Myocardial infarction–cardiogenic shock (AMI-CS) is when the heart suddenly can’t pump enough blood to keep vital organs alive; although the event is relatively rare, it is a common cause of death due to heart attack. The study, published on September 29 in Circulation: Heart Failure, also found that women were less likely to receive key heart attack treatments and interventions that could have potentially life-saving benefits. “This research looks at an important question,” says Saraschandra Vallabhajosyula, MD, clinical fellow in interventional cardiology at Emory University School of Medicine in Atlanta and lead author of the research. Because this event is more common in older women, in part due to younger women having heart protective factors such as estrogen, most studies haven’t looked at outcomes among 18- to 55-year-olds, he says. “We were a little surprised that these women did worse and received less aggressive treatment than men,” says Dr. Vallabhajosyula. Historically, women have been evaluated for a heart attack by a protocol that was designed with men in mind, in which doctors look for classic symptoms such as chest pain. A study published in February 2020 in Circulation: Quality and Outcomes found that women under age 55 may not only experience different symptoms, they also have more variation in symptom combinations. The authors concluded that these differences might help explain why there is higher missed diagnosis rate in young women who suffered a heart attack.
Women Suffering Cardiogenic Shock After a Heart Attack Less Likely to Have Stent or Balloon Procedures, More Likely to Die
Investigators used data from the National Inpatient Sample from 2000-2017 to analyze 90,648 patient hospital admissions on individuals from 18 to 55 years of age; women made up 26 percent of the group studied. The primary outcome of the study was to compare how sex influences the outcomes of AMI-CS in younger adults; researchers also looked at how likely men and women were to get certain cardiac procedures as part of their treatment. Cardiogenic shock causes death in about one-half of the people who survive long enough to be admitted to the hospital, according the study authors. Compared with men, the women included in the study were more likely to be Black, be from a lower socioeconomic status, have comorbid conditions, and be admitted to rural or small hospitals. After controlling for factors including age, race, sex, insurance, and socioeconomic status, which would include factors such as income and education level, researchers found the following results:
Women were less likely to get coronary angiography, a procedure that allows for the detection of blockages in heart arteries during their stay (78.3 percent versus 81.4 percent for men). The difference was even greater on the day of admission to the hospital: 49.2 percent for women versus 54.1 percent for men.Women were nearly 5 percent less likely to receive procedures to open blockages in the arteries, such as stents or balloons: 59.2 percent versus 64 percent, respectively.Women were almost 9 percent less likely to have their heart function aided by a mechanical pump: 50.3 percent versus 59.2 percent, respectively.
One unique aspect of this study is the age range of the subjects, says Sitaramesh Emani, MD, a cardiologist and director of heart failure clinical research at The Ohio State University Wexner Medical Center in Columbus. Emani was not involved in this research. “Cardiovascular disease as a whole in the United States, particularly acute MI, tends to happen in older populations, though we know that certainly any age range can be affected,” says Dr. Emani. A study published in Circulation in February 2019 looked at 20 year trends found that although the heart attack rate has gone down among older adults, it’s risen in people ages 35 to 54, especially for women.
Study Provides Further Evidence in Disparities in Heart Care According to Gender
Unfortunately, the findings are not very surprising because we know that cardiovascular care for women has traditionally lagged behind cardiovascular care for men, says Emani. “Historically and even in more recent studies, we see this persistent underperformance of cardiovascular care delivered to women. Women don’t derive the same benefits or have the same expected outcomes as men in many different cardiovascular diseases; this study drilled down on this very specific subset of heart disease and found that pattern still persists,” he says. These results not only call attention to the disparities that exist in this particular subgroup, they also continue to help us recognize that the inequities in heart care and outcomes exist broadly, says Emani. “If we want to close that gap, we can’t have different access to care or delayed recognition of heart disease in women,” he says. There is also the issue of how to fix it. “Although this study does a good job showing us that the problem exists, it doesn’t really tell us the main reasons that it’s happening,” says Emani. Previous research has shown that women are less likely to be prescribed preventive heart care treatment such as cholesterol-lowering drugs and aspirin, and they are less likely to get advice about making lifestyle changes to reduce their risk of heart attack or stroke, according to a review published in April 2016 in Circulation Research. Even after accounting for age (women tend to have their first heart attack about seven years after men), women have an overall worse survival rate than men, according to the first-ever scientific statement about women and heart disease, published in March 2016 in Circulation. Within five years of having the first heart attack, 47 percent of women will die, develop heart failure or have a stroke compared with only 36 percent of men, according to the statement.
Racial Disparities in Heart Outcomes and Heart Research
“In this particular study, the authors also found that the younger female population presenting with acute MI and shock are more likely to be Black and more likely to live in rural areas,” notes Emani. Cardiovascular disease disproportionately impacts Black women, according to the AHA. Nearly 1 in 2 Black women in the United States age 20 and older have heart disease. There are several factors that contribute to this inequity, but the lack of representation of females, particularly Black females, in research studies is an important piece of the puzzle, says Emani. “Those research studies become the backbone of our current practice guidelines and patterns, and so we need more diversity in our representation of women in the studies that we use to carry the field forward,” he says. An analysis published in February 2020 Circulation looked at 740 cardiovascular trials completed from 2010 to the end of 2017 and found that only 38 percent of all trial participants were women. On a positive note, 50.3 percent of participants below the age of 55 in heart trials were women (compared with only 26 percent of participants in the 61 to 65 age group). But women of color account for only 3 percent of participants in cardiovascular trials around the world, according to the according to the AHA. Information about how to get involved in heart disease research can be found at the AHA’s Go Red for Women campaign.
Recognize the Signs of a Heart Attack, Trust Your Instincts, and Advocate for Yourself
“Heart attacks can present differently in women and in people of different races and ethnicities,” says Vallabhajosyula. “We have to get better at understanding the diversity with which patients present,” agrees Emani. “A heart attack isn’t always somebody clutching their chest. We need to get better understanding that in order to best deploy our modern medical resources in early and calculated fashion to improve outcomes, quality of life and survival." “It’s important for women to know that their symptoms of a heart attack may be different from that of men’s; they should take those symptoms seriously and seek care immediately,” says Vallabhajosyula. According to the AHA, symptoms of a heart attack for women can include:
Chest pain or discomfort, which is the most common sign in both men and women — uncomfortable pressure, squeezing, fullness or pain in the center of the chest that can last for a few minutes or go away and come backDiscomfort or pain in one or both arms, the back, neck, jaw, or stomachShortness of breath with or without chest painLightheadedness, nausea, or breaking out in a cold sweat
“Nobody knows your body as well as you do; if you feel the symptoms of a heart attack, it’s crucial to speak up and be heard and let your priorities be known,” says Vallabhajosyula. Emani agrees, saying, “People know their own bodies the best. If something seems wrong, if something doesn’t seem like it’s going correctly, that should be brought up.” For example, if a female patient goes into her local emergency department with symptoms, it might be initially diagnosed as anxiety or stomach problems, says Emani. “If that diagnosis doesn’t sit right with the patient or the other family members in the room it’s okay ask questions such as, ‘Could it be my heart?”’ he says.
