We now understand how women’s heart disease manifests differently than men’s and why it can be more difficult for our current tests and protocols to diagnose. But what about the women who already know that they have heart disease? Are they the lucky ones experiencing better outcomes?
Sadly, the answer is no. Our male-centric model is failing them as well.
Remember Julie from Chapter 1? I wish that I could say that her close call due to repeated misdiagnosis of her arterial occlusion was unusual, but it wasn’t. Cases like hers happen every day in emergency departments and doctors’ offices across America. Julie’s case is so interesting because the presentation of her symptoms was, in fact, “typical” of the male-centric model. It’s just that no one expected to see the typical symptoms of a sixty-five-year-old male manifesting in a thirty-two-year-old woman’s body.
According to the World Heart Federation, women are less likely to receive the same diagnostic tests as men even when they exhibit the same or similar symptoms; as a result, their heart disease is 50 percent more likely to be misdiagnosed initially.11 (Often, this will result in an anxiety diagnosis!) And despite procedural and prescription guidelines that despite procedural and prescription guidelines that suggest such treatments are valid for both genders, women are 34 percent less likely to undergo procedures like bypass surgery, stent implantation, and other procedures to clear arterial blockages; 16 percent less likely to receive a recommendation for aspirin therapy; and 24 percent less likely to receive a prescription for a statin (cholesterol-lowering) drug. The same study found that when this treatment gap was closed, women’s mortality results improved dramatically, to the point where they were nearly equivalent to men’s.
Another study, which looked at men and women with a form of heart failure referred to as heart failure with reduced ejection fraction (HFrEF), concluded rather bluntly that “although women with HFrEF live longer than men, their additional years of life are of poorer quality, with greater self-reported psychological and physical disability. The explanation for this different sex-related experience of HFrEF is unknown as is whether physicians recognize it. Women continue to receive suboptimal treatment, compared with men, with no obvious explanation for this shortfall.”12
In short, women are not getting the same treatment or quality of care as men. And despite the fact that this disparity in outcomes is widely recognized and documented, no one seems to know why it keeps happening.
Part of the issue is that researchers are not educated enough about sex differences to consider crucial variables in risk factors and female patterns of disease. It’s simply assumed that a heart is a heart and that the results and statistics that apply to men will naturally apply to women as well.
I saw a perfect example of this misconception on a CBS morning show in 2015. A well-known physician commentator was discussing a study that showed that good cardiac health (as determined by EKG/stress tests) in middle-aged men predicted not only a lower rate of cardiac death over the next ten years but also a lower rate of lung and colorectal cancer. When asked if the study included women, he replied, “This study just happened to look at men. One would assume that the results would be similar in women [but] that study hasn’t been announced or looked at yet.”13 Even this renowned doctor was apparently unaware that women at severe risk for cardiac events can still present with “normal” stress test results.
That the results of all-male studies are being That the results of all-male studies are being applied to women so offhandedly should be alarming—but within the medical community, this sort of thing happens all the time. Moreover, inviting the public to assume that stress tests are a major indicator of future good health is not only incorrect but dangerous.
If you’re tempted to say, “But that was years ago!” trust me, this type of thing is still happening. I recently read a study published in the Journal of the American Medical Association (JAMA) Cardiology detailing the results of a fifteen-year study on the relationship between heart disease and exercise.14 This study was also referenced in a New York Times article, which noted, “The researchers focused on the records of 21,758 men, most of them in their 50s. (They did not include women but plan to in a follow-up study.)”15
I could only shake my head and ask myself, Why are women always an afterthought?
Misperceptions about women and how they experience heart disease also contribute to how, when, and to what degree women’s cardiac issues are treated. A great example of this is the way chest pain units are run in hospitals.
A chest pain unit is pretty much what it sounds like. It’s a section of the hospital where people who are having chest pain (or other traditional symptoms associated with cardiac events) are sent for observation and testing. If you come into the hospital with symptoms that might be a heart attack, but it’s not clear to the ED physicians that you are actually having a heart attack, you will be sent to the chest pain unit for twenty-four hours or so. You’ll get repeated bloodwork and EKGs and maybe a stress test. If it’s apparent that something is going on, you’ll be sent to the cardiac ward. If not, you’ll be sent home.
The purpose of the chest pain unit is, ostensibly, to provide a safety net to patients who may be having a major cardiac event but aren’t necessarily in imminent danger or showing the classic symptoms. However, when you look at who is eligible to go to the chest pain unit, it’s easy to see that this entire system and all its attendant protocols are built according to a male-centric model.
While both men and women can exhibit chest pain during a heart attack, there’s also a group of people who don’t have chest pain. This group does include men but, statistically, comprises predominantly women. Both men and women who have a heart women. Both men and women who have a heart attack without that key symptom of chest pain tend to have worse outcomes across the board because they almost always experience a delay in recognition and treatment.
When it comes to who gets sent to the chest pain unit for testing and observation, several criteria inform an ED doctor’s decision. Blood enzyme levels, EKG results, and other factors (many of which we know are not always accurate indicators of heart attack in women) are considered. There’s also a gestalt factor, which basically asks the doctor, “How likely do you think it is that this person’s symptoms are from heart disease?” This subjective assessment is where many mistakes and oversights happen. Doctors are only human, after all.
The difference between male- and female-pattern heart attacks means that women are less likely to be admitted to the chest pain unit and more likely to be sent home without additional intervention. The protocols for observation and testing simply aren’t set up to look for female-pattern symptoms—and so, even women whose hearts are in imminent danger might be sent home with no diagnosis and inconclusive test results.
Even when women are admitted to the chest pain unit, they are less likely to receive the same tests as their male counterparts.
I conducted a study of chest pain unit admissions along with my colleagues Esther K. Choo, MD, and Anthony M. Napoli, MD. We found that “a physicians’ gender may impact test utilization in the diagnosis of acute cardiovascular disease.”16 For example, male physicians appeared less likely to use stress testing in female patients even after controlling for clinical variables. This indicates a disparity in decision making that is correlated with the interaction between male physicians and female patients.
Since cardiologists are the last stop on the decision train for patients in the chest pain unit, they are ultimately the ones who decide whether a patient stays for additional testing or gets sent home. And because a substantial piece of this assessment is subjective, there is room for inherent bias—or a simple lack of understanding about how female-pattern cardiac disease presents—to create a situation where a woman’s heart attack or cardiac dysfunction is overlooked, misdiagnosed, or undertreated.
The final factor that creates poorer outcomes for The final factor that creates poorer outcomes for women with heart disease is the treatment they receive post–heart attack. In her article “The Way to Women’s Heart Health,” Randy Young writes, “According to an AHA scientific statement on acute myocardial infarction (AMI) in women, ‘although referral to CR [cardiac rehabilitation] is designated as a performance measure of healthcare quality after AMI, CR has failed to reach more than 80 percent of eligible women in the last three decades.’”18 When women do receive rehabilitative treatment, it appears to be less comprehensive than that offered to men.
Related Article: Why Women’s Heart Disease Is Not Studied Like Men’s?
- “New Study: Women More Likely to Die After a Heart Attack Due to Unequal Treatment,” World Heart Federation, January 10, 2018, https://www.world-heart-federation.org/news/new-study-women-likely-die-heart-attack-due-unequal-treatment; Oras A. Alabas et al., “Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry,” Journal of the American Heart Association 6, no. 12 (2017). doi: 10.1161/JAHA.117.007123.
- P. Dewan, “Differential Impact of Heart Failure with Reduced Ejection Fraction on Men and Women,” Journal of the American College of Cardiology 73, no. 1 (2019): 29–40. doi:Cardiology 73, no. 1 (2019): 29–40. doi: 10.1016/j.jacc.2018.09.081.
- Jason Kashdan, “Healthy Heart May Help Men Battle Cancer, Study Finds,” CBS News, March 27, 2015, https://www.cbsnews.com/news/cancer-study-men-finds-cardio-exercise-may-reduce-risk-cancer-death-risk. Dr. David Agus is the commentator. Mention happens at 1:00 with a question from the anchor.
- Laura F. DeFina et al., “Association of All-Cause and Cardiovascular Mortality with High Levels of Physical Activity and Concurrent Coronary Artery Calcification,” JAMA Cardiology 4, no. 2 (2019):174–181. doi:10.1001/jamacardio.2018.4628.
- Gretchen Reynolds, “Can You Get Too Much Exercise? What the Heart Tells Us,” New York Times, February 6, 2019, https://www.nytimes.com/2019/02/06/well/move/can-you-get-too-much-exercise-what-the-heart-tells-us.html.
- A. M. Napoli, E. K. Choo, and A. McGregor, “Gender Disparities in Stress Test Utilization in Chest Pain Unit Patients Based upon the Ordering Physician’s Gender,” Critical Pathways in Cardiology 13, no. 4 (2014):152–155. doi: 10.1097/HPC.0000000000000026.
- Napoli, Choo, and McGregor, “Gender Disparities in Stress Test Utilization.”
- Randy Young, “The Way to Women’s Heart Health,” CardiovascularBusiness.com, January 7, 2019, https://www.cardiovascularbusiness.com/topics/structural-congenital-heart-disease/way-womens-heart-health; L. S. Mehta et al., “Acute Myocardial Infarction in Women: A Scientific Statement from the American Heart Association,” Circulation 133, no. 9 (2016): 916–947. doi: 10.1161/CIR.0000000000000351