For years, the way doctors diagnose heart attacks has largely relied on research and testing standards developed using data that came mostly from men.
Now, new international guidelines are drawing attention to that gap, redrawing the plans for testing and care when women are being seen for possible heart attacks. That’s because heart disease remains the leading cause of death among women worldwide. But how they are assessed and tested is based on a male standard of care, says the world heart federation.
For Karen Humphrey, that gap nearly cost her her life.
Humphrey was 47 years old when she first went to a hospital near her home in Chilliwack, B.C., with symptoms she feared could be a heart attack.
“My chest felt like squeezing. I had pain down my arm,” she recalled. She had training in CPR and recognized symptoms that could be those of a heart attack.
Her doctors tested the level of troponin in her blood, a protein released when the heart is damaged. They said her levels were too low to indicate a heart attack. She was also considered relatively low risk because of her age. She said she insisted on more testing and was offered an angiogram to check out the flow in her heart.
Humphrey said some doctors questioned whether she needed an angiogram, which left her feeling dismissed. “My response was, well, if there’s something wrong, I want to know.”
That angiogram revealed a serious problem: there was a 90 per cent blockage in one of her arteries. Humphrey was treated with medication and a stent to restore blood flow.
But her ordeal was far from over.
Her chest pain returned, and without follow-up from a cardiologist or rehabilitation, she said she headed to the emergency room for help with severe heart spasms. “It felt like you’re being strangled from the inside,” said Humphrey. Doctors continued to check her troponin levels.
“They would opt to say no (to a heart attack)... they’re not really high and then they would just send me home,” she said.
After returning several evenings to the ER, Humphrey refused to leave until she got more testing.
“I just went and sat and wouldn’t leave until they listened to me.”
Finally, while health workers were monitoring her heart, she had the heart spasms she complained about, and another heart attack. She fears what would have happened if she had left.
“I was angry, but I also was just really determined because, I mean, because my son ... who’s 21, he’d already lost his dad, and I was like, ‘I’m not leaving my kid an orphan.’”
Gender gap
Humphrey’s experience reflects a growing focus on what researchers describe as a gender gap in the diagnosis and treatment of heart disease.
Troponin is an important marker because damaged heart muscle releases the protein into the bloodstream, but the amount of troponin considered a sign of a heart attack was based on data from men. Studies have shown women have lower levels of this protein.
Now, a task force made up of four international cardiac societies, have issued new heart attack definitions that try to bridge the gender gap, urging doctors to be aware that women have lower levels of troponin than men when having a heart attack.
The guidelines also focus on the different kinds of heart attacks more common in women, that are triggered by things such as childbirth, exercise or stress.
“We need to treat women as women, and if that means addressing the lower troponin, then we are raising awareness and making sure women are being taken care (of),” said Dr. Beth Abramson, a cardiologist at St. Michael’s Hospital in Toronto and longtime champion of better heart disease prevention and treatment in women.
The new guidance will help improve detection, doctors say, but the next challenge for health systems is making sure women are appropriately investigated and treated.
“I’ve had an interest in women and heart disease for over two decades now,” said Abramson, “and it’s taken a while, but at least we’re here” celebrating the fact that women’s health differences are finally being recognized.
The issue goes beyond blood tests
Women can experience heart attack symptoms that are less likely to be recognized as a heart attack, including nausea, indigestion, and shortness of breath. That can contribute to delays in diagnosis and treatment.
Research from Alberta has highlighted the consequences. Dr. Colleen Norris, a professor and associate dean of research in the Faculty of Nursing at the University of Alberta, and a member of the Canadian Women’s Heart Health Alliance, has studied the experiences of women seeking emergency care for possible heart problems.
The research found that about 300 women a year were sent home from emergency departments in the province, then returned with a heart attack within 30 days.
When asked about the findings, Norris said, “I thought we’re missing the boat here.”
The statistics underline why recognizing symptoms and interpreting diagnostic tests appropriately matter. Studies have found that women are more likely than men to die after a heart attack, with delays in diagnosis identified as one contributing factor.
The new guidelines are an important step, said Norris.
“I even had cardiologists who actually said it to a student the other day: ‘There’s no difference between men’s and women’s heart disease. I treat the women exactly the same way I treat the men,’ and I thought, OK, that’s the problem.”
Studies also show women receive less preventive therapy and medications and less angioplasty and rehabilitation. Humphrey said she didn’t have a cardiologist tracking her, nor any rehabilitation until her second heart attack, which she said was diagnosed as a spontaneous coronary artery dissection (SCAD), a heart attack caused by a sudden tear within the wall of a heart artery and is linked to stress.
Now 55, Humphrey is an advocate for women who believe something is wrong but are not being heard.
“If you’re going to a hospital and they’re continually sending you home, and you really think something is wrong, you really need to bring somebody else with you and really go in there and advocate for yourself.”
For women like Humphrey, the hope is that the changes will mean fewer symptoms are dismissed, fewer heart attacks are missed and more women receive the right diagnosis before it is too late.
