A British Heart Foundation (BHF) briefing titled ‘Bias and Biology: How the gender gap in heart disease is costing women’s lives’ was published on September 30 2019. According to this report, around 8,200 women died needlessly following heart attacks in England and Wales between 2002 and 2013 because of delays in diagnosis and in treatment, along with poorer aftercare. This finding is by no means new, as gender inequalities in the treatment of coronary heart disease have been recognised for sometime.
The BHF report was based on a study by researchers at Leeds University of data from MINAP (Myocardial Ischaemia National Audit Project), which studies all patients with acute coronary syndromes (including angina and heart attacks) who are admitted to hospitals in England, Wales and Northern Ireland. According to the report, 3.5 million women in the UK suffer from cardiovascular disease, around the same number as male victims. Yet, out of those women described in the report, one-third were admitted with an initial diagnosis that differed from the final diagnosis, implying a late diagnosis of acute coronary syndrome as well as an under-recognition of coronary heart disease in women. The reality is that cardiovascular disease is the leading cause of death in women throughout the world, and in the UK women are twice as likely to die from coronary heart disease as from breast cancer.
So, why is there a gender gap when it comes to heart disease? . It has been recognised for some time that oestrogens have a protective effect on the heart, primarily through effects on lipid metabolism. Thus, premenopausal women have been thought to have a lower risk of coronary heart disease, one that increases with a premature menopause. These facts have generated a stereotype whereby women are perceived as unlikely to suffer from heart attacks, even though the protective effect of oestrogen can be nullified by other risk factors, such as smoking, high blood pressure and diabetes. This means that both women themselves and doctors examining them are more likely to dismiss symptoms normally suggesting a heart attack in men as being trivial and insignificant in comparison.
Typically, a person suffering a heart attack presents with a sensation of pressure or heaviness in the middle of the chest, which sometimes spreads outwards to the left or both arms, neck, jaw or back. Some people describe other and less characteristic symptoms. Women are more likely to present with symptoms that do not match classical textbook descriptions of a heart attack. They are also less likely to report chest pain. Non-specific symptoms are commoner in women, such as shortness of breath, profound tiredness, lightheadedness and dizziness, anxiety, nausea and vomiting, and profuse sweating . Women have thus been frequently been perceived as being “emotional” and diagnosed with a panic attack or something similar when actually having a heart attack.
The BHF report is welcome, as it promotes a better awareness of coronary heart disease among both potential female victims as well as those medical professionals involved with their care. It is particularly important that doctors and nurses consider the possibility of angina or even a heart attack when women are seen with either typical or only suggestive symptoms of the same.
A new blood test has improved the diagnosis of heart attacks. The measurement of high-sensitivity troponin, a protein which is released from damaged heart muscle, has led to a new “chemical” definition of a heart attack, supplementing the traditional ECG diagnosis. Troponin is currently the preferred “biomarker” of heart muscle injury. The wide availability of troponin testing has facilitated the earlier detection of heart attacks in women. While an elevated troponin level may also identify other causes of heart muscle damage, it frequently draws attention to a heart attack that has hitherto been considered unlikely.
Gender inequality affects many spheres of life. Changes in organisational cultures are leading to greater equality in the workplace. There is no good reason why myths and stereotypes and the resulting biased thinking should continue to deprive women of appropriate high-quality care when they present with the symptoms of coronary heart disease.
Ashis Banerjee (retired Consultant in Emergency Medicine; treated many women with heart disease)