By Sarah Handzel, BSN, RN

People die of heart disease at comparable rates regardless of gender, according to the Centers for Disease Control and Prevention.¹ However, for acute events such as myocardial infarction (MI), gender gaps—and bias—can appear.

Female patients^* are more likely to die of MI across all ages and settings. One study in the European Heart Journal found that women were less likely to be resuscitated by bystanders, and even if so, their survival odds were 40% lower than men. Women were also found to have lower rates of initial shockable rhythm than men.²

Studies on women and heart disease have helped 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 & 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.³

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.

An undercurrent of societal and cultural factors can also contribute to gender bias in cardiology. For example, according to the American Heart Association, women wait an average 11 minutes longer before seeking treatment for a heart attack. ⁴ Indeed, this tendency of late presentation and postponed treatment can result in failing to achieve the target Door-to-Balloon time, which may lead to a worse prognosis or an increased risk of one year mortality.¹⁴

Inherent biases can pose additional problems when they collide with variations in symptoms, risk factors, or clinical manifestations. For instance, as a review in the European Heart Journal notes, women tend to experience longer repolarization phases that feed into a greater QT duration on ECG.⁵ 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.⁶

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.⁶

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.⁷

In part, these issues stem from the historical underrepresentation of women as cardiovascular disease patients in clinical research. It is difficult to say whether or not there are significant differences in actual acute care between female and male patients, as many emergency departments do not include sex as a consideration in screening criteria. The literature does suggest, however, that males are at an increased risk for STEMI and females have increased reporting of non-chest pain symptoms.¹³

Achieving True Health Equity

Achieving true health equality requires researchers to focus on recruiting more women into clinical trials so that the data collected can be objectively analyzed. This, in turn, will help identify factors specific to women that may eventually lead to cardiovascular events.

For example, new research from the University of Florida identifies a possible genetic component that may influence women's heart disease outcomes. The gene, RAP1GAP2, may strongly influence the activity of platelets in women, leading to the possible increased risk of blood clots and heart attack. In contrast, the same gene does not appear to have any relationship to men's heart disease risk.⁸ Further study is necessary to truly understand RAP1GAP2's role in female heart disease, but many more women should be included in this and other clinical research efforts.

Finally, Time reports that women also feel unheard and dismissed at the clinic when they bring up warning signs.⁹ 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.¹⁰

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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 Continuing Medical Education 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. ECGs 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:¹¹

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.¹² The study in Circulation Research highlights several interventions directed specifically at women such as:⁶

Encourage women to complete at least 60 to 90 minutes of moderate exercise each day of the week to combat obesity.
Help women quit smoking. Smoking increases a woman's risk of CAD by 25%.
Use statins as a primary prevention method for women instead of a secondary intervention, which may result in the development of diabetes or myalgias.

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 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.

References:

1. Centers for Disease Control and Prevention. Heart disease factors. CDC. https://www.cdc.gov/heartdisease/facts.htm. Accessed October 6, 2022.
2. Blom M, Oving I, Berdowski J, et al. Women have lower chances than men to be resuscitated and survive out-of-hospital cardiac arrest. European Heart Journal. 2019;40(47):3824-3834. https://doi.org/10.1093/eurheartj/ehz297.
3. Wei J, Henry T. Gender equity in STEMI: Not so simple! Catheterization & Cardiovascular Interventions. 2015;85(3):369-370. https://doi.org/10.1002%2Fccd.25800.
4. American Heart Association News. Heart attacks in women undertreated, experts say. American Heart Association. https://www.heart.org/en/news/2018/05/01/heart-attacks-in-women-undertreated-experts-say. Accessed October 6, 2022.
5. Regitz-Zagrosek V, Oertelt-Prigione S, Prescott E, et al. Gender in cardiovascular diseases: Impact on clinical manifestations, management, and outcomes. European Heart Journal. 2016;37(1):24-34. https://doi.org/10.1093/eurheartj/ehv598.
6. Garcia M, Mulvagh S, Merz C, et al. Cardiovascular disease in women: Clinical perspectives. Circulation Research. 2016;118(8):1273-1293. https://doi.org/10.1161%2FCIRCRESAHA.116.307547.
7. Daugherty S, Blair I, Havranek E, et al. Implicit gender bias and the use of cardiovascular tests among cardiologists. Journal of the American Heart Association. 2017;6(12). https://doi.org/10.1161/JAHA.117.006872.
8. University of Florida. Women's heart attacks are often missed: This gene may help explain why. ScienceDaily. https://www.sciencedaily.com/releases/2022/06/220623184242.htm. Accessed October 6, 2022.
9. Sadick B. Women die from heart attacks more often than men. Here's why—and what doctors are doing about it. Time. https://time.com/5499872/women-heart-disease/. Accessed October 6, 2022.
10. Greenwood B, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proceedings of the National Academy of Sciences of the United States of America. 2018;115(34):8569-8574. https://doi.org/10.1073%2Fpnas.1800097115.
11. Cleveland Clinic. Women and heart rate. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/17644-women-and-heart-rate. Accessed October 6, 2022.
12. Brooks M. Myth busted? No sex differences in typical MI symptoms. Medscape. https://www.medscape.com/viewarticle/917722. Accessed October 6, 2022.
13. Yiadom, Maame Yaa A. B., Christopher W. Baugh, et al. "Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST‐Segment Elevation Myocardial Infarction." Journal of the American Heart Association 6 (3). 2017 https://doi.org/10.1161/jaha.116.003528.
14. Park J, Choi K H, Lee J M, et al. "Prognostic Implications of Door‐To‐Balloon Time and Onset‐To‐Door Time on Mortality in Patients with ST‐Segment–Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention." Journal of the American Heart Association 8 (9). 2019 https://doi.org/10.1161/jaha.119.012188.‌

Sarah Handzel, BSN, RN, has been writing professionally since 2016 after spending over nine years in clinical practice in various specialties.

The opinions, beliefs and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.

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