by Carolyn Thomas 
Heart Sisters (on Blue Sky)
After surviving a misdiagnosed heart attack in my 50s, I was told by my family doctor during our 5-week follow-up appointment that the type of heart attack I’d experienced was widely known as simply the ‘widow maker‘.
This name suggested that a full blockage like mine in this particular coronary artery was usually fatal, thus making the patient’s wife an instant widow. But please note the gender bias here. Men – the only ones who could ‘make’ a widow – were clearly considered to be the ones suffering this heart attack. Doctors don’t, for example, call it the widower maker when a woman like me is the heart patient.
Legendary Emory University cardiologist Dr. Nanette Wenger (now in her seventh decade as a practicing cardiologist) was a young med student at Harvard when she first encountered cardiac research that claimed painful angina symptoms reported by female heart patients were“benign in women”. But Dr. Wenger was skeptical: “I realized that no one had ever bothered to study chest pain in these women.”
In the 1980s, Dr. Wenger among others led a push for equitable inclusion of women in all medical research funded by the National Institutes of Health. Including women in appropriate numbers became an official NIH funding policy in 1989 and was written into law in 1993. Sadly, Dr. Wenger later described this legislation as little more than a directive, adding: “It had no teeth!”
And when legislation that protects women has “no teeth”, researchers learn there will be no consequences for not respecting the law.
When the massive ISCHEMIA research was published in 2019, the Washington Post screamed out this headline:
“Stents and Bypass Surgery are No More Effective Than Drugs”
Right away, I spotted the problem. Of the 5,000+ participants enrolled in this $100 million study, over 3/4 of the final participants were men.
My question: how could anyone accurately extrapolate how the study’s conclusions apply at all to female heart patients when women made up only 23 per cent of the people being studied? To satisfy Dr. Wenger’s equitable cardiac research goal of including women fairly in these studies, why didn’t the principal researchers simply stop recruiting men when they knew how lopsided their recruitment efforts were?
Each cardiac study I write about seems to repeat the same grim conclusions. Different academic author, different title, different sleep-deprived grad students – but all with a weirdly similar conclusion. As my heart sister Laura Haywood-Cory has famously wondered:
“Do we really need yet another study on gender bias in cardiology that concludes:
“Sucks to be female. Better luck next life?”
Well, Laura, apparently we do.
The American Heart Association made headlines in 2016 by publishing its first ever Scientific Statement on Women’s Heart Attacks. Basically, the AHA Statement warned that heart disease in women is essentially under-researched, under-diagnosed, and then under-treated (sometimes even when appropriately diagnosed) compared to our male counterparts.
But I honestly don’t know which part of writing that last sentence upset me more at the time: the appalling conclusions of the Scientific Statement, or the fact that it was the first time in the 92-year history of the American Heart Association that the organization finally decided to issue an official Scientific Statement about women’s heart attacks.
Think about that for a moment. Women had to wait NINETY-TWO YEARS to be included in official heart attack practice guidelines? That requires a remarkable tolerance for under-researching, under-diagnosing and under-treating, especially given the small but deliberate shift around 1970 when physicians gradually – and I do mean gradually – began to address the reality of heart disease in women.
This may seem almost insultingly obvious now. Of course, heart disease affects women as well as men. But if we consider how long heart disease was perceived – often by both physicians and their patients – as a “man’s disease”, you might ponder how many women must have been reporting cardiac symptoms – which were then minimized, ignored or dismissed by well-meaning but poorly informed physicians.
The prevention and treatment of heart disease in women in the past was based on evidence that came from studies of predominantly middle-aged men, explains cardiologist Dr. Jennifer Mieres, a professor of cardiology and co-author of the 2022 book Heart Smarter for Women. As she explained:
“We thought back then that you could treat men and women the same. We had great advances in treatment strategies, but we were applying a one-size-fits-all approach – and clearly that wasn’t working. Treatment guidelines, for example, were well-designed for male patients and their symptoms – yet they don’t help diagnose cardiovascular disease in women.”
The statistics on misdiagnosis of women’s cardiovascular symptoms remain grim. Women are still nearly twice as likely as men to be misdiagnosed in mid-heart attack, and they are 30 per cent more likely to have their stroke symptoms misdiagnosed by Emergency Department gatekeepers.
And when it comes to cardiovascular research, we know that women are under-represented and under-studied. Even the lab mice used in early cardiac studies were male animals.
As a result, diagnostic and treatment guidelines are centered around the primary study enrollees. (Yes, those old white guys!)
Learn more at Does Your Hospital have a Women’s Heart Clinic yet? If Not, Why Not?
But here’s how this gender gap in cardiology has slowly been acknowledged and addressed over decades:
1970: Women’s experience and tolerance of cardiac surgery begins to appear in medical literature [1]
1980: Increased focus on various health issues concerning women (domestic abuse, breast cancer, menopause, cardiovascular health)[2]
1995: A chapter on cardiovascular disease in women is written by the Heart and Stroke Foundation of Canada[3]
1999: The American Heart Association presents a report on the primary prevention of cardiac disease in American women [4].
2004: The American Heart Association provides recommendations on cardiovascular disease risk factor management for women.[5]
2016: The American Heart Association finally issues that notorious first ever scientific statement on women’s heart attacks.[6]
2019: The American Heart Association publishes the stunning results of its National Survey on Women’s Awareness of Heart Disease, in which women’s awareness is significantly worse than its last survey 10 years earlier, and in what even the AHA describes as “a decade of lost ground”. Half of women surveyed, for example, cannot name chest pain as a cardiac symptom.[7]
2024: The pervasive misconception of heart disease as a “man’s problem” still contributes to under-diagnosis and under-treatment for women worldwide. [8]
1. King. K.M., Paul P. (1996) A Historical Review of the Depiction of Women in Cardiovascular Literature. Western Journal of Nursing Research, 18(1): 89-101.
2. Allen, D.et al (1991) “Feminist Nursing Research Without Gender.’ Advances in Nursing Science, 13 (3): 49-58.
3. Heart and Stroke Foundation of Canada: (1995) Heart disease and Stroke in Canada. Ottawa, Canada.
4. Mosca, L. et al. (1999) “Guide to Preventive Cardiology for Women”. Circulation. 99:2480-2484.
5. Mosca et al. American Heart Association Scientific Statement. “Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women.”Circulation. (2004);109:672-693.
6. Laxmi S. Mehta et al. American Heart Association Scientific Statement. “Acute Myocardial Infarction in Women“
7. Cushman M. et al. American Heart Association. “Ten-Year Differences in Women’s Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association.” (2021) Circulation. 6;143(7):e239-e248. Sep 21, 2020.
8. Al Hamid A. et al. “Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review. Cureus. 2024 Feb 15;16(2)
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Q: What do you make of the progress in women’s cardiac care?
Heart Sisters 
My story is sadly similar to other women’s. Misdiagnosis of NSTEMI MI and sent home from Emerg; diagnosed the next day, followed a months-long journey with coronary microvascular dysfunction . Dismissal of and misinformation about the coronary microvasculat dysfunction.
Have hope – because there are more female cardiologists; a 2021 ACC meta study found “data supporting the suggestion that a patient’s outcomes may be positively influenced if they are treated by a physician of the same gender.” https://www.acc.org/About-ACC/Press-Releases/2021/02/22/18/47/Female-Heart-Disease-Patients-with-Female-Physicians-Fare-Better
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Hello Simona – your story is indeed unfortunately similar to the experiences of so many other women during a heart attack, given that we know women are significantly less likely to be diagnosed appropriately – STILL! Thanks for sharing that link to the ACC study (Female Heart Disease Patients With Female Physicians Fare Better).
What I loved about that study’s findings was that, although female heart patients did have better outcomes when they had a female physician, there was one exception: male physicians who had work experience alongside female colleagues also had good outcomes, too. One suggestion that made sense referred to the unique benefit that this group of male physicians experienced because they were overhearing and observing how their female colleagues talk to (and listen to) heart patients every day. Very encouraging findings – I hasten to add however that it would be unfair to imply that male physicians aren’t good doctors (I personally have had a wonderful male cardiologist for the past 18 years who is both a skilled clinician and an awesome human being!)
Take care. . .❤️
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I too survived a “Widower Maker” at age 46. I am 66 and now also have epithelial dysfunction and take a combination of meds to keep that under control.
Every couple of years, I end up in the ER and then overnight in the hospital when the spasms don’t stop and I need help. I lay there in agony because my blood pressure and bloodwork do not match a cardiac issue.
I think my current Cardiologists “gets it” and hopefully my chart is correctly notated. They also think the first 15 seconds that the angina is gone I’m cured and the meds are stopped, only to start up again and then I’m in agony again.
Can I revel in no pain for at least 15 minutes before we make decisions to stop the nitro or whatever worked? Luckily it’s been a couple years and I have felt well.
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Hello Jennifer – you’re describing the basic nightmare for female heart patients – symptoms that are denied, ignored and dismissed. I wonder if a man lying there in AGONY would have his meds stopped within 15 seconds?
I’m so glad you’ve avoided that nightmare for a couple years and are feeling well now. One of my readers told me she carries a document at all times from her cardiologist – in case she’s ever admitted to a hospital where her vasospasm symptoms are being minimized.
Wouldn’t it be nice if docs simply believed women when we tell them we’re in trouble?
Take care. . .❤️
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