20 Mar Heart Attack: Feminine Traits May Delay Cardiac Treatment
MedicalResearch.com Interview with:
Roxanne Pelletier, PhD
Division of Clinical Epidemiology
McGill University Health Centre (MUHC)
687 Pine Avenue West, V Building, Room V2.17
MedicalResearch.com: What made you want to study this disparity between men and women and heart attacks?
Dr. Pelletier: Despite enhanced medical treatment and decrease in the incidence of heart diseases, important sex disparities persist in the risk of mortality following a cardiac event: the risk of mortality is higher in women compared to men, and this sex difference is even more important in younger adults. Therefore, we aimed to investigate potential mechanisms underlying this sex difference in mortality.
MedicalResearch.com: Were you surprised by your findings?
Dr. Pelletier: We were partly surprised by our findings. We hypothesized that there would be sex differences with regards to the process of care in these patients. Indeed, previous studies in older men and women have suggested that women had poorer access to care when undergoing a cardiac event, compared to men. However, we were quite surprised to observe that overall, it is not so much biological sex that matters but rather gender-related characteristics. Unlike sex, which is biologically determined (i.e. male or female), gender has a wider scope and incorporates social norms and expectations for men and women in a society (e.g. social roles such as child caring, housework responsibility, stress management, personality traits, employment characteristics). We expected gender-related characteristics to interact with biological sex to affect access to care. However, we rather observed that no matter patient’s biological sex, those with typically feminine traits and roles, were more likely to experience delays before some procedures and were less likely to receive invasive procedures as well.
MedicalResearch.com: What are “feminine character traits” according to your study?
Dr. Pelletier: We used a validated questionnaire (the Bem Sex Role Inventory, [Bem, SL., 1974]) to assess gender-related traits of personality, where men and women had to rate themselves using a scale from 1 (never true) to 7 (always true) on the following “typically feminine” traits of personality (according to the Bem Sex Role Inventory): Tender; Sympathetic; Sensitive to needs of others; Understanding; Compassionate; Eager to sooth hurt feelings; Warm; Affectionate; Loves children; Gentle.
It is also important to note that we observed not only feminine traits to be in cause in the experience of poorer access to care, but also feminine roles such as being the person who is mainly responsible for doing housework.
These feminine traits and roles increased delays before treatment and lowered the odds of receiving invasive treatment procedures in both men and women.
MedicalResearch.com: What was the difference between men and women heart attack patients when it came to access to care?
Dr. Pelletier: We observed that women were less likely than men to receive an electrocardiogram within the recommended 10 minutes from arrival to the emergency. Compared to men, women were also less likely to receive fibrinolysis (a medication injected in order to unblock obstructed arteries) within the recommended 30 minutes from arrival to the emergency. Our results further suggested that women were less likely than men to actually receive these invasive procedures, which aim to unblock the obstructed arteries.
It is important to note that the objective of our study was not to extensively assess the appropriateness of treatment in men and women. Therefore, further studies should carefully assess whether the sex differences in access to care we observed was appropriate according to men and women’s clinical characteristics
We think that the overall message should be that it might not be biological sex that matters the most, but rather what type of gender-related roles and traits men and women exhibit when they present to the emergency with a heart attack.
MedicalResearch.com: Why would men receive faster access to ECGs and fibrinolysis? Why do you think there was this disparity between men and women when it came to care? And how could it affect health outcomes?
Dr. Pelletier: Multiple and various reasons may explain longer delays in women. As an example, we observed that patients presenting to the emergency with multiple health problems related to heart disease (e.g. diabetes, hypertension, high cholesterol, obesity, a family history of heart disease) were waiting longer before getting an electrocardiogram. This probably happens because it takes longer for the triage nurse to assess these people’s medical history and it may also complicate the treatment algorithm for these patients. Women in our study had a heavier burden of these health problems such as diabetes and a family history of heart disease compared to men. This may be one explanation for the longer delays before electrocardiogram in women.
Another reason may relate to the symptoms men and women experience and report to the triage nurse. As an example, women in our study were slightly less likely than men to report chest pain. This atypical presentation of heart attack may lead triage personnel to initially dismiss a cardiac event in these patients. It is also noteworthy that above biological sex, the way the person presents itself and the way the symptoms are reported and described can have an important influence on the process of care. As an example, it is possible that patients with more typically feminine characteristics, such as being tender or shy, give these patients the appearance that they are too fragile to support undergoing invasive procedures. Also, patients who appear fragile and weak, or who are shy, when compared with those with strong personality and leadership abilities, may be less likely to convince themselves that they require an intervention. Additionally, these characteristics may alter the care provider’s need for an invasive procedure.
Men and women need to be assertive when expressing their needs, and they need to be precise and concise when reporting their symptoms. Also, if they feel chest pain as well as other symptoms, chest pain must always be the first symptom to be reported and the emphasis should be placed on this symptoms.
Delays before receiving an electrocardiogram can indeed have important consequences on health. More specifically, it has been reported by other researchers that patients presenting to the emergency with an ST-elevation myocardial infarction (the most severe type of heart attack) and who do not receive an electrocardiogram within 10 minutes of arrival to the hospital, may have a close to 4-fold higher risk of having another heart attack or to die within the months following their heart attack.
MedicalResearch.com: Aren’t there distinct differences in how men and women have heart attacks? Could this have anything to do with your study?
Dr. Pelletier: We observed that women are slightly less likely to present with chest pain, which can partly explain longer delays in women. Indeed, when patients report atypical symptoms of heart attack when arriving to the emergency, it is more complicate to identify the cardiac event and it brings complexity to the treatment algorithm for these patients. However, it is very important to understand that the majority of the women (and men) in our study reported chest pain.
MedicalResearch.com: What should health officials, doctors, nurses and patients do to try to avoid this disparity in treatment?
Dr. Pelletier: The general population must first be sensitized about this situation. Patients should know that the way they present to the emergency, the way they report their symptoms and express their needs can have an important influence on their access to care. As mentioned earlier, men and women have to be assertive and specific when they report their needs and symptoms. If they experience chest pain along with other symptoms, this should be the first symptom that they mention and they should put the emphasis on this. Medical personnel should, on their side, be aware of the factors influencing access to care and keep in mind that when a patient presents with cardiac-like symptoms, even though they are young or they are depressed, reserved or anxious, they need to be careful not to dismiss a cardiac event in these patients, and to follow the usual treatment algorithm. Also, may be this algorithm should be revised in order to include gender-related aspects such as child care, housework responsibility, and level of stress when assessing patients at the emergency department.
MedicalResearch.com: What are your next steps with this research in mind?
Dr. Pelletier: We currently aim to focus on sensitizing the general public and the medical personnel to the results we observed in our study. We would like these results to help enhance access to care in younger men and women who experience a heart attack.
Our next steps are to further assess whether these differences in access to care influence the risk for these younger men and women of having another cardiac event or to die following this heart attack. We will also assess whether the differences in access to care have an impact on patients’ quality of life and symptoms of depression and anxiety.
Sex-related differences in access to care among patients with premature acute coronary syndrome
Roxanne Pelletier, Karin H. Humphries, Avi Shimony, Simon L. Bacon, Kim L. Lavoie, Doreen Rabi, Igor Karp, Meytal Avgil Tsadok, and Louise Pilote
Sex-related differences in access to care among patients with premature acute coronary syndrome CMAJ cmaj.131450; published ahead of print March 17, 2014, doi:10.1503/cmaj.131450