Heart disease in women often misdiagnosed as stress

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WASHINGTON—Coronary heart disease (CHD) symptoms presented in the context of a stressful life event were identified as psychogenic when presented by women and organic when presented by men, which could help explain why there is often a delay in the assessment of women with heart disease, according to research presented at the 20th annual Transcatheter Cardiovascular Therapeutics (TCT) conference.

"We know that there is a delay in diagnosing CHD in women and this is an important step forward in understanding why," said Alexandra J. Lansky, MD, director of the Women's Health Initiative at Cardiovascular Research Foundation (CRF), which sponsors TCT, and director of clinical services at the Center for Interventional Vascular Therapy at NewYork-Presbyterian Hospital/Columbia University Medical Center, both located in New York City.

The trial, “Gender Bias in the Diagnosis, Treatment, and Interpretation of CHD Symptoms: Two Experimental Studies with Internists and Family Physicians,” was led by Gabrielle R. Chiaramonte, PhD, a postdoctoral associate at the Weill Medical College of Cornell University and clinical fellow at NewYork-Presbyterian. The study examined the effects of patients' gender and the context of how CHD symptoms are presented (with or without mention of life stressors and anxiety) on primary-care physicians' patient evaluations.

In the studies, 87 internists (Study One) and 143 family physicians (Study Two) read a vignette of a 47-year-old male or a 56-year-old female (by age at equal risk for CHD) presenting a multitude of CHD symptoms and risk factors. Half the vignettes included sentences indicating the patient had recently experienced a life stressor and that they appeared anxious, the researchers reported. Each physician read one version of the vignette and then specified a diagnosis, made treatment recommendations, and indicated the etiology of symptoms.

The investigators found a gender bias when CHD symptoms were presented in the context of stress, with fewer women receiving CHD diagnoses (15 vs. 56 percent), cardiologist referrals (30 vs. 62 percent) and prescriptions of cardiac medication (13 vs. 47 percent) than men.

Chiaramonte and colleagues did not observe any evidence of a bias when CHD symptoms were presented without the stress. Results also showed that the presence of stress shifted the interpretation of women's chest pain, shortness of breath and irregular heart rate, so that these were thought to have a psychogenic origin. By contrast, men’s symptoms were perceived as organic whether or not stressors were present.

“In the case of women, anxiety appears to have a pervasive influence on medical judgments regardless of the gender of the healthcare provider making the evaluations,” she warned.

“The selection of internists and family physicians was particularly relevant as they are generally the first medical professionals to assess patients' symptoms and to make treatment recommendations. A greater understanding of factors contributing to gender bias in CHD assessment in this group would thus be especially meaningful,” Chiarmonte concluded.