Public Release: 

Women at heart: Stop the bias

European Society of Cardiology

STOCKHOLM, Sweden (ESC Congress 2005) -- Women presenting with symptoms of heart disease are investigated less thoroughly and treated less aggressively by cardiologists across Europe. This has been one of the key findings from the Euro Heart Survey of Stable Angina, a survey of 3779 patients presenting to cardiologists with a diagnosis of stable angina, chest discomfort on exertion due to coronary disease.

Women were 20% less likely to be referred for an exercise test, the preliminary test to confirm the diagnosis and determine the type of treatment needed, even after accounting for symptom severity, age and other illnesses. After accounting for fewer positive exercise tests among women, women were still 40% less likely to be referred for angiography to determine the presence and extent of coronary obstruction. Women with a diagnosis of angina were also less likely to receive life-prolonging therapies such as aspirin or cholesterol lowering drugs, prescribed to 73% and 47% of women respectively, compared to 84% and 53% of men.

One of the main reasons often quoted by physicians for not investigating or treating women the same as men is that women with chest pain are less likely to have coronary obstruction. This is true. In this survey 37% of women who had an angiogram did not have significant obstruction compared to only 13% of men. But, one year after presentation with symptoms, even women who had been proven to have coronary disease at angiography during the intervening year were less aggressively treated than men. These women were almost a third less likely to have been referred for bypass surgery or angioplasty and fewer received optimal medical treatment (aspirin and lipid lowering agents). Most alarmingly, during one year follow up, women with angina who had proven coronary disease were twice as likely to die or suffer a heart attack as men with similar symptoms. This increased risk was apparent even after adjustment for confounding factors such as age, the presence of diabetes or heart failure.

Despite the fact that cardiovascular disease is the most frequent cause of death in women in Europe, and the cause of death in more women (55%) than men (43%), the perception remains that women form just a small "subgroup" of the coronary disease population. However, this is far from true of stable angina, the most common initial presentation of coronary disease. In fact previous studies have shown that stable angina occurs at least as frequently, and sometimes even more frequently in women as in men in the general population, affecting 5% to 8% of adult women and even with greater prevalence in the elderly.

Women accounted for 42% of the population in this survey, and they were on average only two years older than the men. The gender bias observed in investigating and treating this large group of symptomatic patients is a cause for considerable concern, particularly in the context of the significantly higher rate of death and myocardial infarction among women with proven coronary disease. Such glaring gender disparities at all levels are not universally apparent. The Euro Heart Survey of Acute Coronary Syndomes (ACS) II, chaired by Prof Shlomo Behar of Israel, investigated the pattern of presentation, treatment and prognosis of heart attacks and unstable angina in 32 ESC membership countries in 2004. The results are all the more interesting as they can be compared with those of the Euro Heart Survey of Acute Coronary Syndomes (ACS) I which was conducted in 2000. Both surveys demonstrated gender differences in symptoms, physical findings and ECG patterns at presentation. Women were more likely to have atypical symptoms, more hypertension and higher heart rates, and more heart failure. The earlier survey demonstrated significant gender differences in the use of thrombolytic drugs and angioplasty to treat heart attacks, but the Acute Coronary Syndrome II survey demonstrated significant improvements in the management of women with acute coronary syndromes between 2000 and 2004. Crucially, there were no differences in age adjusted mortality.

Although a series of high profile publications in the early 1990's documenting less invasive investigation and treatment in women generated intense interest in the arena of gender bias, some more recent reports assert that there is "No evidence for the Yentl Syndrome". The Yentl syndrome being the term coined to describe the practice of treating women equally only when they were identified as being the same as men. Fundamental to addressing the misconceptions surrounding cardiovascular disease in women is resolution of this debate and estimation of the true extent of gender bias in current clinical practice. The Euro Heart Survey programme survey results attest not to the continuing existence of gender bias in contemporary practice but also indicates that the persistence of the "not equal until proven so" mindset contributes to the problem. Women with angina present more often with atypical symptoms, but these are "atypical" relative to the classical symptoms described in predominantly male populations. Women are assumed not to have coronary disease, and often are not even investigated, much less treated, on this basis. In clearer cut clinical scenarios, such as in acute heart attack, where ECG changes and other features are less equivocal, women are identified as being the same as men, and treated in more similar fashion. However, even where women are identified as the same as men, there may be a reluctance to use some therapies which have a large evidence base in men, but for which evidence of benefit in women is lacking due to under-representation in clinical trials.

There is cause for optimism in the quest to reduce gender bias, with improvements in the care of women with acute coronary syndromes between 2000 and 2004. But, although the direction of transit is correct, there is a long distance to travel to redress the imbalances observed in the investigation and management of less acute but highly prevalent manifestations of coronary disease such as stable angina.


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