Why heart attack care may be less timely for women

You can use your feminine wiles for many things, but apparently not to get better care at the hospital. A new study, published Monday in the Canadian Medical Association Journal, found that women do not get care as fast as men during heart attacks, especially if they are anxious or identify with feminine gender roles. This delay in care also extended to men who self-identified with feminine gender traits.

"Were not sure why this is the case, Roxanne Pelletier, one of the lead investigators of the study, tells CBC. "Individuals in the study with feminine traits tended to be more vague and not assertive enough when talking about the pain, and were not able to describe their symptoms well to the health care workers."

• Study shows significant gender bias against women with heart disease

Pelletier suggests that the take-home message is that how people present to the emergency department will have a big impact on their treatment. "It is important for people to be assertive and clear about their symptoms when they get to the hospital."

The study looked at 1,123 men and women aged 18 to 55 years who were admitted for acute coronary syndromes (heart attacks or myocardial infarctions and their precursors, such as angina), from 24 centres across Canada, one in the United States and one in Switzerland.

Heart attacks or acute coronary syndromes (ACS) are caused by blockages of the blood supply to the heart muscle, and treatment is usually aimed at getting rid of the clot.

Researchers looked at time-intervals from presentation to various treatments, including:

• Time to first electrocardiogram (ECG).
• Time to balloon catheter (which stretch the clot open).
• Time to removal of the blockage, either by putting in a stent or through medications that break down clots called fibrinolytics.

Men received faster access to ECGs than women with average times of 15 and 21 minutes respectively, as well as faster access to fibrinolytics than women, with average times of 28 and 36 minutes, respectively. Men were also more likely to undergo invasive procedures than women overall (66 per cent versus 48 per cent).

To explain this delay, the researchers assessed differences in clinical presentation as well as gender traits. Traditionally, men with ACS were thought to present with chest pain more commonly than women, making diagnosis easier and treatment quicker. Women, on the other hand, were known for their atypical presentations and lack of chest pain, presenting with 'silent" heart attacks that delayed their treatment.

Cardiologists say newer evidence shows that both sexes present with chest pain. But men describe it as chest pain, and women see it as part of a general 'uneasiness.'

As expected, the study showed clinical differences between sexes. Women presented with more silent ACS as well as more risk factors like high blood pressure, diabetes, and a family history of heart disease.

Anxiety levels were similar across the sexes, but women who presented with increased anxiety were more likely to get delayed care than men.

"Patients with anxiety who present to the emergency department with non-cardiac chest pain tend to be women, and the prevalence of acute coronary syndrome is lower among young women than among young men," writes Dr. Louise Pilote, clinician-researcher, Division of Clinical Epidemiology at the Research Institute of McGill University Health Centre in Montral, and professor of medicine at McGill University with coauthors.

"These findings suggest that triage personnel might initially dismiss a cardiac event among young women with anxiety, which would result in a longer door-to-ECG interval."

But while these clinical differences were present, the authors were surprised to find they were less significant than differences in gender-related traits. Patients were asked to complete a validated survey that asked about gender-related issues such as "traditional" masculine and feminine traits of personality, responsibility for housework, educational level and health status before the event.

"We expected there would be differences but thought they would be more biological than gender related," Pelletier tells CBC.

Dr. Beth Abramson, a cardiologist at St. Michaels Hospital in Toronto and author of Heart Health for Canadians, says this is a reminder to physicians that young women can and do have ACS, and that all patients need to play an active role in their own health and know the warning signs.

"How we communicate to our health care providers is extremely important. Women tend to be worry about everything and everyone but themselves. They need to come to the emergency room and say, 'Hey! I have a problem.'"

While gaps in care between the sexes exist, however, Abramson says the times in the study show that Canadians overall receive excellent care for ACS.

Dr. Meera Dalalis an Internal Medicine resident at the University of British Columbia and a journalism fellow at the Munk School of Global Affairs at the University of Toronto.