What impedes greater understanding of the variations in coronary artery diseases in males and females?
Prof. Bugiardini: For statistical purposes, clinical presentation is of special importance. The pain that women develop is often atypical, which frequently leads to misdiagnosis. It could be the tendency towards over interpreting the relevance of the typical case. It’s the kind of phenomenon that the psychologist Daniel Kahnemann discusses in his bestseller ‘Thinking Fast and Slow’. It’s often difficult to keep in mind the statistical reality behind the vivid, salient impression of the individual case. A strong, immediate impression -- or lack of it, in this instance -- can be very deceptive.
In a survey conducted by the American Heart Association, just half of the women interviewed knew that coronary heart disease is the leading cause of death in their sex. Other survey data suggest that, on a day-to-day basis, women still worry more about getting breast cancer, even though coronary heart disease kills six times as many women every year.
In addition, doctors only occasionally talk to women about coronary risk and they sometimes don’t even recognise the symptoms, mistaking them instead for signs of panic disorder, stress and even hypochondria. Accordingly, the clinical reality is often like this: you see the female patient, you are uncertain about the disease because it doesn’t correspond to what you expect of coronary problems, you place the patient in a hospital, but without prescribing the most beneficial medications. After a few days, the clinical picture becomes clear and you make the correct diagnosis. You realise that a female patient is very often falsely diagnosed at the beginning of their treatment.
Therefore, when you look at the statistics, you see that women are much more likely than men to die within a few weeks of having a heart attack, but you have to remind yourself that women are given less medication than men because the diagnosis is often made at discharge rather than admission to the hospital.
Could that situation be improved?
We’ll reach the critical point when men and women receive more equal, i.e. more accurate treatment. Beyond that critical point we’ll begin to gain a clear understanding of whether the physiological differences between the genders are really responsible for the statistical gap. When preparing the statistics researchers often don’t take into account that female patients aren’t treated with the right medication at the right time.
Statistics can be deceptive. The outcomes of studies may be partially influenced by the fact that there is still a gap when it comes to prescribing the appropriate medication. Women also don’t seem to fare as well as men after taking antiplatelet or anticoagulant drugs, or undergoing certain heart-related medical procedures. Research is only now beginning to uncover the biological, medical and social bases of these and other differences between men and women. We need a huge campaign by the European Society of Cardiology -- a huge effort supporting further studies. It’s crucial to provide training for physicians to employ a more severe, aggressive approach towards women who present themselves to a hospital admission system.
What are the differences that trigger such misunderstandings?
Generally people may be confused because women are more affected when they are older. It would be extremely naïve to think that differences in outcomes could be simply due to an older age. In reality, there are many biological and pathophysiological factors that are not the same in the two genders. Low HDL and high triglycerides appear to be the only factors that increase the risk of death from heart disease in women over 65 years old. Women who smoke are twice as likely to have a heart attack as male smokers. Women have smaller and lighter coronary arteries than men, which makes angiography, angioplasty, and coronary bypass surgery more difficult. The atherosclerosis progresses more toward the adventitia than the lumen. Consequently, women suffer from non-obstructive coronary disease more than men. Women are also more likely to contract endothelial dysfunction, which makes them more susceptible to a lot of triggering vasoconstrictor factors. It should be noted that to suffer from non-obstructive coronary disease does not, however, mean the patient suffers from benign disease. You can still develop thrombosis and myocardial infarction.
In conclusion, most of our ideas about cardiac disease in women used to come from studying it in men. However, there are many reasons to think that it’s different in women. This is a vexing problem and I truly hope we’ll be able answer the questions satisfactorily in the near future.