Women with acute coronary syndromes (ACS) are less likely to be treated with guideline-directed medical therapies, less likely to undergo cardiac catheterization, and less likely to receive timely reperfusion. Women are more likely to present with non-ST segment elevation myocardial infarction (MI) and non-obstructive coronary artery disease. Within a year of a first MI, more women are likely to die than men (26% to 19%). Furthermore, more women are likely to die within the first 5 years (47% to 36%). Women are also more likely to have heart failure and suffer a stroke following an MI.
Clinical research and physician education on the “atypical” clinical presentations of ACS in women over the past 15 years has attempted to eliminate these gendered health disparities. An interesting series of studies, “The Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients,” revealed that the majority of women (87%) and men (89%) presented with chest pain, pressure, tightness or discomfort. However, women were also more likely to present with three or more associated symptoms such as epigastric symptoms, palpitations and pain or discomfort in the jaw, neck, arms or between the shoulder blades (61.9% vs. 54.8% of men). Women with STEMI were more likely to present without chest pain than men (OR 1.51, CI 1.03-2.22) but less likely to attribute the symptoms to muscle pain than men were (15.4% vs 21.2%).
Evidence reveals gender bias may play a role in the disparities women in the United States experience. For instance, for women who were wearing full make-up at the time of presentation, the severity of their chest pain was minimized. This same 2016 survey showed that when women presented to places of care, their symptoms were dismissed until their status deteriorated. One woman was discharged without any diagnostic examination and suffered a cardiac arrest on the way home, although fortunately, she survived. 29.5% of women and 22.1% of men sought medical care for similar symptoms before hospitalization, but 53% of women reported that their provider did not think these symptoms were heart-related compared to 37% of men, with a statistically significant difference at p<0.001. In addition, women were also more likely to have higher delay time in seeking care, which is thought to contribute to health outcomes. The median delay time for women seeking care was 53.7 hours compared to 15.6 hours for men. This was at least partly attributed to socially constructed roles and expectations. There lies an intriguing research opportunity in determining whether this misattribution by providers contributed to women’s misperceptions of their symptoms as stress rather than related to their heart health and consequently contributed to women presenting at later times during acute coronary events.
It has been further established that non-white women experience even greater disparities. Non-white women experience lower exposure to secondary prevention efforts. Non-white women are also less likely to receive counseling on smoking cessation and lipid-lowering drugs. In January of 2020, a 25-year-old black woman presented to an emergency room (ER) in Milwaukee with chest pain. She had been made to wait over two hours, prompting her to leave for a nearby urgent care center in the hope of receiving more immediate attention. She collapsed and died adjacent to her car at the parking lot of urgent care and was pronounced dead a few hours later. The ultimate consequence of gender bias for women of color, particularly black women, is death.
Clinicians can utilize tools such as the American College of Cardiology/American Heart Association (ACA/AHA) to reduce the effects of unconscious bias in their assessment of patients. This is a cardiovascular risk calculator derived from several community cohorts that included women, large minority populations and the cohort from the Framingham studies. Additionally, there exist quick, evidence-based heuristics for measuring cardiovascular risk such as the waist-to-height ratio, which is estimated easily by utilizing a string to approximate a patient’s height, then comparing this length of string to their waist circumference (high cardiometabolic risk: waist circumference/height > ½ of the string length). The waist-to-height ratio is noted to be more accurate than BMI in predicting cardiometabolic risk.
In summary: chest pain, pressure, tightness, or discomfort are the typical symptoms of patients presenting with ACS. Women are more likely to present with additional non-chest symptoms, which is important to note to avoid labeling their clinical presentation as psychosomatic. Most young patients presenting with ACS also have one or more cardiac risk factors, such as diabetes, high cholesterol, smoking, obesity, or hypertension. Thus, heart disease diagnoses should be considered in younger women, especially in those with one or more cardiac risk factors accompanied by chest discomfort and other potentially nonspecific symptoms. Strictly adhering to prevention guidelines for both men and women of all ethnicities and utilizing tools to assess risk could present an opportunity to reduce disparities in the quality of patient care.
As a freshman in college, I learned from Dr. Vivian Pinn via the University of Virginia’s Summer Medical Leadership Program that, for decades, the field of medicine narrowed women’s health to the “bikini area,” despite the fact that cardiovascular disease is the leading cause of death in both men and women. Years later, in medical school, I heard the unfortunate story of a black woman who presented with chest pain and shortness of breath but was made to wait for hours and ultimately died. All this inspired me to write this article, pinpointing areas in which medicine is developing towards gender equity and ways providers can accelerate the forward march.