According to a new study, women in Europe who visit their doctor with the symptoms of possible heart disease are not taken as seriously as men.
In the study, the Euro Heart Survey of Stable Angina, the researchers say they found that women were investigated less thoroughly and treated less aggressively by cardiologists.
Three thousand, seven hundred and seventy nine (3779) patients who had been seen by a cardiologist with a diagnosis of stable angina, and chest discomfort on exertion due to coronary disease, were surveyed.
It was found that women were 20% less likely to be referred for an exercise test, the preliminary test to confirm the diagnosis and determine the type of treatment needed.
This remained the case even after symptom severity, age and other illnesses were accounted for.
It appears that after accounting for fewer positive exercise tests among women, women were still 40% less likely to be referred for angiography to determine the presence and extent of coronary obstruction.
Women with a diagnosis of angina were also less likely to receive life-prolonging therapies such as aspirin or cholesterol lowering drugs, prescribed to 73% and 47% of women respectively, compared to 84% and 53% of men.
One of the main reasons doctors often give for not investigating or treating women the same as men, is that women with chest pain are less likely to have coronary obstruction.
While this is true in some respects, and in this survey 37% of women who had an angiogram did not have significant obstruction compared to only 13% of men.
But, one year after presentation with symptoms, even women who had been proven to have coronary disease at angiography during the intervening year were less aggressively treated than men.
It seems these women were almost a third less likely to have been referred for bypass surgery or angioplasty and fewer received optimal medical treatment (aspirin and lipid lowering agents).
But most alarmingly, during one year follow up, women with angina who had proven coronary disease were twice as likely to die or suffer a heart attack as men with similar symptoms.
This increased risk was apparent even after adjustment for confounding factors such as age, the presence of diabetes or heart failure.
Therefore regardless of the fact that cardiovascular disease is the most frequent cause of death in women in Europe, and the cause of death in more women (55%) than men (43%), the perception remains that women form just a small "subgroup" of the coronary disease population.
However, as far as angina is concerned this is not true as it is the most common initial presentation of coronary disease, and previous studies have shown that angina occurs more frequently in women than in men in the general population.
In this survey women accounted for 42% of the population and were on average only two years older than the men.
This gender bias is a cause for considerable concern, particularly as there is a significantly higher rate of death among women with coronary disease.
Although gender disparities have not been glaringly apparent, other surveys have implied significant gender differences in the treatment and management of heart attacks in women.
A series of high profile publications in the early 1990's documenting less invasive investigation and treatment in women generated intense interest in the arena of gender bias, but recent reports have asserted that there is no evidence of women being treated less equally than men.
Now the Euro Heart Survey results confirm that not only is there a gender bias in contemporary practice but it also indicates that the persistence of the "not equal until proven so" mindset contributes to the problem.
While women with angina present more often with atypical symptoms, these "atypical" are relative to the classical symptoms described in predominantly male populations.
So women are assumed not to have coronary disease, and often are not even investigated, much less treated, on this basis.
In clinical scenarios, such as in acute heart attack, where ECG changes and other features are less equivocal, women are identified as being the same as men, and treated in a similar fashion.
However, it seems that even when women are identified as the same as men, there is possibly a reluctance to use some therapies which have a large evidence base in men, but for which evidence of benefit in women is lacking due to under-representation in clinical trials.
Hopefully in attempts to reduce gender bias, with improvements in the care of women with acute coronary syndromes between 2000 and 2004, we are heading at last in the right direction to redress the imbalances observed in the investigation.