In Heart Attack, Gender Matters
Women Less Likely to Receive Lifesaving Treatments, More Likely to Die From Severe Heart Attacks
By NICOLE MARTIN, M.D.
ABC News Medical Unit
Dec. 8, 2008—
Even though heart disease is the No. 1 killer of American women, female patients don't always receive the same aggressive treatment that their male counterparts do for heart attack, new research suggests.
The researchers further conclude that among patients who have major heart attacks, women are more likely to die -- a disparity that heart doctors say must stimulate change.
"The fact that nothing has changed over the years and that disparities in care persist should outrage all of us and cause a major change in attitude and clinical practice," said Dr. Sharonne Hayes, director of the Mayo Clinic Women's Heart Clinic. "We, in the medical profession set our own benchmarks and guidelines for care, and then are unable to follow our own rules and advice."
"I am very distressed to see that we're still not giving women equally aggressive treatment for acute heart attack as we are men," Dr. Marianne Legato, founder and director of the Partnership for Gender-Specific Medicine at Columbia University College of Physicians and Surgeons, told ABC News Medical correspondent John McKenzie.
The new study, published in the journal Circulation, and sponsored by the American Heart Association's Council on Clinical Cardiology, looked at 25,000 patients with severe heart attacks and 78,000 patients in all. What it found was that women suffering from heart attacks are less likely to receive recommended medications in a timely fashion or undergo procedures to treat artery blockages.
In this study, women with heart attacks tended to be older and have more chronic medical problems than men, which likely accounted for some of the difference in death rates.
However, among patients with a certain type of severe heart attack -- called an ST-elevation myocardial infarction, or STEMI -- women were almost twice as likely to die as men. Specifically, while about 5 percent of men died, 10 percent of women died.
Even when the researchers made adjustments for age and other risk factors, women still had a 12 percent higher risk of death in the hospital. And during the first 24 hours of hospitalization, women with STEMI were about twice as likely to die as men.
Lead study author Dr. Hani Jneid, assistant professor of medicine at the Baylor College of Medicine in Houston, emphasizes that "this population of women [with major heart attacks] needs to be taken care of very aggressively" during early hospitalization. Jneid noted, however, that more research is needed to confirm their findings on early deaths in women.
Why the Gap?
Over the past two decades, the medical community has made great strides in heart attack care. Stents, new medications and better systems for coordinating treatment have saved countless lives. But despite these advances, women still receive less recommended care than men.
Experts cite a host of possible reasons for the gaps in care and death rates, including delays in diagnosis and treatment, bias on the part of health care providers, and lower rates of lifesaving procedures, including cardiac catheterization and stent placement.
And then there is the perception that women are not as prone to heart disease as men.
"We still don't see women as at risk for heart disease," Hayes told McKenzie. "When [a female patient] walks into our office or comes in on the ambulance, people are not thinking 'heart,' so they don't treat it."
That's just what happened to heart attack survivor Debbie Dunn.
"I walked into the emergency room with heart attack symptoms, and for the next three hours was challenged by the medical team," she told McKenzie. "Being only 45 years old, and appearing healthy, they felt I was looking for attention."
Part of the problem may be that for women, in many cases, heart attack symptoms may not be so obvious.
"It is more challenging to decide on how best to care for the average woman compared to the average man having a heart attack," Hayes said. "Her symptoms may be more subtle and there are more of them. Her many other medical problems may need to be taken into consideration, or may distract from the cardiac evaluation."
It's also possible that more women with major heart attacks survive the trip to the hospital and die there, while more men may die before they arrive, said Jneid, who trained as an interventional cardiologist at Massachusetts General Hospital in Boston.
"But this is speculation," he said.
For patients with heart attacks, rapid diagnosis and treatment are essential. When appropriate medical care is delayed, more of the heart muscle is likely to be damaged -- and the risks of complications and death are higher. Therefore, experts say, it is important for all health care workers to be tuned into the possibility of heart attack.
"Health care providers, including EMS personnel, should be made aware of the atypical symptoms of heart attack that are more likely to occur in women, particularly elderly women," said Dr. Malissa Wood, co-director of the Corrigan Women's Heart Health Program at Massachusetts General Hospital. "This can lead to expedited triage and treatment of these women."
Cardiologists also stress the importance of patient awareness.
"Women need to understand their symptoms of heart disease may be different" from men's, said Dr. Suzanne Steinbaum, director of the Women and Heart Disease program at Lenox Hill Hospital in New York City. These may include "shortness of breath or jaw pain, back pain, fatigue, nausea, or even flu-like symptoms. And symptoms that may be concerning, including palpitations [a feeling of the heart racing in the chest] or dizziness, should be evaluated," Steinbaum said.
If women feel that they aren't being taken seriously in the emergency room setting, "they need to ask for a heart problem to be [ruled out]," Hayes said.
Disparities in heart attack care are only part of the problem, however, she said.
"We fall short in treating women for high cholesterol [and] heart failure, implanting lifesaving medical devices [like cardiac defibrillators], and [encouraging] participation in cardiac rehabilitation, to name a few," she said. She stressed the importance of preventative measures, which may include medications and lifestyle modification, in lowering women's heart attack risks.
Closing the Gap
Moving forward, Jneid's group plans to study whether "closing the gap" -- making statistical adjustments for gender differences in heart attack care -- can account for the difference in death rates. They also want to explore how factors, such as ethnicity and weight, come into play.
Hayes agrees that more research is needed to establish why the gender gap persists -- and how it can be eliminated.
"[We need] better protocols of care to help clinicians ... so doctors can see the forest and not just the many trees," she said.