October 23, 2019

The Heart of the Matter: Disparities in Cardiac Health for Women

By Melissa Laitner, SWHR Director of Science Policy

Heart disease is often thought of as a man’s disease because it has long been portrayed that way in the media and because of the historical underrepresentation of women in medical research examining the disease. In reality, heart disease is the No. 1 killer of women nationally, although only about half of women are aware of this fact.

As recognition of this problem increased, research expanded to better scrutinize sex and gender differences in heart disease. We now know that heart disease may look different in women than in men.

In addition to the challenges in recognizing heart disease as an equal-opportunity illness, women are also facing disparities in treatment, new research suggests. A study in the European Heart Journal earlier this year reported that women and men do not receive equal treatment when suffering a cardiac arrest outside the hospital. Last month, a study published in Circulation: Heart Failure indicated that women are less likely to receive innovative new devices to address advanced heart failure. Finally, the Journal of the American College of Cardiology published a study this month demonstrating that women are less likely to receive certain treatments for heart attack compared to men.

The first study examined emergency medical service resuscitation events occurring from 2006-2012 in the Netherlands. Results showed women had a lower chance than men of receiving a resuscitation attempt by bystanders. Those witnessing the cardiac events were less likely to recognize cardiac arrest in women who collapsed as opposed to men, which led to delays in calling emergency services and delays in receiving treatment.

Cardiac arrest occurs when the heart begins beating irregularly and then stops beating entirely, and it can lead to death within minutes, barring electrical shock from a defibrillator. This is different from a heart attack, which occurs when a blockage in an artery restricts blood flow to the heart.

Women in the study were also less likely to undergo certain diagnostic and treatment protocol, and overall less likely survive the cardiac event. While researchers cautioned there were likely multiple reasons contributing to a lower survival rate — women were less likely to go into cardiac arrest while around witnesses, for example — it is clear that unrecognized symptoms of cardiac arrest can have severe effects for women in particular.

The second study examined patients receiving mechanical heart pumps to treat symptoms of advanced heart failures. Heart failure is a chronic and progressive condition where the heart muscle weakens until it is unable to pump sufficient blood to meet the body’s needs. When heart failure reaches an advanced stage in which symptoms become severe and disabling, many patients have the option to receive a mechanical heart pump, called a left ventricular assist device (LVAD). The LVAD is surgically implanted and battery operated, and helps the heart to pump blood while reducing severity of patient symptoms. These devices can act as a “bridge” to heart transplant or as a long-term therapy for advanced heart failures.

Previous studies have suggested socioeconomic status, race, and ethnicity lead to disparities in LVAD placement, and gender disparities have been noted as well. The current study sought to determine whether the introduction of smaller, more technically advanced heart pumps — and the increasingly popularity of the device overall — might increase LVAD use in women. Results of the study (which examined almost 30,000 hospitalizations from 2004-2016) confirmed that women continue to be a smaller population of LVAD recipients. In fact, women represented a larger proportion of recipients in the initial year of the study than in the final year of the study, despite LVAD implantation rates increasing overall for both genders.

The most recent study, conducted by scientists at the University of Edinburgh, demonstrated that certain high-sensitivity blood tests are able to accurately diagnose greater numbers of women suffering from heart attacks, but also that women were much less likely than men to receive recommended treatments for heart attacks. Higher sensitivity in testing resulted in an approximately equal proportion of women and men diagnosed (21% and 22%, respectively). However, women were only half as likely as men to receive treatments such as stent placement, antiplatelet therapy, and long-term preventative medications like statins.

These new studies contribute to a growing body of literature demonstrating sex and gender disparities in heart disease. Notably, women are more likely than men to report their providers are inadequately attentive to risk factors or symptoms of cardiac disease. When patients and providers are not taught to treat risk factors and symptoms of heart disease as equally significant in all populations, it can have a meaningful impact on treatment and prognosis.

Providers must be educated on sources of bias and how bias can affect treatment. Clinic and hospital protocols should be standardized to address issues of bias in treatment and to ensure that all patients receive the highest standard of care. And research should always prioritize a truly representative population so that sex differences can be examined as a matter of course. Broad studies on major chronic illnesses may mask sex and gender differences if results are not specifically analyzed for these issues.

Women have a long history of being taken less seriously in medical settings, and heart disease is simply one more area where women’s health has not been prioritized. For women worried about heart disease, learning how to be assertive in medical settings — reiterating concerns as needed, asking why physicians are choosing a particular course of action, and bringing an advocate with you to appointments — may be helpful. Research also suggests that physician-patient gender concordance (i.e., women patients going to women providers) may help women to receive better cardiac care.

But the onus should not be on patients to ensure they receive high-quality health care. Science and research on heart health must continue to evolve if we hope to fix disparities.