Gender Inequities In Cardiac Care

I posted this originally on 12/17/14 and this one always applies!

I started this blog to work through the why of my heart attack at 42.  I started it just for me and in the beginning, I only shared it with a very small group of longtime dear friends because they wanted updates on how I was doing.   Surprisingly there is much emotion surrounding a cardiac event.  Blogging is a great way to work through this.  It also has a funny way of connecting you to others that are walking the same path as you. I found great relief when I found the blogs of Jen Thorson (My Life In Red) and Carolyn Thomas (Heart Sisters). Just knowing I wasn’t alone and other women had experienced this and lived was an amazing truth to find. Still, it is a great surprise to me that people actually find my blog and read it. That I have the same impact on women that Jen and Carolyn had on me makes me smile.  I know I do because I often receive emails from women reaching out to me in an attempt to find the why in their own cardiac events.  It makes being out on the web worth it.

Not long ago, I received a particularly striking email from a woman in Georgia who had a heart attack over the summer.  She is older than me by almost 20 years and her experience really infuriated me.  She found Jen’s blog and that was the first she knew of cardiac rehab.  She also said she feels  that her doctor dismisses her because she is older and therefore not that important.  She feels young and she was very put off by this treatment.  I have been sitting on this and stewing over it not sure what to write.  I find it unconscionable that in this day and age of modern medicine and technology that this kind of gender and age inequity exists.

I was referred to cardiac rehab however my insurance would not cover it so I only went a few times. I found this to be so odd because my bill from my STEMI was about $250,000.00  That they would cover this and not the recovery and prevention of the next one leaves me scratching my head.  I work managing medical billing so I am not sure why this was so surprising to me but it was.  With all of the studies surrounding the benefits of cardiac rehab it just seems so ridiculous.

According to The American College of Cardiology, “Women with coronary artery disease who completed a 12-week cardiac rehabilitation program were two-thirds less likely to die compared to those who were not referred to the program. In addition, the mortality benefit derived from this evidence-based program appears to be much more striking in women than men with the same condition, yet referrals and attendance among women fall short, according to research being presented at the American College of Cardiology’s 62nd Annual Scientific Session.”( Rehab Associated with Reduced Risk of Death in Women with CAD)

The World Heart Federation states, “Despite the fact that half of the 17.3 million deaths from cardiovascular disease (CVD) each year happen in females , women are still discriminated against when it comes to the management and treatment of this disease. Women are more likely than men to be under-diagnosed and under-treated, mostly because the presentation, progression and outcomes of the disease are different and less understood in women than in men.  Although there has been progress in raising awareness about CVD in women and studying the specifics of the disease, as well as in adapting CVD treatment and care for women, the gap is still too wide.” (HEART TO HEART: EXPERTS CALL FOR AN END TO GENDER BIAS IN CARDIOVASCULAR DISEASE)

A study published in The European Journal of Preventative Cardiology concludes, “CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies.” (Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.)

According to the American Heart Association, “There is ample evidence on the proven benefits of CR/SPPs on CHD risk factors and exercise capacity.3 Moreover, recent data demonstrate that participation in CR/SPP is associated with a reduction in mortality after percutaneous coronary interventions4 and with a dose-dependent reduction in both mortality and recurrent MI for those patients with stable angina or patients after MI or coronary artery bypass surgery.5 Given the significant benefits that CR/SPPs bring to CVD prevention, every recent major evidence-based guideline from the American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) about the management and prevention of CHD provides a Class I–level recommendation (ie, procedure/treatment should be performed/administered) for referral to a CR/SPP6 for those patients with recent MI or acute coronary syndrome, chronic stable angina, heart failure, or after coronary artery bypass surgery or percutaneous coronary intervention. CR/SPPs are also indicated for those patients after valve surgery or cardiac transplantation.6

Despite the clear benefits of cardiac rehabilitation, the use of such programs remains dismally low. Of eligible patients, only 14% to 35% of heart attack survivors7,8 and ≈31% of patients after coronary bypass grafting surgery7 participate in a CR/SPP. Lack of accessibility to program sites and lack of insurance coverage contribute to the vast underuse of cardiac rehabilitation services.3 Another major factor is a low patient referral rate, particularly of women, older adults, and ethnic minorities, to CR/SPP services.3 Accordingly, patients in these latter groups are the least likely to participate in cardiac rehabilitation.7 This is especially noteworthy because women and minorities are significantly more likely to die within 5 years after a first MI compared with white male patients.1

The remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.” (http://circ.ahajournals.org/content/124/25/2951.full)

Women should find it outrageous that despite the research by major well respected outlets they still receive sub-par treatment when compared to men. In my estimation, the only way to change this is for women to take their healthcare seriously and advocate on behalf of themselves. I told the woman that emailed me from Georgia to go to a different cardiologist.  Keep going to a different doctor until you find the one that will take you seriously and will provide you the level of care that you deserve.  I am on my 4th cardiologist and have finally found the one.

I was fortunate that in my situation, I called 911, had a cardiac team waiting on me when I arrived at the hospital, received very quick treatment and was referred to cardiac rehab.  I had no idea that this was not the norm until I started meeting other women who were sent home from the hospital mid heart attack.  They were sent home because they had the flu, they had pulled a back muscle, were having an asthma attack or had indigestion–anything but a heart attack. Once they finally received proper cardiac care, they aren’t referred to cardiac rehab. Unimaginable!

As a woman, you must know that heart disease is your number one killer.  You must make yourself aware of the signs and symptoms of heart attack and stroke.  You must pay attention and you must advocate for yourself when you know something isn’t right. Your life may depend on it.

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4 thoughts on “Gender Inequities In Cardiac Care

  1. I have only one word in response to your Georgia heart attack survivor’s story of NOT being referred by her physician to cardiac rehab:

    “AAAAAARRRRRRRRRRRRRGGGGH!”

    Her example makes me insane, for all the reasons so carefully outlined here. Or in the words of Oregon cardiologist Dr. James Beckerman on the topic of cardiac rehab:

    “It is bad medicine to withhold life-saving treatments, and many physicians are selling their patients short.”

    I’d go so far as to say that doctors who fail to refer all eligible patients to cardiac rehab (listed by every cardiovascular society’s practice guidelines worldwide as a Class I recommendation, which means that a procedure/treatment SHOULD BE performed/administered) are not only practicing “bad medicine”, but are guilty of medical malpractice.

    Although we might all agree that patients (already overwhelmed by what the hell has just happened to them!) shouldn’t have to be the ones researching and advocating and lobbying their docs to receive current best practice medicine, the sad reality seems to be that unless we do all of that, we already know that our outcomes will continue to suffer compared to our male counterparts.

    Can I say it just once more?
    “AAAAAARRRRRRRRRRRRRGGGGH!”

    regards
    C

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    1. And I would respond with AAAARRRRRRRGGGGGH!! It is crazy. There is no reason that it should not be prescribed for every woman! I agree with Dr. Beckerman that it is bad medicine–very bad medicine.

      It is also crazy that I had a doctor that was all for it and the hospital even called to schedule it after I left. All that and my insurance was the issue! That was frustrating!

      Like

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