Women are getting worse medical care than men after a heart attack, resulting in unnecessary deaths, according to a new analysis of 180,368 Swedish patients, followed up for 10 years after a heart attack. When women were given optimal treatment (surgery or stents, aspirin and statins), they did as well as men. And the situation is likely to be even more obvious in the UK, says the British Heart Foundation, which part-funded the study.
And is this glaring gender divide because women ignore their symptoms? Get different symptoms – more easily confused with indigestion? Are taken less seriously by GPs? Are less likely to have heart disease when investigated for chest pain? Are less likely to have tests such as an ECG? Receive different treatment in hospital? And are less likely to be offered implantable devices that prevent later deaths?
The likely answer to all these questions is yes. There’s a subconscious bias at work that means if I see an overweight, middle-aged male smoker with a bit of breathlessness or chest discomfort in my GP surgery, I’m more likely to think “heart disease” and if she’s female to think “acid reflux”. Historically, that may have been statistically understandable, but it’s now an unjustified bias that GPs need to recognise and counter by following proper referral pathways.
Even the most objective of GPs will respond to what a patient says. So women and men alike do themselves no favours by underplaying symptoms or suggesting that they’re sure it’s indigestion or muscle pain. In my experience, women are more likely to self-blame than men: “I let myself go over Christmas and have put on weight so probably I need to just cut down and this pressure in my chest will go.” This is exactly what a woman said to me recently but an ECG showed signs of strain on the heart and triggered an urgent assessment at a rapid access chest pain clinic for specialist care to prevent a heart attack.
I’ve always assumed that although a woman is less likely to present their symptoms and be referred appropriately by the GP, once she gets to hospital, she’ll be treated the same as a man. But this study suggests that even once a heart attack is confirmed, that woman is less likely than a man to get recommended treatment. This doesn’t chime with my clinical impression; our female patients discharged from hospital after a heart attack are on the same drugs and have undergone the same procedures (stents or surgery) if needed as our male patients.
Clinical guidelines are based on objective criteria and gender is not one of them. It requires further interrogation of UK databases to verify whether this same apparent damaging discrimination is happening elsewhere. It would also be useful to hear comment from Swedish cardiologists and their department of health to understand what lies behind this scary story.
On the plus side, we continue to live longer than ever and the rates of circulatory disease (heart disease and stroke) continue to fall. In the UK, most of us will die of cancer, circulatory disease or dementia. Falls in smoking rates, changes in lifestyle and medical advances have all made the chances of having a heart attack and surviving one better than we could have imagined in the 1970s, when my dad died aged 48 after his third heart attack.
But the tragedy is that there are still 42,000 premature deaths a year from heart disease in the UK that are now potentially avoidable. Men and women alike need to recognise the signs, seek medical help and demand prompt and optimal care. And it seems that, as in so many areas, women may need to shout louder to be heard.
• Ann Robinson is a GP
