Life-threatening differences in the way women and men are treated for heart care, persist. Two studies just out in the journal Circulation point out that despite established guidelines for heart care, women still come up short when it comes to the diagnosis and treatment of heart disease. WomenHeart spoke to Sharonne N. Hayes, MD, director of the Women’s Heart Clinic at Mayo Clinic in Rochester, MN and WomenHeart board member to learn more about why the inequities continue and how women can empower themselves and others to achieve equal and quality care for their hearts.
WH: The most recent study in the journal Circulation shows that compared with men, women have a 50% greater chance of being delayed in the EMS setting. A study just a month before pointed out that women are less likely to receive the same care as men in the hospital setting. Do these studies suggest doctors and emergency first responders are really having trouble spotting heart attack symptoms in women?
Dr. Hayes: Yes — While on the one hand, these findings are discouraging and reflect true disparities in care, on the other, we have to acknowledge that health care providers’ best efforts are hindered by the lack of good science about women and heart disease. There is no good study out there that tells us how similar or different women are from men when it comes to heart attacks. Sometimes the symptoms are not clear, clustered differently, and can be attributed to something like indigestion or anxiety. If you find yourself in an ambulance or emergency room, don’t be afraid to say to the paramedic or triage nurse, "I think I’m having a heart attack.” You want a proper diagnosis, and a straightforward blood test and EKG are the starting points. If the thought crossed your mind that you might be having a heart attack, you need to speak up.
WH: Are current hospital guidelines too generalized?
Dr. Hayes: For the most part, no. There may be a role for more individualized or gender-based care in the future, but right now, guidelines help women get the care that has been shown to improve survival and long term outcomes in large groups of patients. Part of the problem now is that the guidelines are less likely to be applied to women compared to men. We know that when hospitals have systems in place to ensure they provide care according to the guidelines, women’s outcomes improve, even more than men’s. An airline pilot would never take off without first going over every single item on a checklist. Check-off lists help doctors and hospitals too. When providers are supported by good systems and better training the decision-making process becomes efficient and doing the "right thing” becomes easy.
WH: Why do these differences exist in the care being given to men and women?
Dr. Hayes: There are multiple reasons. Misconceptions about women’s heart disease grew roots decades ago. In the 1960s, erroneous assertions that heart disease was a man’s disease were widely spread to the medical community and to the public. This led to research almost exclusively focused on cardiovascular disease in men. Many clinical trials in the 70s and 80s excluded women or simply didn’t make an effort to enroll women in sufficient numbers to draw sex-based conclusions. Another reason for the differences in care is caused by physician practice and referral patterns. Many women in the U.S. receive all or most of their medical care from their obstetricians or gynecologists. Traditionally, there has been a greater focus on reproductive and breast health in women than on their other health risks, and conversely, a lower awareness among obstetricians and gynecologists about identifying and treating signs of heart disease. Things are improving, because doctors are now talking more about gender and examining the process of heart disease in women. They want to provide the best care and they think that they are. And health care consumers are doing more too. As a patient, you can ask your doctor "What are you doing to improve the care of women with heart disease?” It’s a question worth asking. And we can’t underestimate the efforts of WomenHeart and other organizations that are doing a great job of educating and empowering women to be more knowledgeable and proactive about their heart health.
WH: Is there currently enough research being done specifically on women with heart disease?
This is a complicated subject. The lack of relevant research in women has resulted in a substantial sex-based knowledge deficit about everything from the "typical” heart attack symptoms in women, to the risks and benefits of commonly used diagnostic tests and therapies. In current cardiovascular research, we are not necessarily analyzing the data by gender and the need for gender-specific studies is not on the radar screen of researchers. Plus it is difficult to recruit women for these trials. Women have not bought into heart disease as a "woman’s” disease, so they don’t see the relevance or potential benefit of seeking out clinical trials. But heart disease is their number one killer, so they should be clamoring to be involved in this research, just as women clamor to participate in hormone trials or breast cancer research. Talk to your doctor about what is available and consider volunteering to participate in an approved clinical trial. Many times stipends are offered and medications are provided free of charge to participants. One website to check is www.clinicaltrials.gov
WH: As researchers learn more about the physiological differences between male and female heart disease, do you anticipate doctors will begin to make better and faster diagnoses?
Dr. Hayes: Yes, with the caveat that research takes time to trickle down to the bedside or patient care. The research community is good at discovering new things, but slow in putting them into practice. For example, studies in the 90s that showed that ACE inhibitors should be used in heart failure patients took seven years to trickle down to actual patient care. Much more data is needed and again one important way women help move the needle is by participating in clinical trials.
WH: Finally, what can women and the medical community do now to improve the identification and care of women with and at risk for heart disease?
Dr. Hayes: It is important to counter the widely held belief that women do not develop heart disease except when they’re old. Heart disease needs to be on the radar screen of every physician at every stage of a woman’s life. We need to continue to educate women and health care providers about women’s heart disease risks, symptoms and the use of appropriate diagnostic tests and therapies. We need to see wider and more consistent use of the American Heart Association evidence-based heart disease prevention guidelines. Most important in bridging this gap in heart care between men and women, is making the medical community and the women they care for more aware that heart disease IS a women’s disease every bit as much… or more… as it is a man’s disease.