Research presented at the 20th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, sponsored by the Cardiovascular Research Foundation (CRF), found that coronary heart disease (CHD) symptoms presented in the context of a stressful life event were identified as psychogenic in origin when presented by women and organic in origin when presented by men. The study could help explain why there is often a delay in the assessment of women with heart disease.
"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, M.D., director of the Women's Health Initiative at CRF, director of Clinical Services at the Center for Interventional Vascular Therapy, a cardiologist at NewYork-Presbyterian Hospital/Columbia University Medical Center, and an associate professor of clinical medicine at Columbia University College of Physicians and Surgeons.
The investigation – "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, Ph.D., postdoctoral associate at the Weill Medical College of Cornell University and Clinical Fellow at NewYork-Presbyterian Hospital. The study examined the effects of patients' gender and the context of how CHD symptoms are presented (with/without mention of life stressors and anxiety) on primary care physicians' patient evaluations.
"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," said Dr. Chiarmonte.
The researchers hypothesized that the presence of life stressors/anxiety would shift the interpretation of women's – but not men's – CHD symptoms, so that these would be perceived to have a psychogenic etiology.
"The greater prevalence of anxiety disorders in women, along with the greater likelihood that women will discuss stressors with their physicians, and the overlap of CHD and anxiety symptoms, contribute to this shift in interpretation," Dr. Chiaramonte said.
In the studies, 87 internists (Study 1) and 143 family physicians (Study 2) 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. Each physician read one version of the vignette and then specified a diagnosis, made treatment recommendations, and indicated the etiology of symptoms.
As the investigators predicted, results showed a gender bias when CHD symptoms were presented in the context of stress, with fewer women receiving CHD diagnoses (15% versus 56%), cardiologist referrals (30% versus 62%), and prescriptions of cardiac medication (13% versus 47%) than men. No evidence of a bias was observed 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.
Dr. Chiaramonte stated, "For women, the presence of stress or anxiety drives the interpretation of accompanying symptoms so that symptoms such as chest pain or shortness of breath undergo a 'meaning shift' when presented in the context of stress or anxiety and they are perceived as a manifestation of the stress or anxiety and not as CHD symptoms. For men, cardiac symptoms drive the interpretation of accompanying symptoms so that anxiety or stress is perceived (rightly so) as a risk factor for CHD and may in fact augment the CHD assessment. The presence of anxiety or stress in men does not deter from the CHD assessment; for women, it appears to preclude a CHD assessment."