Doctors have long known that heart attack symptoms can be more difficult to recognize in women than in men.
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Now, a study brings those two ideas together, suggesting that female heart attack patients are more likely to survive when tended to by female emergency department physicians compared with male emergency department physicians.
The study also suggests that male physicians who have treated more women or have more female colleagues are more successful in treating women.
Yet the study, published Monday in the Proceedings of the National Academy of Sciences, remains exploratory and raises more questions than answers as to what explains this possible gender gap.
"I think what's critical to emphasize is the importance of understanding the diversity of the patient community and ensuring that the physician pool is diverse as well," said Brad Greenwood, the study's main author and an associate professor of information and decision sciences at the University of Minnesota's Carlson School of Management in Minneapolis.
More than 17 million people worldwide die annually from cardiovascular disease, particularly heart attacks and stroke, according to the World Health Organization. That represents about 31% of all global deaths.
Every 40 seconds, someone in the United States has a heart attack, according to the Centers for Disease Control and Prevention. Major signs and symptoms of heart attack in men and women include chest pain or discomfort; nausea, feeling light-headed or unusually tired; pain or discomfort in the jaw, neck, back, arm or shoulder; and shortness of breath, according to the CDC.
Many variables in treatment
The new study included data on 581,797 heart attack patients who were admitted to emergency departments in various Florida hospitals between 1991 and 2010. The data came from the Florida Agency for Healthcare Administration.
The researchers examined differences in the patients' outcomes and survival when seen by either a male or female emergency department physician. The researchers inferred gender based on each physician's name, excluding those with gender-ambiguous names.
The researchers found that gender concordance -- being seen by a physician of the same gender -- reduced the probability of death by 5.4%, relative to the baseline mortality rate in the study sample. The researchers also found that women treated by male physicians were the least likely to survive, compared with patients of either gender treated by female physicians or men treated by male physicians.
On the other hand, women treated by male physicians experienced a 0.02% increase in survival for each woman the physician had treated in the prior quarter, the researchers found. This was not observed among the female physicians.
Female patients treated in emergency departments with a higher percentage of female physicians also experienced better outcomes, the researchers found.
The study had important limitations, including that it examined patient outcomes only in Florida hospitals and that once a patient arrives at a hospital with heart attack symptoms, the emergency department physician probably will not be the only physician involved in the patient's care. There are many other variables that could influence a patient's outcome.
More research is needed to determine why this disparity between heart attack patient outcomes emerged and how it could be linked to a physician's gender.
One possible explanation could be "communication between the patient and the physician," Greenwood said, adding that women may feel more comfortable advocating for themselves with a female physician.
"Since heart disease is often cast as a 'male' condition, male physicians might not pick up on the atypical presentation symptoms women more often show, or at least not to the degree that female physicians do," he said. "We need deeper work to dive in and figure out what's going on."
Among the many variables that could influence a heart attack patient's survival may be the time between when a patient arrives in the emergency department and when treatment begins, said Dr. Nanette Wenger, professor emeritus of cardiology at the Emory University School of Medicine in Atlanta, who was not involved in the study.
The meeting with the emergency department physician for heart attack patients often can be brief, she added, with the majority of care being after hospital admission and by other doctors.
"The variable that I think would be even more important if you're just looking at the outcome of survival is the delay between the time the woman arrived at the emergency room and the time some definitive diagnosis was made and treatment instituted," Wenger said.
"If that woman was sitting in the emergency room for several hours as compared with several minutes, between the women and the men, that might be the difference. So the time would be an important variable, and that's not even addressed by the paper," she said.
"They're looking really at the correlation between the emergency room doctor, who was really the triage doctor who decides to admit the patient to the hospital, and it's a very limited look," she said. "I'm not sure what we can glean from it."
'We should spend our time ensuring that no patient is missed'
The findings should be interpreted with caution, said Dr. Harlan Krumholz, a cardiologist and health care researcher at Yale University and Yale New Haven Hospital in Connecticut.
"The finding is jarring and likely to attract headlines, but the science is not even close to strong enough for anyone to conclude that women coming to the emergency department with chest pain should request a woman doctor," said Krumholz, who was not involved in the study.
"What is important is that a heart attack in women can be accompanied by many symptoms together that can delay the diagnosis. Men and women doctors in the emergency department need to be vigilant in diagnosing heart attacks, especially in younger women who are not usually thought of as having heart disease," he said.
"But whether, on average, women are better in doing that than men is not known," he said. "Meanwhile, we should spend our time ensuring that no patient is missed, regardless of who their doctor is."
Dr. Jennifer Haythe, a cardiologist and co-director of the Women's Center for Cardiovascular Health at Columbia University in New York, treats women with heart disease and has seen heart attack symptoms in women firsthand.
After reading the new study, in which she was not involved, Haythe wondered, "Is the reason that the women had better outcomes when they were treated by female physicians because that their symptoms were taken more seriously from the beginning and that their care was more appropriate at the outset?"
"I think that a lot of women have, over many years, been treated unfairly in the medical community when it comes to their symptoms of potential heart disease," she said. "That's something that's really coming to light now and I think a lot of places are trying to address."
A history of awareness efforts
Efforts to raise awareness about heart attacks in women launched in the early 2000s, said Dr. Nieca Goldberg, a cardiologist and medical director of the Joan H. Tisch Center for Women's Health at NYU Langone in New York, who was not involved in the new study.
If the study were conducted again with more recent data, the findings could be different based on those awareness efforts, she said.
For instance, the American Heart Association's Go Red campaign was created in 2004 to encourage awareness and action around heart disease in women.
"It's predominantly a campaign that's been driven by female cardiologists, and one wonders about how we should also engage the men," Goldberg said. "I think we have to engage all doctors who take care of patients, because every patient has a heart, and we need to make sure their doctor accounts for it."
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