Gender biases in cardiovascular care: why women with a heart attack are diagnosed later and worse

Few diseases are more time-dependent than a heart attack: if not treated in time, the result can be fatal.

A strong pain in the chest usually triggers the alarms of the patient and the medical devices.

Especially if the sufferer is a man.

In women, everything, from the consultation of symptoms to the therapeutic approach, is usually slower and more confusing.

For more than a decade, the scientific community has confirmed gender discrimination in cardiovascular care for women.

"Despite the fact that 35% of women's deaths each year are from cardiovascular disease, they continue to be underdiagnosed and undertreated," lamented

in 2021. And the bias continues: research presented a few weeks ago at the European Congress of Cardiology held in Barcelona reveals that one of the international scales to measure the probability of death after a coronary problem underestimates the risk of hospital mortality in women.

The experts explain that, on the one hand, they consult later and are less aware of cardiovascular disease, but doctors also tend to underestimate the symptoms or, when diagnosed, be more conservative in their treatment.

In the face of a heart attack, the clock is ticking and every minute counts: life comes or goes in a matter of seconds.

In this pathology, for example, an artery of the heart has been obstructed because a thrombus has formed, a clot that interrupts the correct blood circulation to the heart.

The more time passes, the longer the heart is without blood, and the more heart tissue becomes damaged.

That is why it is necessary to consult and treat the problem immediately.

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Scientists have shown, however, that cardiovascular care varies according to gender: they take longer to consult, doctors more to diagnose them and when treating them, they are conservative.

In addition, the available health tools are also biased: an article published this week in

reveals that the GRACE scale, a parameter to stratify the risk of hospital death in people who have suffered a heart attack, underestimates the risk of death in women, “ favoring its incorrect stratification to the low to intermediate risk group, for which the scale does not indicate early invasive treatment”, concludes the study.

In cardiovascular diseases in general, although the incidence is higher in men, mortality is higher in women.

For Ana García, a researcher at the National Center for Cardiovascular Research and head of the Cardiology service at the Hospital Clínic de Barcelona, ​​the results of the study were "quite expected": "The GRACE, like most scales, has been derived from studies where the male predominance is key”, weighs the cardiologist, who has not participated in the study.

The experts consulted assure that this care gap is being addressed, but the problem is multifactorial.

Starting with the perception of the disease: cardiovascular diseases are one of the main causes of death in women, but they are not aware of it.

There is “an information bias” from the beginning, regrets Antonia Sambola, coordinator of the Women in Cardiology Working Group of the Spanish Society of Cardiology: “Women think that the first cause of death is breast cancer and it is not so ”.

The lack of awareness that a heart attack, for example, is not just a thing for men and they can also suffer from it, added to symptoms that may be more imprecise —apart from chest pain, they may also present nausea or general malaise— , Garcia points out, delays the visit to the emergency room.

Sambola, who attend this type of cardiac emergency in Vall d'Hebron, the largest hospital in Catalonia, is blunt: “When you have chest pain, just like a man, you have to consult.

The rest of the symptoms are additional.

What defines and one has to take into account when a patient arrives is chest pain”.

But even among doctors the risk is underestimated or the symptoms are not taken seriously.

“There is a certain bias, it is not associated that women may have cardiovascular disease.

It is common for women who come to the emergency room with symptoms to have consulted for angina pectoris days before and the doctors have told them that this pain may be due to anxiety”, explains Sambola.

Also in other pathologies, such as ventricular arrhythmias or respiratory failure, among other ailments, women take longer to consult.

They arrive later at the health services, but when they arrive, the next step on the scale of action, which is the therapeutic approach, also fails.

Or it stays in the middle.

“It is treated in a more conservative way: less surgery is performed and less interventional procedures are performed.

There is a perception that the patient is more fragile and is treated conservatively”, says García.

A study published in the journal

found that, after a heart attack, women received some of the quality parameters (tests or medical procedures) indicated in this context less frequently, such as timely perfusion therapy for their clinical condition, coronary angiography or antiplatelet treatments, among others .

Mortality was also higher for them: "It is estimated that 8,243 deaths of women could have been avoided during the study period if the achievement of their quality indicator had been equal to that achieved by men," says the study.

Sambola assures that fewer invasive procedures are performed on women because, sometimes, the diagnosis is not well established, but other factors also influence: “There is the issue of fragility.

There are patients who are older and more frail in appearance [with other associated ailments] than men, but this is difficult to assess.

Maybe there is more risk, but the result is better”.

Less access to clinical trials

The other leg that cardiovascular care limps on in terms of gender discrimination is in research: they participate less in clinical trials.

"In studies where it is tested whether a treatment is beneficial, the percentage of women does not reach 30%", laments Sambola.

Why don't they participate?

The voices consulted indicate that, although they reject more than them to participate due to conciliation problems or because they do not have time to go to the follow-up visits, there are also obstacles in the incorporation because they do not meet the access requirements: “For minor women of 55 years, for example, they do not recruit them because they menstruate and it can influence the result.

With ischemic heart disease, many antithrombotics and anticoagulants are used, which will increase menstrual bleeding, will have more anemia and more side effects”, explains the Vall d'Hebron cardiologist.

The cardiologists call for more attention and awareness in self-care, raising education and training for professionals as well, and recalibrating scales such as GRACE to fine-tune the parameters with a gender perspective.

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