much they weighed in high school.

As Dr. Wenger wrote in her editorial:

The cardiac risk factor burden and often the family history of heart disease may be important variables, although apparently healthcare professionals traditionally consider young women to be at low risk.”

In Dr. Wenger’s opinion, attempts to raise public awareness of women’s cardiac risk factors have stalled – despite the past 15 years of expensive public awareness-raising campaigns like the National Heart, Lung, and Blood Institute’s “Heart Truth” campaign, and the American Heart Association’s “Go Red for Women” initiative.

“Women’s awareness of heart disease as the major cause of illness and/or death for women had risen from 33 per cent to slightly over 50 per cent, but this awareness has plateaued in recent years, with the awareness being lowest in the most vulnerable women – those of racial and ethnic minorities.”

Dr. Wenger is not alone in her concern. In the latest American Heart Association’s National Survey, women’s awareness was actually lower than it had been a decade earlier. We are going backwards!  Half of women surveyed, for example, could not identify chest pain as a potential heart attack sign. See also: Women’s heart disease: an awareness campaign fail

Dr. Wenger expects no less from her cardiology colleagues: “The public and professional educational gaps are substantial.

For those who haven’t had the good fortune to meet Dr. Nanette Wenger in person, what you should know is that she is a true legend in her profession. As one of her colleagues observed: “Dr. Wenger has published more research papers in her 80s than most academic cardiologists publish in their lifetime!” 

Her earliest days in medicine were as a young Emory University cardiologist at Grady Memorial Hospital in Atlanta during the 1950s (that’s her in the front row of the group photo, above).  As she mentions in the video shown below: “I’ve been privileged to be the first woman to do many things in many areas – but fortunately, I was not the last!”  With over 1,300 research studies, book chapters, review papers and editorials she has authored or co-authored, Dr. Wenger has had an extraordinarily productive academic career as a clinician, as a researcher, and as an educator of doctors.

She was one of the first cardiologists, for example, to demonstrate decades ago the wisdom of getting her heart attack patients up out of their hospital beds and walking around – instead of the long-held (and dangerous) tradition of enforced bed rest for weeks. She was a strong advocate in the cardiac rehabilitation movement long before this even became a specialty. She was also a dedicated women’s health advocate during a time when doctors believed cardiovascular disease was basically a man’s problem – and one of the first among cardiologists calling attention to the fact that coronary heart disease in women was being both overlooked and inadequately managed. She has relentlessly called for women to be included equitably in cardiac research trials.(1)

I’ve been hearing and reading about this amazing 92-year-young clinical cardiologist, researcher and professor for a long time. Dr. Wenger remains one of our most outspoken and best known champions for women with heart disease. 

Dr. Nanette Wenger accepting her Lifetime Achievement Award from the American College of Cardiology in 2022 (presented by past-president Dr. Mary Norine Walsh)

1. J.S. Alpert: “Nanette K. Wenger: A Woman’s Life in Cardiology”. Clinical Cardiology 27, 114–115 (2004)


Q: Barely 13% of cardiologists today are women. Why have so few women followed in Dr. Wenger’s footsteps?

NOTE FROM CAROLYN:  I wrote more about cardiology’s known gender gap in 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).

See also:

-Dr. Wenger’s essay,A Call To Action for Cardiovascular Disease in Women  (Circulation, May 2022) revealed that despite public awareness-raising efforts, women surveyed in 2019 compared with women surveyed in 2009 were 74% less likely to identify heart disease as their leading cause of death.

Brave men” and “emotional women”:  gender bias and pain

Does your hospital have a Women’s Heart Clinic yet? If not, why not?

“There is no gender bias in medicine. Because I said so…”

Walking the tightrope: women cardiologists in an Old Boys’ Club

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