One afternoon, María G. went to the emergency room after hours finding herself fatal, with much nausea, sweating and severe pain in her chest. Maria is having a heart attack, but after asking some routine questions, the doctor in charge of the case sends her home after prescribing a sedative.
Although María G. is a fictional character, the truth is that for many years it has been considered that women, especially premenopausal women, could not have cardiovascular disease. Even today, and according to a study published in the journal Women’s Health in 2018, men with chest pain are 2.5 times more likely to be referred to a cardiology specialist than women. “When a woman presents to the emergency department with chest pain accompanied by other symptoms, it is much more likely that she will be diagnosed with any other ailment or treated with sedatives or antidepressants before considering the possibility that she may suffer from any heart disease ”, explains Carme Valls Llobet, a doctor specializing in endocrinology and medicine with a gender perspective, in her book Invisible Women for Medicine , published by Captain Swing.
One of the first people to warn about this bias was Bernadine Healy , an American cardiologist who in 1991 published an article in The New England Journal of Medicine in which she christened the problem Yentl syndrome. Healy warned that women were not only less likely than men to receive adequate treatment in the case of having a heart problem, but they were also not well represented in research on prevention, symptoms and treatment of cardiovascular diseases . “Until well into the nineties, studies on this topic only included men, there was a strong mental bias in which it was assumed that women could not have heart attacks,” explains Dr. Valls in an interview. “It is seen that no one was reading the statistics, because for years post-infarction mortality in coronary units has been higher in women.”
Indeed, cardiovascular diseases are the leading cause of death in women worldwide. “In Spain, more women die for this reason than from breast cancer,” explains Antonia Sambola, a cardiologist at the Acute Cardiac Care Unit of the Vall d’Hebron Hospital (Barcelona). Sambola is also the director of a work presented in 2019 at the National Congress of the Spanish Society of Cardiology (SEC) in which mortality in men and women after suffering a myocardial infarction was studied. “We analyzed the data of about 400,000 patients, of which 29% were women, between 2005 and 2015, and we concluded that being a woman increases the risk of dying after a heart attack by 18% ,” explains the doctor. “In addition, women receive fewer reperfusion treatments, such as angioplasties – a technique that restores obstructed blood flow – and this is obviously linked to higher mortality.” Another study published in July 2019 in the SEC magazine also revealed that the percentage of women who receive optimal treatment after an acute myocardial infarction was lower than that of men, and this was associated with higher mortality at 30 days .
Differential diagnoses and treatments are needed
The historical absence of research studies that take into account the gender factor when drawing conclusions has also resulted in the use of treatment tools that have been validated in men, but that in many cases are not effective for the female sector . “There are many, many examples, to begin with, we now know that the electrocardiograms of men and women are different: the QT interval, which indicates the relationship between the atrium and the ventricles, is longer in women, and that makes them more prone to suffer certain arrhythmias ”, explains Dr. Valls. “There are some drugs that can lengthen that QT space even more, and their administration should be monitored especially in women, because it can cause cardiac arrest. We would have to know all these details very well, but the differential pharmacokinetics have not been well studied either. “
Dr. Sambola also agrees on this problem: “all medication is designed for men, when there are great differences in the absorption of drugs, adverse effects, etc. For example, the arteries of women tend to be smaller, but the introducers and the lines tend to have larger diameters , designed for men, so when a patient undergoes some type of ventricular assist there is a greater risk of suffering complications ” . The same thing happens with diagnostic tools: “The parameters used to indicate surgery for valve disease are male, but the ventricles of the heart in women are smaller. And this must also be indexed by the body surface ”, explains Sambola. ” The result is that in many cases surgery is indicated much later than a woman would have, and this delay also increases the risk of mortality .”
In 2017, a study published in the journal Circulation showed that, in resting conditions, the heart rate of women is higher than that of men. “This has very relevant consequences, because it is indicating to us that, if we make an effort, women enter tachycardia earlier,” says Valls. “A faster heart also wears out earlier, the muscles are contracting much faster … the study of tachycardia in women is another pending subject.”
Towards a science with a gender perspective
The absence of scientific evidence on which to base the action guidelines is one of the main obstacles when it comes to promoting medical care more adapted to the needs of women . “That basic research is lacking to develop the protocol. In Canada, for example, there is a constitutional mandate to address the gender perspective in health care. But if they start to make a guide to analyze fatigue, or a specific pain, but there are no studies on that subject, they do not have evidence and they cannot do the guide. It is a fish that bites its tail ”, reflects Dr. Valls.
The truth is that, thanks to the Healy notice in the 90s, research in everything related to cardiovascular diseases is one of the most advanced in this regard, and women are beginning to be adequately represented in these studies. “ The research works on cardiovascular mortality already contain women in 38% . It is a hope, although it is very slowly it seems that things are changing ”, indicates the expert.
Investigative agencies also seem to have awakened to this need. “When requesting funding for a project, many entities already ask you to include sexual differences, to check what happens in males and females. And even more so now that there are finer statistical analyzes that allow us to easily introduce that variable. Researchers have realized that there are differences between the sexes and that they are worth studying ”, explains Sara Cogliati, biotechnologist and researcher at the Severo Ochoa Molecular Biology Center (Madrid). In 2019, Cogliati received one of the L’Oréal-UNESCO Awards for Women in Science for her project ‘Evaluation of mitochondrial function in sexual dimorphism in heart failure’, in which the hypothesis is that mitochondria behave differently in men and women determining a different response during heart failure.
“We have realized that women have different characteristics both in the heart and in other organs. The idea of my project is to induce heart failure in male and female mice, and to analyze everything that happens at the level of the mitochondria, to look for functional differences and molecular mechanisms that then trigger a clinical phenomenon ”, explains the researcher. Why the mitochondria? “It is the fundamental organelle for the production of energy in the cell. The heart is an organ in high demand and also has to finely regulate energy production, which is why we have focused primarily on the mitochondria. In a previous study by my previous research group, led by José Antonio Enríquez at the National Center for Cardiovascular Research, they observed that significant mitochondrial damage also occurs during heart failure, which is why this is an interesting object of study ”. The scientist explains that there are some previous studies that investigate, for example, the role of estrogens (female sex hormones) in mitochondrial function, but that most of the work has been done in relation to ovarian and breast cancer. “Only now is it beginning to see what happens in the heart and of course in other organs. In fact, I am also going to study mitochondrial function in the metabolism of the liver and adipose tissue ”, he concludes.
Gender inequality also influences healthcare
The differences in our biology are not the only factor that justifies that research and medical care also include the gender perspective, since we must not lose sight of the social and psychological factor. For example, recent studies have revealed that it is mothers who are suffering the most anxiety and stress during the pandemic, since it is they in general who assume all the mental and emotional burdens, as well as a greater burden of care. All this also has an impact on health, and specifically on cardiovascular health. “You always have to ask yourself who is responsible for the care”, reflects Valls. In his book, he talks about a study carried out in the 1990s by researchers from the Karolinska Institute on double working hours and that compared the levels of blood pressure and adrenal hormones of Swedish male and female executives who had the same working conditions. The results revealed that, while the tension increased for them at work, the opposite happened to the women. “They secreted more adrenaline and norepinephrine when they got home, with the health risk of going to sleep with that stress rush: sleeping at intervals, having tachycardias or trapezius contractures in the morning, etc.”, Valls explains. . “This type of studies with a more psychosocial nature have not been repeated, but they are necessary because they would help prevent more heart attacks. In the end we are giving cholesterol pills but we leave the woman with the same stress ”.
The data also indicates that when you are having a heart attack, women go to the emergency room half an hour later than men . “Women take care of ourselves less, we minimize symptoms, we prioritize finishing tasks before going to the hospital … we go later and that is also detrimental to the improvement after the heart attack,” explains Dr. Sambola. For all this, it is essential that women become aware that we can also suffer from cardiovascular problems, recognize the symptoms of a heart attack and demand to be treated in the same conditions as men. “Years ago we published in the magazine Mujeres y Salud a translation of the American guide to the prevention of cardiovascular risks for women that reached many people,” Valls tells us. The doctor tells us that, thanks to her reading, there began to be women who, if they came to the emergency room with chest pain and were sent home, would stand up and demand that they perform an electrocardiogram. And, when they did, in many cases it was found that, indeed, they were having a heart attack.
“In the end it is not a question of ill will, because the health personnel is saturated and no one has time to get informed and updated,” reflects Valls. ” What is really needed is for this medicine with a gender perspective to be included in regular teaching in academic programs at universities .” The case of the woman mistakenly diagnosed with an anxiety attack with which this report began was a fictitious case that, however, could very well happen in real life. Many of the health problems that affect women are still included, as Valls comments in his book, under the sad Freudian label of hysteria. “The issue of nerves has always been planned in all medical care for women,” explains the expert. “It is necessary that we also empower ourselves in that sense, that we know that we can also have cardiovascular problems, that we do not deny our own symptoms and that we insist on them so that this type of thing does not continue to happen.”
