The ominous title of this 2019 report,“Cardiovascular Disease and the Female Disadvantage“ makes it fascinating reading for all women, but potentially repellent for the minority of physicians who still dismiss the entire notion of a gender gap in cardiology(1) – sadly, the ones least likely to read it. Yet I know they are out there, because some of them openly call me names on Twitter whenever I cover a scientific paper on this topic.
Luckily for the rest of us, however, the expert writing this report is the very credible Professor Mark Woodward at the University of Oxford (who also teaches at Australia’s University of New South Wales, and at Johns Hopkins University in the U.S.) .
Let’s Start With our PERCEPTION of Heart Disease:
Professor Woodward cites a national survey of women undertaken at the Ottawa Heart Institute that focused on our knowledge and perceptions about our own heart health.(2) Researchers found that most women “lack knowledge of heart disease symptoms and risk factors, and significant proportions are unaware of their own risk status.” He added:
“Despite observations that women’s magazines and social media include much about healthy lifestyles, many women still may be unsure of issues regarding their cardiovascular disease risk.”
Women, he warns, may also be more likely to put their own needs behind family and other priorities than men are, which – as I’ve written about here and here – may actually compromise our own health. See also: Are You A Priority In Your Own Life?
The Ottawa researchers found that:
fewer than half of the women surveyed knew that smoking is a cardiac risk factor
fewer than 1/4 named high blood pressure or cholesterol as risk factors
fewer than 1/3 could identify four common symptoms of a heart attack in women
of those at high risk (based on medical history and risk factors), 62 per cent rated their risk as low to moderate
65 per cent claimed they had the most influence on their family’s health
I believe that the last point could well be the key to changing the face of heart disease (future researchers, take note!) If we can significantly improve women’s awareness of cardiac risk factors and convince them of the need to address these risk factors, can we by extension improve the health of our children and families?
But women aren’t the only ones who currently have unrealistic perceptions about women’s heart disease. Professor Woodward reminds us:
“Just like the general public, medical practitioners are prone to the misconception of cardiovascular disease as being a predominantly male problem.”
When I read this part of the report, I wondered how I must have appeared to the first Emergency physician I encountered back in the spring of 2008.
I had walked calmly through the doors of the Emergency Department at that first visit, on my own steam. I could walk, talk, think, drive my car – did I look like that stereotypical old white guy clutching his chest in agony during a “real” heart attack? (And despite my severe symptoms of central chest pain, nausea, sweating and pain down my left arm – and not unlike what happens to many other women – all of my first diagnostic test results came back “normal”).
So I was promptly sent home, misdiagnosed with acid reflux.
Higher MISDIAGNOSIS Rates:
Professor Woodward points out that the odds of a woman having an incorrect initial cardiac diagnosis on admission to hospital are higher for women than men among all heart attack patients.(3) Women who had a final diagnosis of STEMI* (the most serious type of heart attack) had a 59% greater chance of a misdiagnosis compared with men, while women who had a final diagnosis of NSTEMI* (a slightly less serious heart attack) had a 41% greater chance of a misdiagnosis when compared with men. And Professor Woodward added:
“Since those with an incorrect initial diagnosis were more likely to die within 12 months than were those with a correct initial diagnosis, this suggests that misdiagnosis is an extremely important problem, and more so in women.”
Worse SURVIVAL rates:
It’s important to point out here that Professor Woodward’s international reputation is based on his expertise in statistical methods in medical research. This makes his paper a rich and yet surprisingly accessible read if you’re a woman living with heart disease. It’s particularly true of his analyses of women’s cardiac outcomes.
The figure below features data from another 2018 study, involving over half a million admissions to Emergency Departments throughout Florida.(4) This study showed that survival rates were two to three times higher for female patients treated by female physicians in Emergency compared with female patients treated by male physicians.
And this was not the first study to report that female physicians tend to perform better than male physicians across a wide variety of ailments. Previous studies called this phenomenon “in-group bias”. As Professor Woodward describes it:
“Regardless of the sex of the cardiologist attending, after allowing for several confounding factors, survival was worse for women than for men. A striking feature of these data is that, although female physicians appear to have similar results for female and male patients, amongst patients treated by men, female patients survive their treatment less often than do male patients.
Although the differences in probabilities in Figure 4 are small, this issue if widespread is of immense importance in terms of female lives that might be saved, and is also compounded by the relative lack of female cardiologists in many settings.“
To me, one of the most striking findings of this research was that male physicians who had “more exposure to female patients and female physician colleagues” had more success treating female patients. As the study’s conclusions suggested:
“We found that male physicians are more effective at treating female heart attack patients when they work with more female colleagues, and when they have treated more female patients in the past.
“Given the cost of male physicians’ learning on the job, it may be more effective to increase the presence of female physicians within the Emergency Department. This corroborates prior work of researchers studying racial concordance in medicine, who have consistently concluded that increasing the presence of minority physicians in the hospital is critical. It also underscores the need to update the training that physicians receive to ensure that heart disease is not simply cast as a ‘male’ condition, an observation underscored in the media.”
When this study was first published by the National Academy of Science in August 2018, I vividly remember that the online response to its findings on social media were swift and predictable.
Female physicians seemed far more likely to welcome the study’s recommendations, while a surprising number of male physicians (particularly those working in Emergency medicine) generally attacked the study on all fronts as yet another example of “doctor-bashing”, a blanket dismissal that I too face with alarming regularity every time I write – or even link to studies – about female heart patients being underdiagnosed or undertreated compared to our male counterparts.
Before I even signed my book contract with Johns Hopkins University Press, for example, the (anonymous) cardiologist who had reviewed my 10-chapter draft outline in advance of the contract issued a one-line warning about Chapter 3 (all about diagnosis and misdiagnosis of women’s heart disease):
“Seems like doctor-bashing to me.”
And this was in response to merely a 4-line bulleted list of proposed topics for that chapter.
Apparently, even using the word “misdiagnosis” qualifies as doctor-bashing.
That publishing debate ultimately had a happy ending. As I argued with my editors, “It would be a great disservice to all women reading this book if, given the growing body of research on this important topic, my chapter on diagnosis and misdiagnosis was forced out.”
(So did Chapter 7, by the way, despite the same reviewing cardiologist’s assessment that this chapter was “irrelevant to female heart patients”, and should be removed). I don’t think the reviewing cardiologist quite grasped the irony at the time of a cardiologist telling a female heart patient what is or is not relevant to female heart patients. . .
Now Back To Our Topic. . .
Professor Woodward didn’t stop at simply describing the extent of the known historical bias in cardiology. A specific call to action, I have noticed, is often remarkably absent across medical research: academics study a specific subject, publish a paper describing the extent of the bad news, and move on to the next paper with the requisite disclaimer“more study is required. . .”
But for Professor Woodward, seven months after his “Female Disadvantage” report came out, his template for actually improving this reality (“Rationale and Tutorial for Analysing and Reporting Sex Differences in Cardiovascular Associations) was published in the cardiology journal, Heart.(5)
In his template, he not only confirms what he calls “the historical bias toward the male model of cardiovascular disease”, but also goes on to suggest to his cardiac research colleagues 15 key recommendations to address that gender bias. (NOTE: it’s written in dense medical-ese, but of interest to those of you with a keen grasp on statistical concepts like “inverse variance weighted pooled relative risks.”)
Finally, Professor Woodward warns that such improvements MUST become the norm in cardiovascular disease research “for both humanitarian and clinical reasons”.
Image based on original from Gerd Altmann, Pixabay
1. Woodward, Mark. “Cardiovascular Disease and the Female Disadvantage.” International Journal of Environmental Research and Public Health” Apr. 2019. Vol. 16,7 1165. 1
2. MacDonnell et al. “Perceived vs Actual Knowledge and Risk of Heart Disease in Women: Findings from a Canadian Survey on Heart Health Awareness, Attitudes, and Lifestyle.” Canadian Journal of Cardiology. 2014 Jul;30(7):827-34.
3. Wu J. et al. “Impact of Initial Hospital Diagnosis on Mortality for Acute Myocardial Infarction: A national cohort study.” Eur. Heart J. Acute Cardiovasc. Care. 2018; 7:139–148.
4. Greenwood BN et al. “Patient-Physician Gender Concordance and Increased Mortality Among Female Heart Attack Patients.” Proc Natl Acad Sci USA. 2018 Aug 21; 115(34): 8569-8574.
5. Woodward M. “Rationale and Tutorial for Analysing and Reporting Sex Differences in Cardiovascular Associations.” Heart (British Cardiac Society), 105(22), 2019. 1701–1708.
*DEFINITIONS (see more in my Patient-Friendly, Jargon-Free Glossary of Cardiology Terms)
Q: How important is it that experts like Professor Woodward continue to try convincing researchers to address this gender gap?
The book “Invisible Women: Data Bias in a World Designed for Men“ by Caroline Criado Perez, winner of the 2019 Royal Society Science Book Prize.
-My review of Maya Dusenbery’s book “Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick. WARNING: Do NOT open this book before you have taken your blood pressure meds!
-My own book, “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017), in which I wrote much more about the cardiology gender gap; order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press. Use their code HTWN to save 20% off the list price when you order.