Studies Find Women Less Likely to Get Heart Care
Despite the fact that heart disease is the leading cause of death in women, physicians are much less aggressive in detecting and treating the disorder in women than in men, according to two new studies published today in the New England Journal of Medicine.
In a study covering all hospitals in Massachusetts and Maryland, researchers found that women were significantly less likely than men to undergo radiological tests for blocked blood vessels, procedures to clear such blockages and coronary-artery bypass surgery.
In a second study, conducted at 112 hospitals throughout the United States on men and women who had already had a heart attack, researchers found similar evidence of an apparent “sex bias” among cardiologists.
The new studies are only the latest pieces of evidence that women often receive inferior treatment from the medical profession, which often initially directs innovative therapies and new drugs at men.
Heart disease kills an estimated 500,000 women and 475,000 men annually, according to the American Heart Assn.
“Historically, women’s complaints (about chest pains) have not been taken as seriously as similar complaints by men,” said cardiologist Mary Ann Malloy of the Loyola University School of Medicine in Chicago.
“The biggest shame is that, on a statistical basis, a woman has more warning of coronary heart disease . . . and theoretically has more time to have tests and have the problems taken care of. Their symptoms need to be taken seriously and pursued.”
In a separate editorial in the New England Journal, Bernadine Healy, director of the National Institutes of Health, termed physicians’ sex bias the Yentl syndrome, after the 19th-Century heroine of Isaac Bashevis Singer’s short story who disguised herself as a man to attend school and study the Talmud.
“We must be challenged by the example of coronary artery disease to examine critically the extent to which the Yentl syndrome pervades medicine and medical research and to respond promptly whenever its influence is evident,” she wrote.
Epidemiologists John Z. Ayanian and Arnold M. Epstein of Brigham and Women’s Hospital in Boston studied the record of all patients who had been hospitalized in Massachusetts and Maryland for heart disease during 1987--a total of 82,782 patients.
When they had eliminated the influence of all other factors, they found that men were 28% more likely than women with comparable medical conditions to undergo angiography in Massachusetts and 15% more likely in Maryland. Similarly, Massachusetts men were 45% more likely than women to undergo revascularization, an operation in which physicians clear deposits from blocked arteries, and Maryland men were 27% more likely than women.
The second report presented partial results from the Survival and Ventricular Enlargement trial, a nationwide study of 2,231 men and women who were hospitalized for a heart attack. The researchers found that, even though the women had typically had more severe symptoms of heart disease prior to their heart attack, they were only roughly half as likely as men to have undergone either angiography or bypass surgery.
Loyola’s Malloy said that the surveys reflect some “real bias” on the part of many physicians. “There has always been more interest in the half of the population that contributes to the gross national product and, until recently, that was the male half.”
But many reasons for the disparity go beyond male chauvinism, she added. Testing women for coronary heart disease is more difficult than testing men, she noted, both because chest pain in women can have a larger number of non-coronary causes and because treadmill tests--the most common technique for discerning heart disease--”give more inaccurate results in women.”
Furthermore, she noted, it is more difficult to perform surgical procedures on women because their arteries are smaller than men’s and thus harder to work with. Coronary bypass procedures have a higher mortality rate in women than in men, 4% compared to 2%. But that difference, she noted, reflects the fact that women are typically older and have more advanced disease when they undergo surgery.
The two new studies are follow-ups to previous studies that showed that women who complained of chest pains were referred for coronary angiography (a common test that uses X-ray movies to show buildups clogging the heart’s arteries) less frequently than men. In addition, women were referred for coronary-artery bypass surgery at a more advanced stage of the disease than men, thereby leading to a higher postoperative death rate.
But those older studies were conducted at single hospitals and many critics argued that they reflected only local experiences in the areas studied. But the new studies demolish that argument by showing that the practices are widespread and pervasive.
The new studies come at a time when government agencies are reconsidering whether female patients should have a larger part in clinical trials of new drugs and therapies. In the past, women have frequently been excluded from such trials on the grounds that they could become pregnant or that their hormonal cycles could have an unpredictable impact on results.
For example, researchers reported Wednesday in the Journal of the American Medical Assn. that a daily dose of aspirin could reduce the incidence of second heart attacks in women. Similar results in men were reported two years earlier.
Critics also note that the prestigious National Institutes of Health, one of the world leaders in medical research, has no branches for gynecological or obstetrical research, which means that breast cancer, menopause and other health issues of women get short shrift.
To remedy these deficiencies, NIH has recently begun the Women’s Health Initiative, a multidisciplinary program that will address the major causes of death, disability and frailty among middle-aged and older women.
Concluded Healy: “It is our hope that the bold and charming heroine Yentl will survive, but that her syndrome will slip back into history as a curiosity of times gone by.”
Comparing Coronary Care
According to two recent studies, U.S. women with heart conditions can expect to receive significantly less medical attention than their male counterparts. Here is a look at the female/male ratio for various coronary procedures. (Angiography uses X-ray motion pictures to detect blocked blood vessels; revascularization is a surgical technique to unplug blocked veins.)
LOCATION BYPASS SURGERY ANGIOGRAPHY REVASCULARIZATION Women/Men Women/Men Women/Men Maryland* NA 100/115 100/140 Massachusetts* NA 100/139 100/131 All U.S.** 100/184 100/187 NA
*Brigham & Women’s Hospital. All subjects had heart disease.
**Survival and ventricular enlargement trial. All subjects had already had a heart attack.
NA means not available
SOURCE: New England Journal of Medicine
Compiled by Times researcher Michael Meyers
