Although heart disease is the number one leading cause of death, accounting for approximately 23% of all deaths in America, women presenting with acute myocardial infarctions, or heart attacks, are less likely to receive proper treatment when compared to men. 

Judith Lichtman, a professor at Yale University, conducted a study evaluating this inequality. She and her team interviewed about 3,000 patients who were hospitalized with acute myocardial infarctions and collected information regarding symptom presentation, patient perception of their own symptoms and the course of diagnosis and treatment. They found that both women and their physicians were less likely to attribute their symptoms to heart attacks than men. In fact, 53% of women reported that their physicians did not believe their symptoms were indicative of heart attack as opposed to 35% of men who reported the same.

“The structural gender bias in cardiology stems from a historical failure to ensure gender balance in cardiology research,” wrote Dr. Sean Cai, a professor in the Department of Medicine at the University of Toronto. 

Cai wrote that the guidelines for the treatment of heart disease in women are based on studies that predominantly enrolled men. For example, aspirin was found to be a possible preventative medicine for heart attacks in the Harvard Physicians Health Study, which surveyed 22,071 participants, all of whom were male. 

The Journal of the American College of Cardiology published a study that investigated this lack of representation of women in clinical trials. They examined the participation of women in cardiovascular disease trials and found that women are under-represented in clinical trials for coronary heart disease and heart failure.

In addition, research has shown that current risk prediction models for acute myocardial infarctions do not include female risk factors, such as polycystic ovary syndrome, premature menopause, pre-eclampsia or preterm birth. These models do not describe the role of other pathologies in the development of acute myocardial infarctions in women, creating a critical error in the current estimation of cardiovascular risk.

A study conducted by Dr. Harlan Krumholz, a cardiologist and health care researcher at Yale University, examined the symptoms of patients who were hospitalized with acute myocardial infarctions. He found that, although chest pain is the predominant symptom for heart attacks in both sexes, women exhibited substantially more variation in atypical symptoms than men. Krumholz wrote that these findings may provide an explanation for the higher missed diagnosis rate in young women with AMI and may have important implications for teaching and improving clinicians’ ability to recognize the diagnosis of AMI in women.

“Usually the medical staff know that they experience [symptoms] differently. That’s why if a female comes with epigastric pain, they want to rule out cardiac problems,” said Usha Bhandari, a registered nurse at Pomona Valley Hospital Medical Center. “Usually they are pretty good with that, but definitely — so many times I have seen the doctors misdiagnose and they are sent home and they come back with bigger problems.”

One reason for the higher chance of misdiagnosis in women is because women are more likely than men to develop small vessel disease, a condition where blockages occur in the tiny vessels within the heart muscle rather than in the large, surface arteries. 

“We see a lot of women who have classic angina [heart-related chest pain], but their major coronary arteries look normal, so they are told it’s not their heart. But you might have a heart attack if the condition is not treated,” said Dr. Nadita Scott, a cardiologist and co-director of the Corrigan Women’s Heart Health Program at Massachusetts General Hospital.

Scott writes that small vessel disease is more difficult to diagnose than blockages in the larger arteries because of the differing size of vessels.

“Females presenting with cardiac chest pain, a lot of the time they get misdiagnosed as having anxiety or as having some other cause for their chest pain. Whereas males, they automatically get referred to the cath lab or they get treated a little differently, medically,” said Dr. Deepti Upparapalli, a cardiologist at Christiana Care Health System, “Within cardiology, it’s well known that being a male is a risk factor for having underlying heart disease. That is why a lot of the time when males come in, we automatically look for heart disease or blockages in the heart. Whereas in females, we know that they present with atypical symptoms so we have to consciously remember that atypical pains can be a cardiac type of pain in females.”

Traditional medical textbooks and forms of training underestimate the likelihood of women contracting heart disease by reinforcing outdated information about how it presents and manifests distinctly in men and women, emphasizing the need for a major shift in approach when treating heart disease. For both men and women, evidence-based approaches are needed to minimize the length of time between the onset of symptoms and treatment.

“I think that educating the doctors or giving more exposure and experience with different types of patients when training doctors [and] educating doctors during residency about the differing symptoms can help prevent dismissal,” said Dr. Rohini Patel, a Physical Medicine and Rehabilitation Specialist at Concentra Medical Center.

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