Dr. Gregory Weiss, a critical care cardiologist, offers perspective on a study examining disparities in the diagnosis and treatment of women who experience acute myocardial infarction.
More and more evidence suggests that women are diagnosed and treated differently than men when it comes to acute myocardial infarction (AMI) or heart attack. In fact, research presented at this year’s ESC scientific congress shows that chest pain is misdiagnosed more frequently in women who present to the emergency department than men. In a statement, Dr. Gemma Martinez-Nadal of the Hospital Clinic of Barcelona states:
"Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being underestimated in women."
Oddly, it is not just clinicians that start out with a low suspicion for AMI but women themselves that doubt the diagnosis. In this study, Dr. Martinez-Nadal and colleagues examined gender differences in the presentation, diagnosis, and management of patients admitted with chest pain. Researchers collected the emergency physicians’ initial diagnosis based on clinical history, physical exam, ECG, and laboratory studies. From these data a first impression was made by the admitting physician.
From analysis of the data, it was quickly determined that women were presenting to the hospital much later than men following the onset of symptoms. Dr. Martinez-Nadal sounds the alarm:
"This is worrying since chest pain is the main symptom of reduced blood flow to the heart (ischemia) because an artery has narrowed. It can lead to a myocardial infarction which needs rapid treatment."
In addition to presenting later, researchers found that the diagnosis of acute coronary syndrome (ACS) was more likely to be considered the cause of chest pain in men compared to women. Further, the low suspicion of ACS in women was maintained regardless of the number of cardiovascular risk factors or the presence of typical chest pain. Results showed that 5% of women were initially misdiagnosed compared to 3% of men.
These facts, presented at this year’s ESC Acute CardioVascular Care 2021 meeting, are not new to many of us who see gender disparities every day in clinical practice. Dr. Martinez-Nadal does a great job bringing the numbers into the light with this study. The problem here is that, to spite cardiovascular disease being the number one killer of women, it has long been associated more with men. When women themselves have preconceived notions about chest pain being anything other than a heart attack, they put themselves at a serious disadvantage but when we as clinicians do the same, we put their lives in jeopardy.
Having met and treated thousands of patients with acute coronary syndromes, I can tell you that, man or woman, they come in frightened and confused. They expect us to rapidly diagnose and treat them without delay or bias. The truth is that there is bias in medicine and it is our job to recognize it and change our behavior. While men and women may present with different symptoms when experiencing AMI, the level of suspicion should be the same and a uniform workup should be performed.
One place this disparity can be addressed prior to an emergent visit to the ER is in the primary care physician’s office. We should take this information and pass it on to patients. Women with cardiovascular risk factors should be counseled to take chest pain seriously. Just as important as informing them of the symptoms associated with having a heart attack is the encouragement to seek help quickly rather than deny the possibility. Education is one of the most important “treatments” we can provide. This presentation at the ESC scientific congress 2021 places particular emphasis on education. Education for clinicians and patients alike.
The work undertaken by Dr. Martinez-Nadal and colleagues underscores the continuing disparities facing patients due to no fault of their own. The lives of all of our patients are important. In conclusion, we should all spread the words of Dr. Martinez-Nadal in an effort to level the field and expand treatment for women experiencing chest pain.
"Heart attack has traditionally been considered a male disease, and has been understudied, underdiagnosed, and undertreated in women, who may attribute symptoms to stress or anxiety. Both women and men with chest pain should seek medical help urgently,” said Dr. Martinez-Nadal.
This study, “No one left behind: improving acute cardiovascular care for women,” was presented at the 2021 ESC Acute CardioVascular Care 2021 Online Congress on March, 14th 2021.