Women and heart disease: How the gender-gap costs lives

What springs to mind at the mention of heart disease? I immediately associate it with the media’s representation of the disease:

The round-bellied father who indulges in regular fry-ups collapses to the concrete floor of the garage where he works
The grey-suited CEO, facing far too much pressure from his demanding life, huddled over on his way out of a bad business deal
The pepper-haired husband, crawled up on the contemporary kitchen floor, desperately trying to reach for the phone

What do these all have in common?

Every example I imagined was centred around a man.

Initially, I thought that this was just my own perception of the disease. So, I googled ‘person having a heart attack’ to see what came up. I was met with an onslaught of images of men, with the very occasional (very old) woman. Heart disease must only affect men, I concluded. That had to be the case, otherwise how else could you explain this male bias in its media representation? Unfortunately, I soon realised that this was far from the truth.

You, like me, may be surprised to know that 1 in 15 women die from heart disease. Additionally, in the UK (1):

830,000 women are living with heart disease
Heart disease kills twice as many women as breast cancer
35,000 women are admitted to hospital following a heart attack each year (an average of 98 women a day, or 4 per hour) (2)

These statistics unsettled me. As did my complete unawareness that this disease could not only affect me in later life but could be the cause of my death. Yet, I really didn’t know much about it at all.

I began to wonder, if the media representation is so gender-biased, what other factors related to heart disease are biased against women?

What is heart disease?

Heart disease is medically referred to as coronary heart disease, ischaemic heart disease, or coronary artery disease. It is the most common form of cardiovascular disease and one of the UK’s leading causes of death, and the most common cause of premature death (3)(4). In fact, every 8 minutes someone in the UK dies from the condition (1)(3).

Heart disease symptoms

The NHS lists the symptoms as (4):

- Chest pain

- Shortness of breath

- Pain throughout the body

- Feeling faint

- Feeling sick

The cause of heart disease

Heart disease is caused by atherosclerosis, where your coronary arteries become constricted due to a build-up of fatty deposits (atheroma) within their walls (5)(4). The arteries that become interrupted supply your heart with oxygen-rich blood, thus, your arteries may eventually become so narrow that your heart becomes oxygen-deprived (ischaemia) (2). Furthermore, if a deposit breaks off, it can form a blood clot which can block your artery completely, resulting in a heart attack (myocardial infarction) (2)(5).

Atherosclerosis can be caused by various lifestyle factors, namely smoking, lack of exercise, a fatty diet, and excessive alcohol consumption. It can also result from other conditions such as high cholesterol, high blood pressure (hypertension), or diabetes (4). On top of these factors, there are certain predispositions for heart disease that cannot be controlled, including family history, age (risk goes up as you become older) and ethnic background (South Asian and Black African/African Caribbean backgrounds have an increased risk) (5).

How does heart disease affect women?

Although it is true that across all ages men have higher rates of heart disease than women, similar proportions of men and women die from the disease (6). The disease onset age varies slightly between men and women, with women usually having heart attacks 7–10 years later than men. This is thought to be because younger women are protected by oestrogen, which increases HDL (good) cholesterol and decreases LDL (bad) cholesterol, therefore, it is only after menopause that their risk of heart attack increases (2)(6).

With that said, there is a common misconception that younger women are immune from heart attacks. This is not the case. Younger, otherwise healthy women are more likely than men to experience a rare type of heart attack called spontaneous coronary artery dissection (SCAD). In fact, 80% of people with SCAD are women. SCAD occurs when a tear forms in a blood vessel in the heart, which allows blood to collect between the vessel layers, reducing the flow of blood through the artery. It can lead to a heart attack, cardiac arrest, or even death (2).

It is important to note that the symptoms of heart disease can also vary between the sexes as although men and women can both experience chest pressure, women can experience a heart attack without this symptom (7). Furthermore, there is evidence that women who have similar risk factors to men may have a greater chance of developing heart disease (2). For example, diabetes increases the risk of heart disease in women more than it does in men, and women smokers are more likely to have a heart attack than male smokers (6). Many women, including myself, are unaware of these additional posed risks, which could mean that, collectively, we may underestimate our chances of experiencing a heart attack or heart disease.

Women are less likely to recognise heart attack symptoms

It is evident that men are conditioned to be much more aware of the possibility of having a heart attack than women. This means that when they develop the symptoms of a heart attack, such as chest pain, they are more likely than a woman to seek medical intervention. This was proven by a global systematic review (including over 40 articles) which found that the average delay between the onset of symptoms and arrival at the hospital for men ranged between 1 hour 24 minutes to 3 hours 30 minutes. Whereas for women, the delay ranged between 1 hour 48 minutes and a staggering 7 hours 12 minutes (8). The longer treatment is delayed, the greater the potential of permanent damage to the heart. Therefore, this delay in receiving treatment puts women’s lives at risk (2).

The inequality of care for women

Efficiently diagnosing a heart attack is the key to recovery – a person who has an incorrect initial diagnosis of a heart attack has a 70% higher risk of death after 30 days compared to someone who receives the correct diagnosis (2). Sadly, women are 50% more likely than men to receive the wrong diagnosis of a heart attack (9). A potential reason for this is that women tend to have smaller blood vessels and are more prone to microvasculature disease (problems with the smaller arteries that branch out from larger ones) and blockages of these smaller vessels are often missed by diagnostic equipment (10).

Unfortunately, this is not the only example of how women are disadvantaged throughout their treatment for heart disease. A study conducted by the University of Leeds, funded by the British Heart Foundation, used anonymised data from the UK’s national heart attack registry (Myocardial Ischaemia National Audit Project) over a 10-year period. It reported that (11):

Women who have a heart attack where the coronary artery is completely blocked were around 3% less likely to receive restoration of blood flow, using procedures such as drugs or stents (a small tube that keeps the passageway open), than men
Women who have a heart attack caused by a partially blocked coronary artery were 34% less likely to receive a coronary angiography imaging test within 72 hours of their hospital admission than men (coronary angiography is a vital step in treatment because it helps doctors to see the extent of the disease and decide on the next treatment steps)
Women were less likely to be prescribed drugs that helped to reduce the chance of having a second heart attack

Most importantly, the study concluded that over 8,200 heart attack deaths among women in England and Wales could have been prevented had they received equal treatment to men (11). This equates to 2 women a day dying unnecessarily, purely because they are not men (2). The most shocking part is that the study did not include all heart attacks in the UK over the 10-year period, thus, it is likely that the true number of lives lost to unequal care is much higher.

Women have been continuously excluded from research

Women have historically been omitted from most clinical research – cardiovascular trials are no exception. A study published in the American Journal of Cardiology investigated the representation of women in cardiovascular clinical trials that supported drug approval (by the Food and Drug Association) from 2005–2015 (12). It reported that women were underrepresented in clinical trials for heart failure, coronary artery disease, and acute coronary syndrome. This gap in knowledge can have huge implications as public health programmes and diagnostic criteria, consequently, can place emphasis on the disease symptoms experienced by men and can, therefore, focus on treatments that benefit men. Furthermore, this gap can infiltrate the media and create the impression that these diseases do not affect women.

Conclusion

There is a misperception that heart disease is a man’s disease, yet worldwide, heart disease is the single biggest killer of women (2). There is a clear bias toward men in not just the media representation of the disease but in its medical intervention. Women are more likely to be unaware of their symptoms, arrive at the hospital later, have a delay in diagnosis or a misdiagnosis, be undertreated, and ultimately be underrepresented in research. These discrepancies between the two genders accumulate and eventually create a substantial gender gap in the treatment of heart attack and heart disease. Ultimately this costs women their health, happiness, and lives.

I feel extremely grateful that I have had the opportunity to write this blog post and complete my own research on the matter. I feel better equipped to deal with heart disease having done so. However, I fear for the women, who through no fault of their own, remain unaware of the potential this disease has of costing their health. Furthermore, I fear for the women with heart disease who will face the consequences of male-favoured healthcare. Women must be at the forefront of healthcare, not just an afterthought.

For more information or support, please visit https://www.bhf.org.uk/

References:

BHF UK CVD Factsheet [Internet]. 2022 Jan. Available from: https://www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics—uk-factsheet.pdf
Bias and Biology [Internet]. British Heart Foundation. [cited 2022 Jul 6]. Available from: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/women-and-heart-disease/download-bias-and-biology-briefing
Daponte-Codina A, et al. Gender and Social Inequalities in Awareness of Coronary Artery Disease in European Countries. Int J Environ Res Public Health. 2022 Jan 26;19(3):1388.
Coronary heart disease [Internet]. NHS. 2018 [cited 2022 Jun 29]. Available from: https://www.nhs.uk/conditions/coronary-heart-disease/
Coronary heart disease [Internet]. British Heart Foundation. [cited 2022 Jun 29]. Available from: https://www.bhf.org.uk/informationsupport/conditions/coronary-heart-disease
Gender matters: Heart disease risk in women [Internet]. Harvard Health. 2006 [cited 2022 Jul 6]. Available from: https://www.health.harvard.edu/heart-health/gender-matters-heart-disease-risk-in-women
Heart Attack Symptoms in Women | American Heart Association [Internet]. [cited 2022 Jul 6]. Available from: https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/heart-attack-symptoms-in-women
Nguyen HL, et al. Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review. Circ Cardiovasc Qual Outcomes. 2010 Jan;3(1):82–92.
Women are 50% more likely than men to be given an incorrect diagnosis following a heart attack [Internet]. British Heart Foundation. [cited 2022 Jun 30]. Available from: https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2016/august/women-are-50-per-cent-more-likely-than-men-to-be-given-incorrect-diagnosis-following-a-heart-attack
How heart attacks differ in women [Internet]. [cited 2022 Jul 6]. Available from: https://www.ucihealth.org:443/blog/2019/02/women-heart-health/
Did you know there is even a gender gap when it comes to coronary heart disease? [Internet]. International Women’s Day. 2018 [cited 2022 Jun 29]. Available from: https://www.internationalwomensday.com/Missions/14502/Did-you-know-there-is-even-a-gender-gap-when-it-comes-to-coronary-heart-disease
Scott PE, et al. Participation of Women in Clinical Trials Supporting FDA Approval of Cardiovascular Drugs. J Am Coll Cardiol. 2018 May 8;71(18):1960–9.