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Women who have heart attacks may face a greater risk of death when treated by male doctors in emergency rooms, according to a new study published in the Proceedings of the National Academy of Sciences.
Some 88 percent of people who have heart attacks live through the initial event, say the researchers. But this study found that female heart-attack patients cared for by female ER doctors were two to three times more likely to survive than those cared for by male doctors. The researchers say male doctors may have difficulty communicating effectively with female patients and seeing things through their eyes.
“I don’t think this should be interpreted as ‘women should avoid male physicians,’” says the lead author, Brad Greenwood, Ph.D., an associate professor of informatics and decision sciences at the Carlson School of Management at the University of Minnesota Twin Cities. “But making sure that female patients advocate for themselves and are not dismissed is important. Making sure you're heard is important."
Heart disease continues to be the No. 1 killer of men and women in the U.S. But heart attacks tend to be deadlier for women: 26 percent of those 45 and older die in the first year after an initial heart attack compared with 19 percent of men, according to the American Heart Association (AHA).
A variety of factors are probably at work. “Women have been less likely to be referred for cardiac rehab, less likely to be referred for angiograms and stress tests, less likely to be given lifesaving medication when discharged from a hospital after a heart attack,” says Suzanne Steinbaum, D.O., director of women's cardiovascular prevention, health, and wellness at the Mount Sinai Hospital in New York City, who wasn't involved in the new research.
And women, who, on average, have their first heart attack at age 72 compared with 65 for men are apt to seek help later than men do, she notes.
So what can you do to ensure that you get the right treatment? Plenty. Here's what the research reveals and the steps you can take.
What the New Study Found
For this study, researchers from several universities used data from more than 500,000 male and female heart-attack patients in Florida ERs between 1991 and 2010.
They looked at the differences in survival rates based on the gender of the treating physician, and found that women were significantly more likely to survive when cared for by a female doctor, “suggesting that unique challenges arise when male physicians treat female patients,” the authors wrote. Men were slightly more likely to survive when treated by a female doctor, but those numbers weren’t considered significant.
The study also found that survival rates were somewhat better for both men and women cared for in the ER when they saw male doctors who'd previously treated more women, and when the ratio of female to male doctors in that ER was higher. Typically, say the researchers, about 10 percent of ER doctors are women.
“That indicates there is some learning that’s going on,” says Greenwood. “If they (male doctors) have more exposure to female patients, they learn. As the number of prior female patients increases and the ratio of female physicians to male physicians increases, the penalty associated with being treated by male physicians for female patients is ameliorated.”
The study does have some limitations, the authors noted. For instance, it didn’t explore the possible causes of the gender disparity or consider the potential effects on care from other healthcare providers, such as nurses and residents.
Why Are Women Treated Differently?
Some research over the years suggests that heart attack symptoms may be less obvious and more difficult to detect in women, and that they are more likely to display atypical signs.
Other studies, including one published in Circulation this past February, which interviewed people between 18 and 55 after they’d been hospitalized for heart attacks, found that roughly 90 percent of women and men experienced chest pain or pressure—long considered the cardinal sign of heart attack.
“The most recent data shows that actually, women’s symptoms of obstructive coronary artery disease are generally the same as men’s symptoms,” says Rita F. Redberg, M.D., a professor of medicine in the UCSF division of cardiology. “In general, women are slower to seek help and slower to receive help and diagnoses after the visit, but it is not related to atypical symptoms in women—it’s more related to the mistaken conception that heart disease is a man’s disease.”
Still, the February study found that women were more likely than men to report other symptoms in addition to chest pain, such as nausea or discomfort in the jaw, neck, arms, or between the shoulder blades.
Multiple symptoms may muddy the diagnostic waters, according to an editorial published in Circulation in February 2018. “When this happens, patients, family members, and healthcare providers are often less clear that the heart is the source of the problem,” the authors wrote.
Whether the symptoms are the same or somewhat different, experts generally agree that heart-attack care tends to vary by gender. The February Circulation study, for instance, found that when men and women sought medical care for similar heart-attack symptoms, 53 percent of the women were told by healthcare providers that they were not likely heart-related. Only 37 percent of men received that same assessment.
Disparities may continue in post-treatment. Anyone who has had a heart attack should be prescribed medication to protect the heart—such as low-dose aspirin as well as blood pressure and cholesterol-lowering drugs—and be referred to exercise and cardiac rehabilitation programs.
But women are not only less likely than men to be referred to rehab, says Steinbaum, they also may not get the proper medication, either. A study published last April in the Journal of the American College of Cardiology—funded by the biopharmaceutical company Amgen—found that only 47 percent of women who filled prescriptions for cholesterol-lowering statin medication after a heart attack were prescribed the “high intensity” doses that are recommended.
How to Get the Right Care
The experts agree that a number of steps can increase the likelihood of proper care. For instance:
Be clear about your risks. Talk with your doctor about your personal risks of heart disease. And be aware that in addition to factors such as a family history of heart disease or having high blood pressure or high cholesterol, women may be more likely to have nontraditional risk factors, according to a February 2018 editorial in Circulation written by Nanette K. Wenger, M.D., an emeritus professor of medicine in the division of cardiology at the Emory University School of Medicine. She noted, for instance, that autoimmune disease and conditions such as preeclampsia and preterm birth may increase a woman's risk.
Other research in 2018 suggests that women who've already had a heart attack may be more likely than men to experience chest pain as a result of emotional stress, and that belly fat—which can increase the likelihood of heart disease—may also be riskier for them.
Know the signs of a heart attack. Some heart attacks may come on suddenly, with intense symptoms. But according to the National Heart, Lung, and Blood Institute, most begin slowly, and symptoms can start up to a couple of weeks ahead of the actual event.
So call 911 right away if you experience chest pain, discomfort in other parts of the upper body—such as one or both arms, the back, abdomen, neck, or jaw—or shortness of breath. Pay attention to other possible symptoms, such as a cold sweat, nausea, or lightheadedness.
“We always tell women if you have any symptoms between the naval and nose that come up with exertion, either physical or emotional exertion, and go away with rest, you have to consider your heart,” says Karol Watson, M.D., Ph.D., co-director of the UCLA program in preventive cardiology and director of the UCLA Barbra Streisand Women’s Heart Health Program at the David Geffen School of Medicine.
Get help even if you’re unsure that it’s a heart attack. “There are some overreactors, but in general, women are pretty attuned to their bodies and kind of know if something is not right,” says Watson.
Speak up at the hospital. Tell the ER doctors about your personal and family history. For example, knowing that your mother had a heart attack at age 50 or that you’ve been diagnosed with prediabetes may change the way they view your risk. Clearly explain your symptoms, how long you’ve had them, and—this is crucial—that you’re concerned about your heart. “Once those words come out of your mouth, it’s the doctor’s obligation to look into that,” says Steinbaum.
Make sure you get the right tests. “The tests depend on what symptoms you are having and how likely or certain the doctor is, or whether he or she needs more information," says Redberg. "It is possible you would not need any testing if your symptoms are not suggestive of an urgent or acute event, or you may be referred to your primary care physician for follow-up and decisions regarding testing.”
If a heart attack is suspected, expect to have an angiogram, which checks for blocked or narrowed coronary arteries, quickly, says Redberg. But angiograms may miss a type of heart disease more common in women—coronary microvascular disease—which damages smaller arteries in the heart, according to research from the National Institutes of Health. In addition, plaque, deposits of fat and other substances, tends to be spread more evenly through women’s arteries, making it harder to see in a standard angiogram.
So when that test is normal for a woman suspected of having had a heart attack, the doctor should consider performing an intravascular ultrasound to look inside the arteries in more detail, says Steinbaum.
Prep yourself for future good health. If you are diagnosed with a heart attack, before you go home, ask what medication you’ll be prescribed to prevent another heart attack, and make sure you’re clear on how you should follow up with your primary care doctor or cardiologist. And make the time for healthy habits, such as eating right and exercising, and cardiac rehab, which decreases the risk of a second heart attack.
And last, know that there have been improvements in heart-attack care for women. Deaths from cardiovascular disease have dropped precipitously among them since 2000, according to Wenger, because more are being included in medical studies and doctors' understanding of gender differences is increasing.
Editor's Note: An earlier version of this article appeared in the May 2017 issue of Consumer Reports magazine.
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