Gender Differences in the Treatment of Myocardial Infarction

[Time for change]

Heart disease is the leading cause of death in the United States in both men and women. It accounted for more than 652 thousand deaths in the United States in 2005, which was about 27% of total deaths that year. By far the largest sub-category of heart disease deaths is coronary heart disease, which is an obstruction of the arteries that supply the heart muscle with blood. When the obstruction of the coronary arteries is great enough, the amount of oxygen-carrying blood reaching the heart muscle (myocardium) is reduced, which can result in the death of heart muscle, which is known as a myocardial infarction – or a “heart attack” in common language. This situation usually requires aggressive treatment measures, consisting either of direct relief of the obstructed coronary artery or arteries (called percutaneous coronary intervention) or coronary artery bypass surgery, in addition to drug treatment.

It has long been known that men, on average, are Gender differences in Rx more aggressively treated for coronary heart disease (CHD) than are women. And it has also long been known that, although CHD is more common in men, it is more highly fatal in women. That has raised the question of WHY, if it is more fatal in women, is it treated more aggressively in men.

There has been no consensus on the answer to that question. One theory has been that the less aggressive treatment in women is do to the fact that women with CHD tend to be older and have more serious co-existing diseases than do men. Their older age and more serious co-existing diseases could and often do pose a barrier to aggressive treatment of their CHD. However, most studies that have analyzed this issue have found that treatment of men for CHD is, on average, still more aggressive than the treatment of women even after statistically controlling for age and co-existing disease. Those studies therefore showed that age and co-existing disease cannot fully explain the more aggressive treatment of CHD in men than in women.

The two other most prominent theories to explain the less aggressive treatment of CHD in women are: 1) Gender bias (of unknown reason) against women – meaning that doctors tend to give women insufficient treatment for CHD; or 2) More severe disease of the coronary arteries in men than in women – which could justify more aggressive treatment in men than in women.

In this post I’ll discuss a research study that I conducted at the Food and Drug Administration (FDA) to explore the second theory noted above – that men are treated for CHD more aggressively than women because they have more severe disease. This study was funded by the Office of Women’s Health at the FDA, whose main mission is to “Protect and advance the health of women through policy, science, and outreach”. It was the first large study that analyzed gender differences in treatment of CHD by comparing groups of men and women who had similar degrees of severity of coronary artery disease. I will present the results of this study at FDA conferences on September 25th and November 10th, and they will be published in the journal Clinical Cardiology.


FDA STUDY TO ASSESS GENDER DIFFERENCES IN THE TREATMENT OF MYOCARDIAL INFARCTION


Methods

The data for this study came from a registry (the acronym is CRUSADE) of coronary heart disease patients maintained at Duke University Medical Center. In collaboration with researchers from Duke University, we analyzed the records of 32,888 patients who were diagnosed with myocardial infarction and treated at 522 different clinical sites throughout the United States from 2001 through 2006.

Of the 32,888 patients who were included in our study, 18,448 received diagnostic cardiac catheterization. That is a procedure whereby a radio-opaque dye is injected into the coronary artery system, followed by X-rays to assess the degree of obstruction of the coronary arteries.

We divided the study population into four different categories of CHD severity: no significant obstruction; one coronary artery obstructed; two coronary arteries obstructed; and, three coronary arteries obstructed. We also divided the population into four different age groups. We then compared the percentage of men vs. women who were treated with either coronary artery bypass surgery or percutaneous coronary intervention within each of the groupings by age and number of obstructed coronary arteries. We did that so that we could be confident that all of our gender comparisons involved women and men with similar degrees of coronary artery obstruction and age.

We also made similar gender comparisons with regard to drug treatment for five different drugs that are commonly used to treat acute myocardial infarction.


Results

In 7 of the 16 age-CHD severity groups, men were characterized by a statistically higher frequency of coronary artery intervention than were women. There were no age-CHD groups in which women were characterized by a statistically higher frequency of coronary artery intervention than men.

As an example, consider men and women with obstruction of one coronary artery: In the less than 65-year age group, 86% of men were treated with coronary intervention, compared to 77% of women; in the 65-74-year age group, 82% of men were treated, compared to 74% of women; in the 75-84-year age group, 79% of men were treated, compared to 73% of women, and; in the 85-year and above age group, 73% of men were treated, compared to 70% of women.

Similar findings (i.e. greater frequency of treatment in men than women) were found for four of the five drug treatment categories that we analyzed.


The meaning of these findings

These findings go a long way towards showing that the reason for more aggressive treatment of CHD in men than in women is not due to a greater severity of CHD in men than in women, since we compared men and women with similar numbers of obstructed coronary arteries against each other. This study doesn’t completely rule out a greater severity of CHD in men than in women as the explanation for their more aggressive treatment. It is possible, for example, that men with a given number of obstructed coronary arteries had more obstruction of their arteries than women with the same number of obstructed coronary arteries (That data was not collected in this study). But then, if more severely diseased coronary arteries explained the greater frequency of coronary artery intervention in men compared to women, then what would explain the more frequent use of drug treatment in men than in women? In summary, these results go a long way towards ruling out greater severity of coronary artery disease in men as an explanation for their receiving more aggressive treatment than women.


GENDER-BASED TREATMENT BIAS?

In the conclusion to our soon to be published journal article we address the possibility of gender-based treatment bias, by asking the key question:

If the lower rates of coronary intervention and medical treatment in women can be explained neither by differences in diagnostic findings nor age, that raises the possibility of a gender-based treatment bias on the part of physicians, which leads them to consider CHD less seriously in women than in men... That is a very serious matter, given that the prognosis of CHD is generally worse in women than in men and that their worse prognosis is possibly explained at least in part by less aggressive treatment in women.

There are other possible explanations for the gender differences in treatment. For example it is possible that physicians treat women less aggressively for this disease because women prefer to be treated less aggressively. I’m not saying that’s likely, but it does seem possible, and as far as I know that possibility has never been extensively analyzed. And, there could be other explanations that most of us haven’t thought of.


WHY would physicians have a treatment bias against women?

One explanation that might explain a physician treatment bias against women with respect to CHD is the simple fact that CHD is more common in men than in women. But based on the results of this study, that explanation doesn’t seem very likely, since women still receive less frequent treatment of CHD even when they’ve been diagnosed with it by angiography.

After giving the matter much thought, it seems reasonably possible to me that the explanation involves socio-economic status and insurance coverage. Women on average make less money than men, and they’re likely to have worse insurance coverage. A study by Charlotte Muller showed that:

Women use more family and personal funds and rely more on Medicaid; men have more and better coverage by private insurance and are more likely to be covered by Veterans Administration programs and by Workers’ Compensation. Women, paying more expenses out of pocket than men, are more likely to have unmet health care needs.

A relative lack of insurance coverage is undoubtedly translated into less medical care. With regard to Muller’s studies:

It is interesting to note that when men and women are given routine examinations for the same conditions, men tend to receive more tests; perhaps this indicates that men’s complaints are often taken more seriously than women’s.

Yes, it could indicate that men’s complaints are often taken more seriously than women’s. But it could also be explained by less insurance coverage – or by a combination of these two reasons.

A much smaller study that I participated on using funds from the Office of Women’s Health at the FDA suggested that black patients are less aggressively treated for CHD than white patients. It is possible that a relative lack of health insurance coverage partly explains the differences in CHD treatment by both gender and race.

Our next step, if I can get permission to continue with this research, will be to examine how socioeconomic status in general, and different kinds of insurance coverage in particular affect differences in CHD treatment by race and by gender.

[pecwae]

1. Triple rec if only I could. Thanks. nt

[Time for change]

12. Thank you

[lbrtbell]

2. It's gender bias -- period.

I can't mention the names of the major hospitals and clinics, but my family members have worked for several prominent ones. Doctors are overwhelmingly Republican and sexist, and this shows in their treatment of patients.

At one clinic, the doctors' attitudes toward women were so bad, that the top female executive transferred to another facility, because the doctors constantly refused to respect her or obey the rules. (Some went so far as to download porn on company computers.)

Other doctors flat-out refused to treat women or even the elderly! Those patients were too "troublesome".

One clinic toyed with the idea of not treating Medicare patients at all, because they wanted a more well-to-do clientele. That idea sank like a rock, because (duh!) elderly people tend to have more illnesses than rich people.

I know this is only anecdotal, not actual research, but the truth is IN the anecdotes. Because, in any study, no doctor is going to admit how he truly feels toward certain groups of patients.

[Time for change]

3. Thank you for your input on this

It's a little difficult for me to fathom the kinds of things you're talking about because since I began my public health career more than 30 years ago I've been exposed in my working life mainly to public health professionals -- including physicians. Public health professionals (including public health physicians) are one of the least bigoted groups of people you'll ever meet.

But the results of the research I've described in this OP definitely do point towards physician gender bias as the explanation for less aggressive treatment of CHD in women. So anecdotes like those you describe here are useful in helping me to see things from an angle that I'm not used to, thereby getting me to better consider certain ideas that I don't have first hand experience with.

[havocmom]

26. Personal observations: Women's symptoms get blown of most of the time

Too many doctors still think we are just making most of it up. By the time they even look for heart disease in women, it is too often further along the trail toward killing us.

I guess we should be happy many doctors aren't still writing orders for valium and the likes. There is a reason the pigs want a return to the 50s, they had a big chunk of women passive on drugs. But they still don't take our problems as seriously as men's symptoms, then they seem annoyed that more of us die from that 'first' heart attack. They don't admit they are likely missing the first one, maybe even the second and third.

Just pat me on the head and smile. Sure, that'll take care of things :grr:

[TygrBright]

4. You make some very good points.

And you may be spot on among the younger generation of physicians.

However, the root of the gender bias in older generations of physicians may well be acquired during medical school. I had a physician once (and ONLY once!) who told me that "when a man will admit he has a health problem, I take it very seriously. But women tend to call me every time they have a headache or a stuffy nose."

Needless to say, I did not return to that physician. However, I have had other physicians who, while not being as explicitly honest, made it clear that they had some of the same bias.

Women are whiny, hypochondriacal attention-seekers who exaggerate every little ache-- men are uncomplaining stoics who won't admit to weakness until it overwhelms them.

Ask anyone over fifty.

sourly,
Bright

[Time for change]

7. Yes, I think you have a good point there

Society in general was more disrespectful towards women several decades ago than they are today. I'm sure that physicians picked up that general attitude to a large extent, and many never got over it.

And women comprise a much higher percentage of doctors now than they did before.

My mother had some stories to tell me about how it used to be.

[Dr_Willie_Feelgood]

8. Something to that?

I was raised that a man should never see a doctor unless wheeled in on a stretcher. The Navy reinforced the idea that that, if you weren't on death's door you need to suck it up.

Football: Twisted ankle? Broken leg? Walk it off!

Basketball: No blood, no foul!

Feel like crap? Take an aspirin and get back to work, ya lazy bum!

The Macho Life - Shortening Lifespans Since the Dawn of Civilization

[DemReadingDU]

5. Very interesting.

Hope you can continue this research.

[Time for change]

15. Thank you -- I intend to

I know that the Office of Women's Health is very interested in this. In my experience, they have been much more scientifically oriented and less politically oriented than most parts of the FDA. Working on projects with them has been the best part of my experience at FDA.

[Fire_Medic_Dave]

6. Doesn't help that women experience atypical pain symptoms with AMI...

much more often than men do. I can't remember a single woman with an AMI that described "classic" AMI pain. Having said that it should not be an excuse, it is widely known that AMI patients present with a wide spectrum of symptoms. 12 lead EKGs are cheap and quick. I have found that on average women wait much longer to call 911 than men experiencing the same symptoms. My 2 cents anyway.

[Time for change]

11. That is true. However,

the part of this study (described in the OP) that compared coronary intervention rates in men vs. women looked only at patients who had had angiography, and made comparisons that were stratified by the number of diseased coronary arteries. Therefore, the fact that the women in the study may have experienced atypical pain was irrelevant to this analysis, since they had already been diagnosed with MI and confirmed by angiography.

[Fire_Medic_Dave]

19. True, but delaying the angiography because of late diagnosis often makes the MI worse.

[Time for change]

28. That's true. My only point was that

the difficulty in diagnosing MI in women doesn't negate the fact that even after they are diagnosed they are treated less aggressively in men -- as the research described in this OP shows.

[Fire_Medic_Dave]

29. Very true.

[seabeyond]

16. point. if women have different "classic" symptoms, why are they not known and why is male symptons

known as the classic.... ergo applicable to all.... when it isnt.

i am saying

you say women experience other symptoms. why are only the male symptoms recognized? and not the females symptoms

[Fire_Medic_Dave]

18. The female symptoms are less indicative of AMI.

Respiratory distress, back pain, general malaise. In addition there is consistent "classic" AMI symptoms woman to woman. They are known but they often lead one down a different treatment path delaying critical tests, making the results of those tests less reliable and masking symptoms. For instance respiratory distress, is most likely treated with oxygen. I have seen ST elevation and Bundle Branch Blocks disappear on an EKG within 1 minute of oxygen being applied to a patient. So when that EKG is run in the ER it looks normal then the doc says lets run a stress test just to be safe and low and behold hours later it is discovered that the patient has a significant coronary artery blockage.

[JTFrog]

9. K&R

[barbtries]

10. thank you for sharing

and for the work that you do.

[BlancheSplanchnik]

13. I read about this study somewhere before...

fairly recently, but I can't remember where I read it. Maybe Women's e-News.

I'm glad to see the gender bias angle is being pursued. I think it's pervasive and so often disregarded. Would be worthwhile to consider internalized gender bias among women too, as you mention there are more female doctors than in the past.

Makes me think of a book, "For Her Own Good". It's more of a history of gender bias and the damage done to women, but I would say that such extreme dismissive and controlling attitudes to women don't go away in a mere ~40 years.

Huh... so many thoughts on the subject -- just my subjective impressions, but still......



Anyway, SO glad to see your work here!!!!

You're a real light in the world, TfC


Very good outline summary of the book here: http://www.pinn.net/~sunshine/book-sum/owngood.html
For Her Own Good:
150 Years of the Expert's Advice to Women
Barbara Ehrenreich and Deirdre English
originally copyrighted 1978, Anchor Books, 1989 edition

Ehrenreich and English discuss the advice professionals, particularly ministers, doctors, and psychiatrists dispensed to women, how and why they lost power in the 1960, and what has replaced them.

Table of Contents

Motherhood to the Sexual Marketplace

One Introduction: The Romantic Solution
Two Witches, Healers, and Gentlemen Doctors
Three Science and the Ascent of Experts
Four The Sexual Politics of Sickness
Five Microbes and the Manufacture of Housework
Six The Century of the Child
Seven Motherhood as Pathology
Eight From Masochistic
Afterword: The End of the Romance

[Time for change]

14. Thank you for the reference Blanche -- and all the information on it

I have found Barbara Ehrenreich to have many very important insights. This should help me to better understand some of our research findings that I'm seeing, and plan for the next stage.

[BlancheSplanchnik]

23. You're welcome, TfC :)

I'm thrilled I could contribute something more practical beyond "hey you rock!" --- not that there's anything wrong with that... :D

anyway, the book is a little dated,; I've had my copy for a looooong time. But like I said, I think there's alot of useful info and insight there.

[icymist]

17. Excellent post and a very important study.

I especially found interesting your comparison between the differences of CHD treatment for women and men and between black patients and white patients. Do you believe the doctors are creating such treatment discrepancies or do the insurance companies play a greater role when making these decisions? Access to good insurance coverage seems fitting explanation to some of these cases, however, I wonder how much discrimination is brought about by the insurance companies board themselves. It would be interesting to see how the makeup of the board who makes these decisions are compared to the patients themselves, (i.e. a predominately white, upper-class male board in the South making medical decisions for racial and sexual minorities in the North).

[Time for change]

21. Thank you. You pose some interesting and important questions

I can't answer your questions with confidence, but I believe that probably both the insurance company and the doctor play a role in making these decisions. I think that these things should be looked into in detail -- especially given the national debate over health insurance, it would behoove us to have more detailed information on how various types of health insurance affect the care that people -- and minority groups in particular -- receive.

[katkat]

20. yup

I'll just add in a couple of facts I know of.

I used to live near Stanford. You perhaps are familiar with the gender bias situation involving Dr. Francis Conley. I was stunned when this hit the papers. A leading medical center in this day and age filled with plain out bigotry, not just subtle bias, against the women on its staff. Heaven only knows how they treat female patients.

When I moved to Rhode Island and was looking for a cardiologist, I went to a new department at a major hospital which supposedly specialized in women's cardiac health. I'll omit the details for privacy's sake, but I was badly misdiagnosed. Fortunately no harm was done except extreme stress and misery until it was sorted out elsewhere. Of course, extreme stress and misery is not that great for the heart, either.

[Time for change]

22. I hadn't heard of Dr. Conley

That brings to mind what happened to my mother-in-law a few years ago. She had a myocardial infarction and was transferred to a specialty hospital after an initial work-up at her local hospital. But the wrong records were transferred to the speciality hospital, and she probably died as a result of that. At the time I didn't think of it as an example of gender bias -- just pure incompetence and irresponsibility. But who knows?

[lumberjack_jeff]

24. Attributing everything to sexism does society a disservice.

In every age cohort, more men die of heart disease than women.
http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_10.pdf

Up to age 65 heart disease kills twice as many men as women. Only by age 75 do the death rates begin to equalize, but by then the average man has been dead two years.



Given the fact that heart disease is more often fatal for men than women, and at a younger age, I find it hard to agree that differences in treatment are most likely based on sexism. Heart disease which is is a chronic problem for women is fatal for men.

[Time for change]

25. Notwithstanding the fact that more men die of heart disease than women...

the facts remain that among those who have CHD, women are more likely to die than men, AND that women receive less care for it than men. The reason that more men die of CHD than women than men is that it is a lot more frequent in men than women.

I don't have time right now to dig up the reference, but I came across several of them during my research on this. I will get it later today and post it here.

[Time for change]

27. Here you go

http://www.labmeeting.com/paper/25578356/bennett-redberg-2004-acute-coronary-syndromes-in-women-is-treatment-different-should-it-be

The vast majority of acute coronary syndrome (ACS) trials conducted over the past two decades support the view that women have persistently higher mortality and morbidity...

Also, I want to make it clear that I haven't attributed these findings to sexism. I said in my journal article that:

If the lower rates of coronary intervention and medical treatment in women can be explained neither by differences in diagnostic findings nor age, that raises the possibility of a gender-based treatment bias on the part of physicians, which leads them to consider CHD less seriously in women than in men...

Gender-based treatment bias may or may not be the result of sexism. We don't have enough data on the potential reasons for gender-based treatment bias to attribute a specific cause to it.

[katkat]

30. another facet

Here's an interesting article that appeared in the Times:

http://www.nytimes.com/2009/09/15/business/15device.html

'A new review of patients using defibrillators has found that they do not appear to benefit women with congestive heart failure, although some experts cautioned that the finding might reflect shortcomings in the data being studied."

I'm beginning to think there is a vast gap in the understanding of how heart disease works in women, probably because studies were done on just men for so long.