People die of heart disease at comparable rates regardless of gender, according to the Centers for Disease Control and Prevention. However, for acute events such as myocardial infarction (MI), gender gaps—and perhaps gender bias—can appear.
Overall, female patients* are more likely to die of a heart attack across all ages, across many settings. One study in the European Heart Journal (EHJ) found that women were less likely to be resuscitated by bystanders, and even if they did successfully receive bystander help, their survival odds were 40 percent lower than men. Compared to men, women were also found to have lower rates of initial shockable rhythm.
Studies on women and heart disease have helped to unpack the disparities between outcomes—chalking many up to biological differences, such as variances in MI symptoms or waveforms based on sex. But even with those potential differences, there are implied (albeit unintentional) gender biases in cardiology decision-making that can limit diagnostics and effective care. According to a paper in Catheterization and Cardiovascular Interventions, for example, women with STEMI receive medical management alone at rates higher than men, and they also have symptom-to-balloon times that are nearly 20 minutes longer than that of men.
How well providers recognize and react to such biases can affect how well their patients fare during acute events. Here's why this is the case, how you can check your own bias, and how prompt ECG testing can help.
The Roots of Gender Bias in Cardiology
Gender bias in medicine, and particularly cardiology, is tied to systemic issues of representation throughout the care continuum. There are more male cardiologists, researchers, and trial participants, and over time this has skewed medical education, guidance, research, and even care quality toward men as the baseline.
As an example, a report in Gender and the Genome discussed a German medical textbook published in 2010 that had clear gender biases. For instance, the textbook recommended that practitioners remove restrictive clothing, such as neckties, during MI episodes, but it did not refer to items such as bras.
There is also an undercurrent of societal and cultural factors that can contribute to gender bias in cardiology. For example, according to the American Heart Association, women often wait longer before seeking treatment for a heart attack, and the COVID-19 pandemic may be exacerbating this trend. Indeed, the tendency to postpone treatment may be contributing to the alarming lack of heart attack patients in EDs, which is presumably linked to fears of contracting the virus. This combination of issues could spell troublesome care delays in the months ahead.
Inherent biases can pose additional problems when they collide with variations in symptoms, risk factors, or clinical manifestations. For instance, as one review in the EHJ notes, women tend to experience longer repolarization phases that feed into a greater QT duration on ECG. They are also more likely to have conflating factors, such as uncontrolled hypertension after the age of 60 or physical inactivity, according to an analysis in Circulation Research.
How Gender Bias Affects Cardiac Care
In practice, these dimensions of bias can hinder the efficacy of care plans for patients identifying as female. As the Circulation Research analysis notes, physicians are more likely to provide preventive treatments or guidance (such as scripts for statins, recommendations for lifestyle modifications, or referrals to cardiac rehab) to male patients than to female patients with similar risk profiles.
Bias can also thwart diagnostics, as a study in the Journal of the American Heart Association indicates. When asked what they would recommend for hypothetical patients with similar profiles, cardiologists recommended angiography for men more often than for women. They were also more likely to view male patients as strong and risk-tolerant. Female cardiologists exhibited lower levels of this implicit bias than their male counterparts.
Moreover, Time reports that women also feel unheard and dismissed at the clinic when they bring up warning signs. Such stories shed anecdotal light on research from the Proceedings of the National Academy of Sciences of the United States of America indicating that women are 1.52% more likely to die from a heart attack if they're treated by male emergency physicians than men who are treated by female providers.
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Checking Bias in Diagnostics and Care
Physicians can and should recognize how their own implicit biases may be affecting their decision-making related to women and heart disease—and boosting representation is one of the best ways to do that. Enrolling more patients identifying as female in clinical trials can help inform future guidelines in a more gender-inclusive way. More self-awareness and investments in CMEs related to gendered differences is another good strategy.
In addition to understanding variances in symptoms of cardiovascular conditions, providers should remain conscious of how bias may influence their diagnostic choices. ECG can be an effective and swift tool at the point of care for all patients, but heart rate and ECG presentations may differ according to a patient's sex. As the Cleveland Clinic observes:
- Women tend to have a more rapid heart rate at baseline, which can be influenced by hormonal fluctuations, such as those that occur during perimenopause.
- Men tend to have a shorter QT interval than women.
- Women are more likely to have certain arrhythmias, such as supraventricular tachycardia, long QT syndrome, and sinus node dysfunction.
- Men and women can present with different manifestations of atrial fibrillation and sudden cardiac death.
Medscape reveals that experts differ on whether MI symptoms actually vary as much as reported; that said, some sex-based differences may require modifications to care plans based on the patient's workup. This table from Circulation Research outlines potential areas where interventions may vary according to a patient's sex.
Most importantly, providers should listen to their patients' symptoms and concerns, spend as much time as possible with every encounter, and actively work to mitigate their own biases. Doing so can help to narrow the gaps and may ultimately save more patients from becoming casualties of bias.
*For the purposes of this article, we are referring to "women," "female," "men," and "male" as reported in the cited studies. Most research does not track current gender identity or gender assigned at birth.