Women with heart dis­ease are dis­missed. And it's killing them

The Guardian Australia - - Opinion - Nikki Stamp

Hys­te­ria was an an­cient term used to de­scribe un­con­trol­lable emotions, re­sult­ing in the ad­mis­sion of many women to asy­lums for symp­toms such as a “ten­dency to cause trou­ble”. The source of the al­leged in­san­ity was said to come from the uterus, thus the treat­ment in some cases was a hys­terec­tomy. While no longer a recog­nised med­i­cal con­di­tion, it has a legacy in mod­ern medicine.

As is of­ten the case, I was in a multi-dis­ci­plinary meet­ing of heart doc­tors as the only woman. It’s a sit­u­a­tion that I have be­come un­com­fort­ably com­fort­able with. The meet­ing be­gan and our first pa­tient was a woman in her 40s. She had been seen by doc­tors in the com­mu­nity and at the lo­cal emer­gency depart­ment with pain in her arm and short­ness of breath. Each time, the di­ag­no­sis was anx­i­ety.

Fi­nally, some­one did a blood test called a tro­ponin, a marker of heart in­jury. “Just in case,” was the rea­son given. The test showed that the cause of the symp­toms was in­deed a heart at­tack. More tests showed the cul­prit, a tight block­age of the coro­nary ar­ter­ies starv­ing her heart in­ter­mit­tently of oxy­gen. As the men in the room dis­cussed the pos­si­ble treat­ments for the woman, they kept com­ing back to the fact that “she had no symp­toms”.

I found my voice. “But she does have symp­toms, they’re just not male-type symp­toms. Look at her, she has had he symp­toms at­trib­uted to anx­i­ety on at least three oc­ca­sions. It’s very typ­i­cal of how we man­age women’s health”.

Some stared blankly at me. Oth­ers rolled their eyes. One ed­u­cated me on the science be­hind symp­toms and how that cor­re­lated with treat­ment, as if I didn’t know. All of a sud­den I felt like I had been lumped in the same bas­ket as this pa­tient: melo­dra­matic, pushy and anx­ious.

The fact is, when it comes to women’s health, and in my field specif­i­cally – women’s heart dis­ease – women are dis­missed. Women are also con­di­tioned to dis­miss their own symp­toms for fear of ap­pear­ing “silly”, and health care pro­fes­sion­als such as doc­tors and nurses do the same. Over and over again, this dis­missal of a woman’s symp­toms leads to de­lays in di­ag­no­sis, treat­ment and could cost lives.

We are of­ten so shocked to learn that health care is bi­ased. Whether it by gen­der, race or your eco­nomic means, we all feel that in a hos­pi­tal, those who min­is­ter to the sick and the sys­tems they work in should see past any of these dif­fer­ences to pro­vide ap­pro­pri­ate care. And while the rea­sons that care varies based on gen­der are more com­plex and nu­anced than overt sex­ism, the end re­sult is dire for women.

Even in the most ex­treme ill­nesses, a car­diac ar­rest where the heart has stopped, by­standers are much less likely to pro­vide life­sav­ing CPR. In re­search done by the Amer­i­can Heart As­so­ci­a­tion, only 39% of women whose heart stops get CPR in a pub­lic place. Men on the other hand get CPR 45% of the time

and are a whop­ping 23% more likely to sur­vive. It may be due to the fact that by­standers are ner­vous about re­mov­ing her cloth­ing or touch­ing her breasts. Even in death (or near death), we’re plac­ing mod­esty above sur­vival.

Heart dis­ease is the lead­ing cause of death world­wide for men and women. In con­trast to pop­u­lar opin­ion, women are two to three times more likely to die of heart dis­ease than breast can­cer. Re­search has shown that women are more likely to die af­ter a heart at­tack than men, es­pe­cially when they are young women. The rea­sons for this dif­fer­ence are as­tound­ing. In Aus­tralia, if you are Abo­rig­i­nal, you are 64 times more likely to have rheumatic heart dis­ease, and higher if you are fe­male – an ill­ness largely erad­i­cated from de­vel­oped pop­u­la­tions. The com­bi­na­tion of gen­der and race is even more lethal.

Women are less likely to recog­nise the symp­toms of a heart at­tack be­cause they are dif­fer­ent than a man’s. Women don’t nec­es­sar­ily feel that clas­sic de­scrip­tion of chest pain; they get short­ness of breath, arm pain or tired­ness. From there, women are less likely to un­dergo tests to check their heart such as coro­nary an­giog­ra­phy (a spe­cial x-ray test of the coro­nary ar­ter­ies), re­ceive treat­ment like stents or heart surgery or state-of-the-art med­i­ca­tions. In fact, ac­cord­ing to a Bri­tish study, women who had a heart at­tack were 59% more likely to get the wrong di­ag­no­sis in the first place.

Un­til re­cently, re­search into women’s heart dis­ease has been min­i­mal. In many con­di­tions that are sub­ject to re­search, fe­male pa­tients make up only a small por­tion of study par­tic­i­pants. It means that the “best treat­ments” are best treat­ments for men. Drugs that have changed the way we treat heart dis­ease and saved many lives may not work as well in women and they may also have side ef­fects that are unique to women.

It’s not just in hearts ei­ther. Women get mis­di­ag­no­sis or un­der­treat­ment in con­di­tions like en­dometrio­sis, aor­tic aneurysms or de­men­tia. In the UK, Na­tional In­sti­tute for Health and Care Ex­cel­lence (Nice) guide­lines were de­vel­oped in or­der to re­duce the de­lay in di­ag­no­sis of en­dometrio­sis which can be as long as seven years. When they are in pain, women don’t re­ceive the painkillers that men do; in fact they’re more likely to be given a seda­tive med­i­ca­tion – for the anx­i­ety that is di­ag­nosed by a health­care worker, not the pain that the woman ac­tu­ally feels.

As a woman and as a doc­tor, I find this con­stant and wide-reach­ing bat­tle to achieve eq­uity in such a ba­sic hu­man right as health­care so frus­trat­ing. Al­though I am fe­male, I am not be­ing the least bit melo­dra­matic when I say that this bias means that women will die. And if they don’t, they will keep en­dur­ing a health sys­tem that leaves them un­well and with a poorer qual­ity of life than if they had been a man with pain in his chest.

As frus­trat­ing as it is and as much as I want to lay blame, the real­ity is that the bi­ases in health­care ex­ist largely be­cause of cen­turies of bad science, so­cial norms or a lack of women in medicine and re­search. They per­sist to­day, aided by un­con­scious bi­ases that we all have and that our health­care sys­tem has. Un­less we chal­lenge these bi­ases and de­mand re­search and treat­ment that is de­signed for women, we are go­ing to be liv­ing this cy­cle of be­ing sec­ond best in health­care for many, many years to come.

Where to from here? With grow­ing num­bers of fe­male doc­tors and women in med­i­cal re­search, we hope that these women will take up the chal­lenge to solve the prob­lems that plague women’s health by bat­tling on the front line.

But as dis­heart­en­ing as this all sounds, I urge you to not stop push­ing for the health­care you de­serve. As pa­tients, you too have the tools to change the way women re­ceive their health­care. There are peo­ple who will lis­ten to you and un­der­stand your body and treat you in the way you need.

For those of us in the health­care sys­tem, our role is sur­pris­ingly sim­ple: to un­der­stand that women die be­cause they are women. It’s our job to lis­ten and treat ev­ery­one with the as­sump­tion that they are not hys­ter­i­cal.

• Dr Nikki Stamp is a car­dio­tho­racic sur­geon

Women are less likely to recog­nise the symp­toms of a heart at­tack be­cause they are dif­fer­ent than a man’s

‘Women don’t nec­es­sar­ily feel that clas­sic de­scrip­tion of chest pain; they get short­ness of breath, arm pain or tired­ness’

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