Gender Differences In Cardiac Care
By Alice Y. Chang, M.D.
Brigham and Women's Hospital
Did you know that women are more likely to die after a heart attack than men are? Did you know that women also get fewer procedures than men to prevent recurrent heart attacks? Are these differences justified?
In some cases, studies of women and heart disease have shown that they do have different risk factors than men and should be treated differently. In other cases, however, there are differences in care that have no justification and can only be explained by inappropriate gender discrimination.
Recognize that heart disease, NOT breast cancer, is the leading killer of women in the United States. It is, therefore, important that you take steps to protect yourself against bias in medicine by being armed with information and the right questions to ask.
How Women Are Truly Different
It is important to recognize how women are different when it comes to heart disease so you can act on those differences.
How To Overcome These Differences
Women having a heart attack wait longer to seek care at a hospital than do men. Women and their health-care providers tend to have a false sense of security about a woman's heart-attack risk. Add to this a difficulty in recognizing heart attack symptoms in women, since women do not always have the typical pain or pressure in the middle of the chest. The result is that it takes longer for women with heart attacks to get to the emergency room. This delay in treatment may explain why women have a higher risk of death after a heart attack.
Diabetes increases a woman’s risk of developing heart disease more than a man’s. We don't understand why there is this difference, but women with diabetes need to modify this risk.
Obesity and a sedentary lifestyle are greater risk factors for women than for men. Women should see these risk factors as stronger warning signs of future heart disease than men.
An African-American woman has a much higher risk of heart disease than does a white woman. This racial difference also holds true for men, but the risk difference is greater in women, possibly because rates of diabetes and obesity are higher among African-American women.
For women, a level of HDL ("good cholesterol") below 35 is a stronger predictor of heart disease than a high level of LDL ("bad cholesterol"). Most people follow the success of cholesterol-lowering treatments by changes in LDL level. For women, it is important to pay attention to changes in the HDL level as well.
You can protect yourself by increasing your awareness of your special risks of heart disease and modifying those risk factors under your control.
How Women Are Treated Differently
Learn how to recognize symptoms of heart disease and get to a hospital quickly for treatment. In addition to chest pain, women are more likely to have:
- Left arm pain or discomfort
- Pain going to the neck or jaw
- Shortness of breath
- Unexplained sweating
- Upset stomach or nausea
- Unexplained anxiety or fatigue
Take charge of your health by maintaining or lowering your weight and starting an exercise program. Even a little helps, and starting sooner than later is better. Brisk walking for as little as three hours a week has been shown to make a difference. If you have not been exercising at all, make sure you talk to your health-care provider before starting.
Ask about your HDL level when reviewing your cholesterol numbers. Exercise and certain medications specifically help to increase your HDL number.
In the following cases, differences in treatment are not always justified. Being aware of these differences, you can learn to advocate for yourself so that you get the most effective care.
How To Get Better Treatment
- Women are less likely to have invasive procedures for heart attacks and heart disease. The argument for fewer invasive procedures is that studies show that women have a higher risk of complications, including heart attack and death. Women with heart disease are more likely to have diabetes, which leads to blockages throughout the artery rather than in one small area that can be more easily opened up with a balloon. In addition, women tend to have smaller blood vessels that are harder to keep open. However, while these differences are important to discuss and acknowledge, it does not mean that women should not be offered the same procedures as men.
- Women with known heart disease or who have had a heart attack are less likely to receive standard medication treatments and proven therapies for lowering the risk of another heart event. These medications include beta-blockers, ACE inhibitors, statin cholesterol-lowering medications and aspirin. There is no excuse for the difference in medication treatments. These medications have been studied to reduce the risk of recurrent heart attacks and death in women as well as men.
- Women with heart disease are less likely to receive counseling about weight loss, dietary changes and how to quit smoking. It is unclear why there should be a difference in advocating lifestyle changes for women. It is possible that health-care providers also become lulled into a false sense of security that heart disease is not as serious in women as in men and do not try as hard to lower risk factors in women.
What The Future Holds
- If you have heart disease, review your list of medications with your health-care provider. Are you getting a beta-blocker (such as Atenolol, Carvedilol, Toprol XL, Lopressor), a statin cholesterol-lowering medication (such as simvastatin, lovastatin, pravastatin, atorvastatin), an ACE inhibitor (such as lisinopril, enalapril, captopril), and an aspirin. If not, why not?
Ask questions about your treatment. In particular, ask your doctor when he or she would recommend a balloon angioplasty or even surgery to treat your symptoms or disease. What reasons does your doctor give if he or she doesn't recommend a procedure?
Voice your opinion. While it is true that women are at higher risk of complications after a procedure, many women might decide that it is a risk worth taking, because of either severity of symptoms or the chance to prolong life or improve quality of life. Make sure your doctors know how you feel.
Consider a second opinion. If you don't like the answers you get to your questions or feel you haven't been able to get your opinion heard, ask for a second opinion. Also, remember that your primary-care provider is not only a good source of information and advice, but also can be your advocate in considering a more aggressive approach.
While women have come a long way in this society, there still are situations in which we must negotiate being appreciated for our differences while also being treated equally and fairly. The same issues and dilemmas arise in medicine. Ultimately, we hope to see changes in medicine and tailored treatment for women so that it will no longer be said that women with heart disease don't do as well as men. For now, we can still improve the care of women by advocating for ourselves and others.
Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.