Women suffer inequality in cardiac care

Posted: 01/10/2019

Women are twice as likely to die from coronary heart disease leading to a heart attack than they are from breast cancer. Yet while this is a leading cause of death in both sexes, in women it is poorly understood by patients, and under-diagnosed and under-treated by the medical profession, meaning that 8,200 women may have died unnecessarily over the last 10 years.

This is according to a campaign by the British Heart Foundation ‘Bias and Biology’[1].  The campaign seeks to correct the misconception that heart disease is a problem affecting men only, and to assist both patients and medical professionals in recognising the potential for a heart attack at an early stage.

The briefing identified multiple factors contributing to the difference in management and survival rates between the sexes. For instance the average age of women experiencing a STEMI (ST-elevation myocardial infarction – the most serious form of heart attack caused by a complete blockage of a coronary artery) is older than in men (by nearly 10 years), and women tend to have more comorbidities than men. However, the studies make it clear that there are missed opportunities to make a prompt diagnosis and to provide a similar level of care to both sexes.“

The discrepancies start from the outset. On average, women tend to present to hospital later than men do, because they are less likely to recognise the symptoms as indicative of a heart attack. There is also a misconception that younger women simply don’t tend to have heart attacks and therefore they are less likely to seek hospital treatment even with symptoms which can be typical of a heart attack.

The study debunked the myth that women suffer unusual or atypical signs of heart attacks. In fact, when questioned carefully, women and men described their symptoms in the same way. The symptoms vary between patients, but typically include central chest pain that doesn’t improve; pressure or tightness in the chest; pain radiating down the left arm, or both arms, or to the neck, jaw, back or stomach and feelings of sickness, sweating, light-headedness, or shortness of breath.

Unfortunately delays in patients seeking treatment may then be compounded by delays in diagnosis. A person receiving an incorrect initial diagnosis is 70% more likely to die within a 30 day period than a patient receiving an immediate correct diagnosis, and women are 50% more likely to receive an incorrect diagnosis than men[2]. Women are 34% less likely than men to receive coronary angiography, which is frequently the definitive method of diagnosing a STEMI.

Treatment too tends to be poorer in women. Research in 2016[3] reviewed over 600,000 acute medical admissions for heart attacks and compared the treatment of women to that of men, looking at 16 indicators of the quality of that treatment. On average, women received a poorer standard of treatment. For instance, they were 3 per cent less likely to have blood flow restored to the heart using drugs or stents, and 4.2 per cent less likely to be given appropriate anti-clotting drugs.

Following treatment of an initial event, women are then, on average, less likely to take steps to address the risk factors of a future cardiac event, and less likely to receive appropriate treatment. The risk factors that are fairly well known include smoking, high blood pressure, high cholesterol, and diabetes. In fact these risk factors increase the risk in women more than they do in men, and therefore it is of greater benefit to women to stop smoking, treat high blood pressure and address potential diabetes or high cholesterol levels. Yet the study suggests that women are more likely to underestimate their personal risk of heart attacks and less likely to address lifestyle factors. This is then compounded again by apparent bias in the medical profession, with GPs 2.7 per cent less likely to prescribe statins to women than men, and 7.4 per cent less likely to prescribe beta-blockers.

Even in research that aims to improve our understanding of cardiovascular disease, women are underrepresented, with two thirds of studies being carried out on men[4]. Historically men appear to have been more likely to put themselves forwards for studies.

There is, therefore, overall, a significant discrepancy between the recognition, diagnosis and treatment of heart disease and heart attacks in women compared to men. This includes both patient factors and substandard treatment by the medical profession. The intention of the BHF’s campaign is to redress that balance.

The first step the BHF has identified is to raise awareness amongst the public, to ensure that women know their risks and to take action to look after their heart health. This is largely the purpose of the current campaign. Following that, steps will be required to tackle the inequality within the medical system. Further research is needed to establish why women do not receive the same standard of care, and some progress is being made here. For instance, recent studies have developed highly sensitive tests for troponins, a hormone released during a heart attack. The studies suggest that men and women may produce different levels of troponin, and therefore different thresholds may need to be applied.

Emma McCheyne, senior associate in Penningtons Manches Cooper’s clinical negligence team, commented: “The differences in the quality of treatment between the sexes is stark. It’s important to note that most people will receive good care if they suffer a heart attack, but on average two women are dying unnecessarily every day, and prompt, accurate diagnosis is critical. Unconscious bias seems to play a key role and with better education of the public and the medical profession, I would hope to see these statistics improve shortly.” 

[1] www.bhf.org.uk/-/media/files/heart-matters/bias-and-biology-briefing.pdf

[2] Wu, J, Gale CP, Hall M, et al. Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study. Eur Heart J Acute Cardiovasc Care. 2018;7(2):139-148  doi: 10.1177/2048872616661693. Epub 2016 Aug29

[3]Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study Heart. 2018;105(7): 516-523. doi: 10.1136/heartjnl-2018-313959. Epub 2018 Nov 23.

[4] Nguyen QD, Peters E, Wassef A, Desmarais P, Rémillard-Labrosse D, Tremblay-Gravel M. Evolution of Age and Female Representation in the Most-Cited Randomized Controlled Trials of Cardiology of the Last 20 Years. Circ Cardiovasc Qual Outcomes. 2018;11(6):e004713. doi: 10.1161/ CIRCOUTCOMES.118.004713

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