Medicine & Ethics

The Silent Bias in Cardiac Care: Why Women’s Heart Attacks Are Still Misdiagnosed

By Mohamed Samy Saafan, YouthCare Connect

Each year, thousands of women go to hospitals’ emergency rooms after experiencing the warning signs of a heart attack but leave after receiving no treatment. Women with heart disease often experience delayed diagnosis, slower treatment, and worse outcomes compared to men with similar cardiac conditions. This gap is due in part to the fact that men were used as standard patients for research, shaping the standards used in medical education, research, and clinical practice for diagnosing and treating cardiovascular disease.

The Male Standard in Cardiology

Heart disease remains the number one cause of death for women across the globe, but for a long time, heart disease had been considered by many to be a man’s disease (Cader et al.). For years, women were left out of many cardiovascular research studies leading to the setting of diagnostic standards based on the males’ presentations of chest pain radiating into their left arm along with chest pain being considered the classic presentation of a heart attack caused by lack of blood getting to the heart. Many women do have the chest pain associated with MI, but many other women have less classic presentations, such as having nausea, pain in the jaw, dizziness, fatigue, or shortness of breath (Cader et al.). As a result, many women’s symptoms are labeled as “atypical” simply because they differ from the historically accepted male standard.

Equality Versus Equity

The distinction between equity and equality is important in understanding how this issue continues to exist. Equality means everyone receives the same approach to medicine. Equity includes adjusting treatment to take into consideration various factors, including each patient’s specific needs and experiences. In cardiac care, there is an assumption that treating all patients equally will be fair. However, if the diagnostic protocols are based on predominantly male research, then women will be at a disadvantage when trying to conform to standards that were never meant for their bodies and symptoms.

The Cost of Delayed Recognition

The ramifications of late detection can have catastrophic results. A study looking into gender inequalities regarding how ischemic heart disease was treated concluded that women experienced more delayed recognition and treatment of an acute coronary syndrome (heart attack) and that every minute counts when experiencing a heart attack (El Bassiri et al.). Any delay in obtaining the appropriate medical intervention increases the risk of irreversible damage to the heart, development of heart failure, and ultimately death. A large body of research indicates that women generally receive less timely medical intervention than men when experiencing the same cardiac conditions (Shah et al.).

Listening Beyond Stereotypes

Emergency care providers struggle with how to interpret patients’ symptoms when a patient presents to an emergency department. A systematic review examining acute cardiac care found disparities across all stages of treatment, including emergency department triage, treatment planning, and recovery care (Vallabhajosyula et al.). Women reporting exhaustion, nausea, or chest discomfort are sometimes told that stress or anxiety may be causing their symptoms before cardiac disease is fully considered. These assumptions reflect how cultural stereotypes about women can continue to influence clinical judgment.

Researchers have begun addressing the gap between clinician evaluations and national evidence-based guidelines for treatment of female patients. In Canada, for example, an emergency department created a protocol for assessing women’s chest pain due to the finding that traditional assessment strategies were not successful in identifying female emergency patients at risk for cardiovascular emergencies (Jaffer et al.). The development of female-specific protocols is indicative of a broader issue; that is, for many years, standard cardiac evaluation instruments were assumed to apply equally to men and women, despite their lack of inclusive evaluations for women’s experience.

Behind every statistic is a patient whose symptoms were minimized or dismissed. Imagine a woman arriving at the emergency department after hours of chest tightness, nausea, fatigue, and difficulty breathing. Instead of receiving an urgent medical evaluation for a heart problem, she is told that it could just be due to stress. By the time she is diagnosed as having suffered a heart attack, precious time for treatment has been lost. For many women, not only is the medical emergency a source of stress and pain, but so too is being initially treated as if they are lying or not legitimate.

Rebuilding Cardiac Care

Women’s symptoms in cardiology cannot be termed as “atypical” while male presentations are always treated as the standard. The practice of medicine must develop by identifying gaps in care and developing improved methods of research, education, and clinical practice to address and fill these gaps of care. Medical schools must put a greater emphasis on the different ways that cardiovascular disease in women shows up, and future clinical trials must include a greater number of women in the research samples. Emergency departments must have a diagnostic approach that allows physicians to listen carefully to their patients without relying so heavily on their out-of-date assumptions or biases.

Modern medicine has technology that produces great achievements, such as saving millions of lives; however, simply having technology will not erase bias from our healthcare system. Advances in healthcare will take more than just faster imaging and improved ways to assess patients; there must also be a change in behaviours and attitudes of healthcare providers that allow them to value women’s experiences in the same way they value men’s experiences. It is not enough for a healthcare provider to be compassionate about listening to women; it is clinically necessary to listen to women.

In order to promote an equitable healthcare system for all, we need to advocate for research, training, and clinical practice that value women’s experience in both clinical practice and research as critical to achieving success in cardiac care.