Why Women’s Heart Disease Is Not Studied Like Men’s?

Despite the fact that heart disease is the number one killer of women, women are still not being included in proportionate numbers in large heart disease trials and that’ why we didn’t studied enough the women’s heart disease!

In fact, on average, only about 30 percent of cardiac trial participants are women. And even when women take part in larger numbers, very few of those studies are designed to conduct sex-specific analysis—so the fact that we are enrolling more women doesn’t mean we are getting more or better information. In fact, the information we’re getting is reinforcing the male-centric model of heart disease diagnosis and treatment, not reversing it.

Here’s a great example of this. When a man havin a cardiac arrest comes into the ED, it’s often a scene like what I described at the beginning of this chapter. The EMTs are doing CPR, everyone is rushing around, and once we get him inside, the man is “shocked” to bring his heart back to a normal rhythm. (We don’t use paddles anymore like you see in the TV shows or do dramatic countdowns before we shock someone, but you get the picture.)

See Also: Women’s Heart Disease Is Not Treated Like Men’s

What we don’t know?

What most people don’t know is that men in cardiac arrest are more likely to exhibit a pattern we call ventricular fibrillation, or V-fib. This is a type of cardiac arrhythmia in which the heart “quivers” rather than beats, resulting in loss of consciousness and little or no pulse. V-fib is also the “shockable” heart rhythm, meaning that an electrical jolt to the heart muscle will often “reset” the electrical impulses that control the ventricles and start the heart beating normally again.

One study found that if you’re able to get the heart to restart in a case of V-fib, cooling the patient helps reduce inflammation and protects the brain during the healing process. The idea is that you can live a lot longer when you’re hypothermic than you can when you’re overheating; the colder it is, the less energy your body uses on metabolic functions. So when we cool V-fib patients by way of cooling pads placed around the body or an intravenous device, they are more likely to wake up with their brain and other vital organs undamaged (or less damaged) by the short-term lack of blood flow.

Of course, this was a hugely exciting discovery, and hospitals around the country immediately began to put this simple cooling procedure into practice. But immediately, I noticed a big issue. The study was only performed on V-fib patients—who happen to be mostly men.

Women in cardiac arrest are more likely to come in with pulse-less electrical activity (PEA), or asystole, which is where the heart stops beating altogether and “flatlines.” And despite what happens on the TV dramas, this condition is not shockable. Unless the heart spontaneously restarts on its own (which does happen on occasion), our only tools are epinephrine and old-fashioned CPR.

This is just one example of how our male-centric approach creates innovative treatment options for men but underserves women. The fact is that V-fib patients have a better prognosis, so from a study-design standpoint, they were a better choice than patients with PEA to evaluate for this kind of neurological protection. Clinically and ethically, it makes sense to study the issue where you might be able to make a bigger difference; it’s good study design.

The issue isn’t that researchers chose to study V-fib. It’s that, despite the enormous lifesaving implications of this research, women were underrepresented in it due to the nature of the condition being studied. In practice, research like this expands my options for treating V-fib patients but doesn’t give me additional tools for treating many of my female cardiac arrest patients, because techniques like the one described above were not sanctioned for use in non-V-fib patients.

One current study is looking at cooling “non-shockables,” which would solve a large portion of the issue mentioned above—but the results are years away from becoming part of the algorithm for treating PEA patients in ED settings. This kind of thing is fairly common. Studies are structured around male models first, and then “follow-up” studies look at the models first, and then “follow-up” studies look at the same treatments, procedures, or effects in women. But while those secondary studies are being approved and conducted, women lose out on potentially lifesaving benefits.

Then there’s the issue of plain old exclusion. As I mentioned in Chapter 2, when we explored the evolution of male-centric medicine, women of reproductive age must often be tested for pregnancy as a condition of their participation in clinical trials, and there’s always the concern that they might become pregnant during the course of the trial.20 Recently, an ED physician and researcher invited to speak at Brown University outright admitted to me that his hospital had excluded female patients from their ED-based study because they didn’t want to incur the time and expense of pregnancy testing. This underscores the reality that, in some clinical environments, female bodies are considered obstacles to effective research, not necessary factors in studying the human population.

References:

  • Hypothermia After Cardiac Arrest Study Group, “Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest,” New England Journal of Medicine 346 (2002): 549–556. doi: 10.1056/NEJMoa012689
  • Jessica E. Morse et al., “Evidence-Based Pregnancy Testing in Clinical Trials: Recommendations from a Multi-Stakeholder Development Process,” PLOS ONE 13, no. 9 (2018): e0202474. doi: 10.1371/journal.pone.0202474.

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