Are Women Missing Out?

Do women miss out on needed cardiac care?

Numerous studies over the past decade have documented significant differences in the cardiac care received by women and men. Studies have shown that women with suspected coronary artery disease have fewer additional diagnostic tests, such as cardiac catheterization, than men do [24] and that women hospitalized with heart disease are less likely to receive coronary artery bypass surgery, angioplasty procedures, [2] or clot-busting thrombolytic drugs to restore blood flow to the heart.[13]

Some investigators, like Duke University’s Daniel B. Mark, MD, argue that these differences in care can largely be explained by the fact that differences in presentation and sensitivity of tests make heart disease harder to diagnose in women. Also, women frequently have less severe disease despite being generally older and having more diabetes, hypertension, and other complicating conditions than men at onset of CHD, Mark says in a recent editorial in the Journal of the American Medical Association.[15]

But Mark acknowledges that a bias against women may still be operating, as seen in the results of a study by Kevin A. Schulman, MD, then at Georgetown University Medical Center, and colleagues.

Schulman and colleagues used actors to portray patients with symptoms of coronary artery disease.[23] Even when women and men displayed identical histories, primary care physicians judged the women significantly less likely to have heart disease than men, and black women were significantly less likely to be referred for cardiac catheterization than were white women and black or white men. Race and sex had no effect on referrals for exercise stress testing.

Some real-world evidence also suggests that under identical circumstances, women may get less aggressive care, leading to poorer outcomes. For example, Peter J. Kudenchuk, MD, and colleagues at the University of Washington, Seattle examined records on more than 1,000 men and women with a confirmed heart attack.[13]

Although men and women differed little in their symptoms or electrocardiogram findings, or in time before receiving treatment, women were half as likely as men to receive thrombolytic drugs or undergo catheterization, angioplasty, or bypass surgery. Even after adjusting for the effects of age and other baseline characteristics, women were twice as likely to die while in the hospital than were men.

Survival May Be a Matter of Time

The longer patients delay in seeking treatment after experiencing heart attack symptoms, the higher the likelihood they will experience further disability or death. That’s because methods to open clogged arteries -- usually by using clot-busting medications, anticoagulants, and other medications or balloon angioplasty -- have their maximal effect if administered within an hour of the onset of symptoms. Yet many patients wait much longer before seeking medical care.

In their study of 360,000 heart attack cases, Robert J. Goldberg, PhD, of the University of Massachusetts Medical School, and colleagues found that patients took 5.5 hours, on average, after symptoms began before seeking care at an emergency room.[9]

As has been shown in previous studies, women delayed significantly longer than men (6.2 hours vs. 5.4 hours), blacks delayed longer than whites (6.3 hours vs. 5.6 hours), and older patients delayed longer than younger patients (6.1 hours for those over 75 vs. 4.8 hours for those under 55).

Other research has shown that the severity of symptoms people experience affects how quickly they seek care. People who have sudden severe chest pain seek care most quickly, but those with severe pain that increases over time delay just as long as those with less severe pain.[18]

Educational efforts to reduce treatment delays should focus first on detailing the range of possible heart attack symptoms, concluded a panel convened by the National Heart, Lung, and Blood Institute (NHLBI).

Although many patients expect a heart attack to be accompanied by crushing chest pain and unconsciousness, symptoms can be intermittent or come on gradually. And while chest pain is the most common symptom in women as well as men, both men and women with heart attacks often complain of back pain, shortness of breath, or nausea and vomiting alone.[21] Symptoms among women and the elderly may be even more non-specific.

The second focus of educational efforts, according to the NHLBI panel, should be on what to do when a heart attack is suspected. Dialing 911 is the preferred strategy. People who contact their physician first can double the delay in receiving appropriate emergency care.

Emotional issues are also important. Patients frequently attempt to downplay the severity of their symptoms and allay their anxiety by attributing heart attack symptoms to indigestion or other causes. Emphasizing the rewards of acting quickly is likely to be more effective than stressing the risks of sudden death, the panel concluded.

Finally, these messages should be conveyed to partners, spouses, and family members, since people tend to consult those close to them about suspected heart attack symptoms.

These and other strategies are being tested in an NHLBI-sponsored trial that has just been completed in 20 U.S. communities.[22] Led by James M. Raczynski, PhD, at the University of Alabama, the educational campaign is targeting patients at high risk of heart attack, health care providers, and community members and organizations to increase knowledge and awareness of the need for action in the event of heart attack symptoms. Investigators expect the findings will prove valuable in designing national efforts to reduce heart disease illness and death.

Know Your Risks: A Web Guide

The Internet is awash with information on cardiovascular disease, but the American Heart Association (AHA) is betting that its soon-to-be launched interactive Web site can dramatically reduce heart attack and stroke risk among those who use it.

Visitors to the site, called "One of A Kind," complete a questionnaire about their diet, exercise habits, and health history. The program then creates a personal risk profile and action plan to help individuals reduce their heart disease and stroke risk.

"I could go anywhere and read something about smoking, high cholesterol, or high blood pressure," says Kathryn Taubert, PhD, AHA’s director of cardiovascular science. "But if I have all three risks, here [on the One of a Kind Web site] I’ll get a message back that is tailored to me and explains why I am at particular risk. And the message may be different if I am a 60-year-old woman, or a 40-year-old man, or if I also have diabetes."

Tailoring information to each individual is key to the program, Taubert says. Research has shown that people who hear health messages individually tailored for them are more likely to quit smoking [26] or reduce fat in their diets,[6] she says.

Information is also tailored to each individual’s readiness to make changes in their lives, as indicated by their responses on the questionnaire. "If someone says they are not ready to quit smoking, you come back at them with messages about smoking, but you don’t try to ram it down their throats," Taubert says. "A person might be more willing to work on their diet. If you can get them off the dime on one thing, they very often will go ahead and try to make a change in another area."

Participants update their health status as needed and complete follow-up questionnaires periodically throughout the year, allowing the program to assess their progress and highlight the positive changes they’ve made and the areas they still need to work on.

The AHA is marketing One of a Kind to large employers for use in their work-site health promotion programs. The organization hopes it also will be incorporated by several other health Web sites on the Internet.

People will also be able to access the program through AHA’s Web site at http://www.americanheart.org this spring.

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The Research:

American Heart Association. (2000). 2000 Heart and Stroke Statistical Update. Dallas, TX. http://www.americanheart.org/statistics/index.html.

Ayanian JZ & Epstein AM. (1991). Differences in the use of procedures between women and men hospitalized for coronary heart disease. New England Journal of Medicine, 325(4):221-225.

Blumenthal JA, et al. (1995). Mental stress-induced ischemia in the laboratory and ambulatory ischemia during daily life. Association and hemodynamic features. Circulation, 92(8):2102-2108.

Blumenthal JA, et al. (1997). Psychosocial factors and coronary disease. A multicenter clinical trial (ENRICHD) with a North Carolina focus. North Carolina Medical Journal, 58(6):440-444.

Blumenthal JA, et al. (1997). Stress management and exercise training in cardiac patients with myocardial ischemia. Archives of Internal Medicine, 157:2213-2223.

Campbell MK, et al. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84(5):783-787.

DeBusk RF, et al. (1994). A case-management system for coronary risk factor modification after acute myocardial infarction. Annals of Internal Medicine, 120:721-729.

DeBusk RF. (1996).MULTIFIT: A new approach to risk factor modification. Cardiology Clinics, 14(1):143-157.

Goldberg RJ, et al. (1999). Duration of, and temporal trends (1994-1997) in, prehospital delay in patients with acute myocardial infarction. Archives of Internal Medicine, 159:2141-2147.

Gullette ECD, et al. (1997). Effects of mental stress on myocardial ischemia during daily life. Journal of the American Medical Association, 277(19):1521-1526.

Jiang W, et al. (1996). Mental stress-induced myocardial ischemia and cardiac events. Journal of the American Medical Association, 275(21):1651-1656.

King AC, et al. (1991). Group- vs. home-based exercise training in healthy older men and women. A community-based clinical trial. Journal of the American Medical Association, 266(11):1535-42.

Kudenchuk PJ, et al. (1996). Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (The myocardial infarction triage and intervention registry). American Journal of Cardiology, 78:9-14.
Linden W, et al. (1996). Psychosocial interventions for patients with coronary artery disease. A meta-analysis. Archives of Internal Medicine, 156:745-752.

Mark DB. (2000). Sex bias in cardiovascular care. Should women be treated more like men? Journal of the American Medical Association, 283(5):659-661.

Miller NH, et al. (1997). Smoking cessation in hospitalized patients. Results of a randomized trial. Archives of Internal Medicine, 157(4):409-415.

Milner KA. (1999). Gender differences in symptom presentation associated with coronary heart disease. American Journal of Cardiology, 84:396-399.

National Heart, Lung, and Blood Institute. (1997). Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction. Bethesda, MD. http://www.nhlbi.nih.gov/about/nhaap/highrisk.htm.

National Heart, Lung, and Blood Institute. (2000). Healthy Heart Handbook for Women. Bethesda, MD. http://www.nhlbi.nih.gov/health/public/heart/other/hhw/index.htm.
Ornish D, et al. (1998). Intensive lifestyle changes for reversal of coronary heart disease. Journal of the American Medical Association, 280(23):2001-2007.

Penque S. (1998). Women and coronary disease: Relationship between descriptors of signs and symptoms and diagnostic and treatment course. American Journal of Critical Care, 7(3):175-182.

Raczynski JM, et al. (1999). REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. American Journal of Preventive Medicine, 16(4):325-334.

Schulman KA, et al. (1999). The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine, 340(8):618-626.

Shaw LJ, et al. (1994). Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Annals of Internal Medicine, 120(7):559-566.

Sherwood A, et al. (1999). Endothelial function and hemodynamic responses during mental stress. Psychosomatic Medicine, 61(3):365-370.

Strecher VJ, et al. (1994). The effects of computer-tailored smoking cessation messages in family practice settings. The Journal of Family Practice, 39(3):262-270.

West JA, et al. (1997). A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. American Journal of Cardiology, 79(1):58-63.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

Funding for this series was provided by the Robert Wood Johnson Foundation.

© Copyright 2000, Center for the Advancement of Health

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