Women and Heart Disease – Part 2
In the second of two blogs, Enable Law lawyerLaurence Vick looks at medical risk factors in women’s heart medicine, and how they support accusations of a gender bias.
In my last blog I showed how, compared to men, women are less likely to be believed when they’re having a heart attack, less well-treated during and after a heart attack and more likely to die from one.
In this blog I would like to describe specific medical conditions which place women at a higher risk of heart complications.
Women who had a NSTEMI (Non-ST-elevation myocardial infarction – a form of heart attack) are 34% less likely than men to receive timely coronary angiography within 72 hours of their first symptoms.
Coronary angiography uses dye to reveal narrowing and blockages in arteries and is a crucial step in heart attack care. Research shows patients who receive early angiography for NSTEMI have better outcomes. Women were less likely to be prescribed statins and beta blockers when leaving hospital – medication which helps to lower the risk of a second heart attack.
Women who had a STEMI, a heart attack where the coronary artery is completely blocked, were less likely than men to receive emergency procedures including drugs and stents to restore blood flow to the heart.
In a 2016 study “Impact of initial hospital diagnosis on mortality for acute myocardial infarction”, a team at the University of Leeds headed by Professor Chris Gale considered the difference in survival rate that early diagnosis of STEMI or NSTEMI can make. Their research found that women who suffer a heart attack are 50% less likely than men to be correctly diagnosed.
SCAD (Spontaneous Coronary Artery Dissection) is a rare emergency cardiac condition which predominantly affects women in late pregnancy or soon after giving birth. Although SCAD causes a small percentage of heart attacks overall it is the most common cause of heart attack in women under 50.
It is a good example of the challenge of arriving at a correct diagnosis by traditional techniques, because a woman may suffer a SCAD heart attack without any heart arteries being blocked. Instead, an artery of the heart suddenly closes upon itself.
Women may appear healthy and have no obvious risk factors. SCAD can only be diagnosed with an angiogram demonstrating blood flow in the heart’s blood supply. There is a risk that SCAD patients can be discharged from hospital in the middle of a heart attack that may remain undiscovered for days. Further, SCAD is often misdiagnosed, leading to treatment which can cause more damage to the affected artery.
BeatSCAD is a UK charity doing an excellent job of raising awareness of the condition and working with the BHF and the research team at Leicester University, Glenfield Hospital.
A 2019 University of Oxford study found GPs were 9% more likely to miss the signs of heart failure in women.
The symptoms of heart failure don’t vary between the sexes, but the causes do.
In men, the most common cause is heart disease or having had a heart attack. In women, the chief cause is uncontrolled high blood pressure which, over the years, puts a strain on the heart. The extent of the underdiagnoses of heart failure was observed to be so great – especially among women – that the true figure affected could run into the millions.
A 2013 study showed women have long been under-represented in clinical trials for treatments to a condition which has worse outcomes for them.
Abdominal aortic aneurysms (AAAs) are a bulge or swelling in the main blood vessel that runs from the heart down through the chest and abdomen. AAAs are more likely to rupture in women, and women over 65 who develop an AAA face a higher risk of death. Women’s outcomes following surgical procedures for AAA are also reported to be significantly worse when compared to men.
Maternal health implications
Issues arising in pregnancy which have heart-related risk factors include:
- gestational diabetes
- persistent high blood pressure and pre-eclampsia
- pre-term delivery
- polycystic ovarian syndrome
Maternal heart disease has emerged as a major threat to safe motherhood and women’s long-term heart health. In the US disease and dysfunction of the heart and vascular system is now the leading cause of death in pregnant women and women after childbirth – accounting for around a quarter of pregnancy-related deaths. The figure for the UK is around half of that.
Type 2 diabetes increases the risk of heart disease in everyone with the condition but, it is thought, more so in women. Women with diabetes frequently have added risk factors such as obesity, high blood pressure and high cholesterol.
US studies show that although women tend to develop cardiovascular disease around ten years later than men, diabetes removes that advantage. In women who have already had a heart attack, diabetes can double the risk of suffering a second heart attack and increases the risk for heart failure.
Type 1 diabetes is associated with a 47% excess relative risk of heart failure in women compared to men. For women with Type 2 diabetes the excess risk is 9% higher. Around four million people in Britain are living with diabetes, with the majority (92%) suffering from Type 2. Around 44% of all cases are women.
The chemotherapy used to treat breast cancer may increase the risk of cardiovascular disease which remains a lasting threat for breast cancer survivors. Heart problems can appear more than five years after treatment.
In The Sports Arena
Historically female athletes have also been under-represented in the research relevant to sports cardiology but in recent years studies have been carried out into gender differences as an important biological variable. Heart conditions including Athlete’s Heart in women can present in a very different way from men. This is reflected in guidelines for the interpretation of ECGs. I will be covering cardiac testing in sport and the medico-legal implications of gender on key issues within sports cardiology in a future article.
Progress has been made in raising awareness of heart disease and the threat it presents for women’s health. Ways must be found though, and still more needs to be done to redress the imbalance and close the gap in treatment and health outcomes for women and expand gender-focused research and the development of gender-based guidelines.
This September the British Heart Foundation will launch their Women and Heart Disease campaign, aiming to narrow the gender inequality in cardiac medicine, and I hope this will be a significant step towards the provision of equal heart care for all.
New report highlights how the NHS is failing women: University of Leeds. All-Party Parliamentary Group on Women’s Health report. 19 July 2019
Link between diabetes and heart failure stronger in women than in men. 18 July 2019
‘Bias and Biology – BHF panel on gender inequalities in heart disease’ 27 June 2019
Heart disease is the No. 1 killer of women, but the research has long favored men: Emily Dwass LA Times 23 May 2019
European Heart Journal study ‘Women less likely to receive bystander CPR than men, research shows’ May 2019
Women Less Likely To Be Resuscitated If They Have A Heart Attack In Public. 22 May 2019https://www.huffingtonpost.co.uk/entry/women-less-likely-to-be-resuscitated-if-they-have-a-heart-attack-in-public-and-more-likely-to-die_uk_5ce424c6e4b087700995a61e?utm_hp_ref=uk-health
Why are women with diabetes at greater risk for poor heart health? 14 May 2019
Caroline Criado Perez: How sports science is failing women 18 April 2019https://www.telegraph.co.uk/womens-sport/2019/04/18/caroline-criado-perez-sports-science-failing-women/
Cardiovascular risk for women developing Type 2 diabetes improving despite gender-bias: University of Manchester/Diabetes UK. 15 April 2019
Women Die From Heart Attacks More Often Than Men: Here’s Why
1 April 2019
7 Heart Attack Symptoms in Women You Shouldn’t Ignore. Barbara Sadick. 1 April 2019
Invisible Women: Exposing Data Bias in a World Designed for Men – Caroline Criado-Perez
22 Mar 2019
Cardiology’s problem women: The Lancet. 9 March 2019
Why This Healthy Woman Had 2 Heart Attacks At 41. Korin Miller 27 February 2019
The deadly truth about a world built for men – from stab vests to car crashes. Caroline Criado-Perez Guardian. 23 February 2019
Could new cardio-obstetrics field curb rise in pregnancy related deaths? 18 February 2019.
Why Are Heart Attacks Becoming More Common in Women Under Age 54? Korin Miller 13 February 2019
Medicine’s Biggest Blind Spot: Women’s Bodies Epstein 12 February 2019
Women need to be aware of risks of heart attack, cardiologist says. Olga Toleva 10 February 2019
Why heart disease is often missed in women: The myth of the ‘widowmaker’ Dr Scott Lear 5 February 2019
7 Subtle Heart Attack Symptoms Women Should Never Ignore. 1 February 2019
Go Red for Women: Red Dress Collection. American Heart Association 2019
Carolyn Thomas HeartSisters blogs – to date
University of Leeds BHF/Wellcome Trust-funded study ‘Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study’ (Estimated 8000 women die due to unequal heart attack care) 22 November 2018
Saving Lives, Improving Mothers’ Care: More action needed to prevent maternal deaths across the UK. University of Oxford. 1 November 2018
Women under-treated for heart attack die at twice the rate of men. University of Sydney. Cardiac specialists alarmed by disparity in treatment outcomes in Australian hospitals. 23 July 2018
Delayed and missed diagnoses are common for women with many other disorders as well. June 2018
Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists. Martha Gulati et al. 12 June 2018
OB-GYNs, cardiologists join to fight the No. 1 killer of women. 10 May 2018
Why Women’s Hearts are Different. Dr Nikki Stamp 24 April 2018
Abdominal Aortic Aneurysms In Women Are More Dangerous Than In Men. Dr Mustafa Ahmed. 13 April 2018
Heart and Stroke 2018 Heart Report: Ms Understood. Women’s hearts are victims of a system that is ill-equipped to diagnose, treat and support them
Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circ Cardiovasc Qual Outcomes. February 2018.
Doctors Missed Heart Attack Signs in Women 50% of the Time. 22 February 2018
Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick 24 August 2017 Maya Dusenbery
A Woman’s Guide to Living with Heart Disease: Carolyn Thomas. Johns Hopkins University Press, 2017.
Women have a 50% higher chance of getting an incorrect initial diagnosis, even after having a heart attack. British Heart Foundation. 30 August 2016https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2016/august/women-are-50-per-cent-more-likely-than-men-to-be-given-incorrect-diagnosis-following-a-heart-attack
How sexist stereotypes mean doctors ignore women’s pain. Siobhan Fenton. 27 July 2016
Why Doctors Still Misunderstand Heart Disease in Women: reconsidering the “typical” heart-attack symptoms Vidhi Doshi in The Atlantic. October 2015
The Reality Of Heart Disease: A Wake-Up Call For Women. 29 September 2014.
Why heart attack care may be less timely for women. Meera Dalal. 18 March 2014
More Women Dying Of Heart Disease, Yet Men Still Get More Treatment. Marijke Vroomen Durning. 29 July 2013
Abdominal aortic aneurysms in women: Journal of Vascular Surgery. Women’s outcomes following surgical procedures for AAA are also reported to be significantly worse as compared to men. April 2013
Men and women get sick in different ways: Developing gender-specific medicine is a major challenge of the future 22 March 2013
Myocardial Infarction in Women: lessons from the NHL WISE study Dr Martha Gulati et al. March 2012
Saving Women’s Hearts Dr Martha Gulati 2011HTTPS://WWW.AMAZON.CO.UK/SAVING-WOMENS-HEARTS-CONVENTIONAL-STRATEGIES/DP/0470678453
Myocardial infarction in women: promoting symptom recognition, early diagnosis, and risk assessment February 2009