Women's heart attack care improving but not fast enough, researchers say
Heart attack symptoms in women include chest pain and tightness, as well as shortness of breath, nausea, light-headedness and fatigue. (Getty Images: PeopleImages)
In short:
Australian researchers have found disparities in heart attack care between men and women have reduced, but women remain less likely to receive life-saving treatment.
It's estimated the gender gap in care won't close for at least another decade without further action.
What's next?
Further research is needed to understand how to improve outcomes for women, as well as continued improvements in awareness and education, experts say.
Australian women having a heart attack are less likely to be promptly diagnosed and treated compared to men, although the gender gap in cardiac care is narrowing.
A new study, led by researchers at the University of Sydney and published in the Medical Journal of Australia, analysed hospital records and heart attack outcomes in almost 30,000 people in NSW over nine years.
Study lead author and Westmead Hospital cardiologist Clara Chow said previous research had found women having a heart attack were more likely than men to face delays in diagnosis and treatment, and die as a result.
"What we found was that outcomes are improving for both men and women, and they're improving at a faster rate for women … except the gap [between men and women] is far from closed.
"If we continue at the same rate, it will be over a decade until we see the gap actually close."
Despite some improvements in heart attack care, women remain 13 per cent less likely than men to receive an angiogram — a test to check for blocked arteries — and 16 per cent less likely to receive a percutaneous coronary intervention, a procedure to unblock arteries that usually involves placing a stent.
Professor Chow said one reason women experienced critical delays in diagnosis and treatment was because their symptoms often looked different to those seen in men.
"They're less likely to get the classic clutching of the chest pain, and more likely to be a bit breathless and have some tightness," she said.
As a result, women — and those around them — may not recognise they're having a heart attack, including health professionals, who can be slower to diagnose them.
"I still see, as a clinician, these unconscious biases in how we treat men and women in the [health] system," Professor Chow said.
Gap in heart attack care closing
The researchers reviewed hospital records of 29,435 adults in NSW who, between 2011 and 2020, experienced an ST-elevation myocardial infarction (STEMI) — a severe type of heart attack caused by a complete blockage of a heart artery that requires urgent treatment.
"[STEMI] probably makes up about a quarter [of all heart attacks], and is the most common first presentation of a heart attack," Professor Chow said.
"The electrocardiogram presentation [which shows the heart's electrical activity] is very clear with respect to how it looks, so it's easy to recognise."
Professor Clara Chow is academic director of the Westmead Applied Research Centre at the University of Sydney. (Supplied: University of Sydney)
In addition to looking at whether patients received timely care, researchers analysed rates of major adverse cardiovascular events — such as strokes — and all-cause mortality (the total number of people who died from any cause) in the following 12 months.
Women made up almost 30 per cent of study participants and were generally older and more likely to have existing health problems such as heart failure, dementia and diabetes.
The researchers found that, compared to men, women had higher rates of major adverse events and were six per cent more likely to die within 12 months of a heart attack — even when accounting for existing medical conditions.
But they also found this gap appeared to be narrowing.
Over time, the rate of all-cause mortality in heart attack patients dropped slightly faster in women than men.
Rates of adverse cardiovascular events also dropped overall, but — again — appeared to decline slightly faster in women.
The study also found the use of procedures such as angiogram and a percutaneous coronary intervention (or stent) had increased at a faster rate in women compared to men.
"The good news is we feel raising awareness [of women's heart attack symptoms] has cut through, and people are recognising this … but the gap is closing too slowly," Professor Chow said.
Sonali Gnanenthiran, a cardiologist at The George Institute, said although the findings were "encouraging", it wasn't clear whether the faster reduction in all-cause mortality among women was a result of better cardiac care.
"It could be from improvements in cancer treatments or other conditions … there are a lot of other things that contribute to all-cause mortality," Dr Gnanenthiran, who works at Concord Hospital and was not involved in the study, said.
Each year, nearly 20,000 women have a heart attack in Australia. (Unsplash: Pixabay.com)
She added that the lower rate of angiogram and percutaneous coronary intervention procedures in women, while likely the result of inequitable treatment, may also be affected by higher rates of coexisting illnesses.
More sex-specific research needed
Dr Gnanenthiran said the findings of the study were consistent with other research from Australia and overseas that had demonstrated "a significant disparity in heart attack management" between men and women.
Dr Sonali Gnanenthiran is a cardiologist and researcher at The George Institute for Global Health. (Supplied: The George Institute)
And while it provided evidence that it was possible to narrow this gap, both experts said more research was needed to understand how to improve cardiovascular care and outcomes in women.
"There needs to be more sex-specific research … because currently only 20 to 30 per cent of [cardiovascular] clinical trials are made up of women," Dr Gnanenthiran said.
"They do some sub-group analyses, but women are not a sub-group.
"We need much more inclusive recruitment strategies, more flexible timings of appointments, more remote engagement … so we can better target this high-risk population."
More research would allow health professionals to "customise" the management of heart attacks in women, Professor Chow said, and could lead to the development of sex-specific guidelines.
High blood pressure, for example, was a leading risk factor for heart attacks, but women developed cardiovascular events such as heart attacks and strokes at lower blood pressures than men, Dr Gnanenthiran said.
"Does that mean women need different blood pressure targets compared to men? It's a question that is now being raised. We need more research, and when people write guidelines, this is something to consider."
Women's risk factors go overlooked
In recent years, there has been an increasing awareness of how heart attack risk factors and symptoms can differ between men and women, but both experts said continuing to improve knowledge and education was key, including among health professionals.
"It's not just cardiologists. It has to be emergency doctors and general practitioners," Dr Gnanenthiran said.
"It's really important because hopefully [it means] they're less likely to dismiss women presenting with atypical symptoms, and more likely to send them for preventive checks."
Professor Chow said female-specific risk factors for cardiovascular disease, such as having a history of gestational diabetes, pre-eclampsia and early menopause, were often overlooked.
"I am sometimes surprised about women [presenting with a heart attack] not perceiving their risk, when it seems obvious there have been a few flags in the past," she said.
"Women with gestational diabetes or high blood pressure in pregnancy, for example, are at risk of having a heart attack in the future.
"I see that women don't recognise these are risk factors, and health professionals don't recognise that they should be encouraging women to get heart health checks when there are early signs."
In Australia, heart health checks are encouraged and available for free (at practices that bulk-bill the service) for people who do not already have heart disease and are:
- 45 years and over
- 35 years for people living with diabetes
- 30 years for Aboriginal and Torres Strait Islander people.
Professor Chow said people with other risk factors, such as high blood pressure (including during pregnancy) or a family history of cardiovascular disease, should be checked earlier.