Heart disease is the leading cause of death for women worldwide – but alarmingly, according to a briefing released by the British Heart Foundation (BHF), they are 50% more likely than men to be misdiagnosed. This, alongside various other factors, may account for the higher mortality rates in women – although women tend to develop heart disease later in life than men (which is thought to be related to the protective role of oestrogen), in the UK they are still twice as likely to die from heart attacks resulting from Coronary Heart Disease than from breast cancer.

One study found that the mortality rate for women in the year immediately after suffering a heart attack was 38%, compared to 25% for men. This is most likely a result of the fact that women tend to delay seeking medical help for their symptoms for longer; a systematic review published in 2009 that looked at 42 different studies found that the median range in the amount of time between the onset of symptoms and seeking medical help ranged from 1.8 to 7.2 hours in women. For comparison, according to this review, men displayed a range of 1.4 to 3.5 hours.

This may be an effect of women perceiving heart attacks as a “male problem”, as demonstrated by focus groups conducted in the USA, making them less likely to consider a heart attack as the cause of their symptoms. Many women may therefore view their condition as less urgent and are all too often surprised to receive a heart attack diagnosis. These patient perceptions are by no means restricted to the USA – as Dr Sonya Babu-Narayan (Associate Medical Director of the British Heart Foundation) put it, “women are dying needlessly because heart attacks are often seen as a man’s disease”.

“This may be an effect of women perceiving heart attacks as a ‘male problem’”

Unfortunately, this perception may not be limited to the patients. A 2018 study of heart attack patients in Florida hospitals from 1991 to 2010 found a higher rate of mortality among female patients treated by male doctors, whereas patients treated by female doctors had similar outcomes, regardless of the gender of their patients. Given that women are underrepresented amongst cardiologists – making up only 28% of cardiology trainees and 13% of cardiology consultants – this is a concerning revelation.

A University of Leeds study (funded by the British Heart Foundation) that analysed the UK’s National Heart Attack Registry concluded that at least 8000 deaths in female heart attack patients may have been prevented had they received the same standard of care as men, and that women were twice as likely die in the 30 days after experiencing a heart attack. Women were 2.7% less likely to receive treatments such as stents and reperfusion (treatment that restores blood flow to the heart) in a timely manner and were 7.4% less likely to be prescribed beta-blockers (drugs that reduce your chances of experiencing a subsequent heart attack). The longer a heart attack is left untreated, the longer cardiac muscle is deprived of oxygen and the more damage is incurred. Prompt treatment is therefore absolutely crucial in preventing deaths.

It has been suggested that one reason why women are more likely to be misdiagnosed and receive treatment that does not necessarily meet their needs is that symptoms present differently in men and women. Some studies have indicated that women are more likely to present with a wider range of symptoms than in men, such as nausea and stomach pain, which could explain why misdiagnosis is more common.

This idea has more recently been disputed by the BHF, who funded research carried out by the University of Edinburgh which looked at the symptoms of 274 people (90 women and 184 men) attending the Emergency Department at Edinburgh Royal Infirmary who were diagnosed with a heart attack. They used a troponin test (a test checking levels of the protein troponin in the blood, which is released in response to heart tissue damage). The study found no major differences in the symptoms experienced between the genders. However, it has only recently been realized that levels of troponin in women who have experienced heart attacks are lower than those in men. Previously, the diagnostic threshold was assumed to be the same for both, and the use of gender-specific thresholds and tests with a higher sensitivity has been shown to increase the affirmative diagnoses in women by 42% (compared to only 6% in men).

Unfortunately, there is a lack of evidence to state whether or not men and women display different symptoms and responses to treatment, as women have been chronically underrepresented in clinical trials. An average of only one in three trial participants is female, meaning women are being diagnosed and treated on the basis of advice drawn predominantly from male populations. This information gap has delayed important revelations about cardiovascular health in women, including the fact that gestational diabetes and preeclampsia are linked to a higher risk of heart disease, and the discovery that a little known type of heart attack called Spontaneous Coronary Artery Dissection (SCAD) predominantly affects young, healthy women.

“An average of only one in three trial participants is female, meaning women are being diagnosed and treated on the basis of advice drawn predominantly from male populations”

Disparities in the rate of cardiovascular disease have also been found in transgender individuals. It is difficult to assess the scale of the problem seeing as so little research has been done, however, a recent study demonstrated that transgender women were found to have a 2-fold increase in the rate of myocardial infarction compared to cisgender women, even after adjusting for other risk factors such as age, smoking and other diseases (a similar increase can be found in transgender men compared to cisgender men). Sadly, it appears that the increased stress experienced by transgender individuals as a result of discrimination is likely contributing to this elevated risk.

All this points to one inevitable and important conclusion – that more research needs to be done to specifically investigate cardiovascular health in groups other than cisgender men. The assumption that everyone conforms to the cismale default is costing lives, and can only be resolved by an improved understanding of the peculiarities occurring among other groups.