Study shows women not happy with cardiac care

Physician attitudes impact patient progress

The first national survey of women with heart disease has found that more than half of them are dissatisfied with their health care and face significant obstacles to recovery.

Of the women who reported dissatisfaction with some aspect of their health care, 58% pointed directly to physician attitudes and communication styles as their main complaint, specifically citing physician insensitivity, rudeness, abruptness, and ignorance about heart disease in women.

In addition, more than half of the survey respondents said they suffered mental illness as a result of their heart disease, with ailments ranging from anxiety (17%) to clinical depression (38%), or both (21%).

"This survey is a wake-up call for health care professionals who need to understand how much their attitudes and communication styles influence their female patients’ willingness to ask questions, participate in medical decisions, and adhere to recommended treatment and lifestyle modification," says Sharonne Hayes, MD, director of the Mayo Clinic Women’s Heart Clinic in Rochester, MN, and a co-author of the survey report, published in the January/February edition of Women’s Health Issues.

Although the researchers only surveyed 204 people, the responses are significant in that so many women were saying the same thing, Hayes tells Medical Ethics Advisor.

"I would look at this as sort of a preliminary study. We received no funding and it wasn’t a random digit-dialing survey with a high level of scientific scrutiny, so we need to be careful about generalizing," she notes. "But the thing we noticed is that they singled out the physician experience as their most problematic."

The survey was sponsored by Washington, DC-based WomenHeart: The National Coalition for Women with Heart Disease and was conducted by surveying women who had joined the organization or who had requested information from the coalition in some way.

Hayes and colleagues decided to do a formal survey after WomenHeart staffers were inundated with callers reporting bad experiences and asking for better resources to cope with their heart conditions.

"They just started hearing from so many women who told their stories about the good, the bad, the horrible, there was a sense that we really didn’t know what the experience of being a woman with heart disease was like," Hayes reports. "So they decided to formalize it with a survey."

Missed diagnoses

A significant number of respondents reported that their primary physician initially misdiagnosed their condition as something nonclinical. Only 66 women (35%) who reported symptoms and 68% of their physicians correctly recognized their symptoms as potentially related to the heart. Eleven percent of patients reported their physician misdiagnosed their conditions as panic disorder, stress- or menopause-related conditions, or hypochondria.

The findings are consistent with other research showing that physicians still have a blind spot when it comes to recognizing that women are at risk for heart disease, says Hayes.

While physicians are likely to consider a cardiac diagnosis in a 45-year-old man with shortness of breath and chest pain, they are less likely to consider the same diagnosis for a woman with the same characteristics, she says.

"Most physicians are misled into thinking that a younger women who is thin and looks healthy does not have heart disease, even when she is having classic symptoms," she continues. "Obviously, if she is diabetic and smokes and she is 65, a good doctor is going to think heart. But if she is 45 and thin and doesn’t look like she has health problems, they might not."

The fact is, heart disease is the No. 1 killer for both men and women, something physicians as well as the rest of the population seem not to realize, says Nancy Loving, WomenHeart’s director and herself a heart attack survivor.

"I don’t know how this came to be considered a man’s disease,’ but it has, even though it kills just as many women," she notes. "When you talk to most women, they are afraid of getting breast cancer or cervical cancer, but things like heart screenings and cholesterol counts aren’t even on their radar."

If the women themselves are less likely to consider themselves at risk for a heart attack, they may not think to report appropriate symptoms to their doctor or seek medical attention, she adds.

Symptoms not that different

It’s a mistake to attribute the discrepancy in diagnosing to differences in symptoms experienced and expressed by women and men, says Hayes.

Although some research indicates women may experience atypical symptoms of heart disease, the data are very limited.

"What data we do have on differences in symptoms is pretty weak," Hayes says. "There are more similarities than differences. So focusing on the differences isn’t going to be very fruitful. If you look at symptoms of acute heart attack, the No. 1 symptom in both women and men is chest pain or some type of chest symptom. But maybe female patients aren’t even asked if they are having symptoms."

All the data obtained have been in retrospective studies — reviews of medical records of patients found to have heart disease, she explains. If the physician never asked the patient about chest pain, it’s not likely to be in the medical record.

The low numbers of respondents reporting referrals to cardiac rehabilitation was also a disturbing finding, Hayes adds.

"This is not the first study to discover this," she notes. "In fact, if you look at the nationwide average, both men and women are under-referred to cardiac rehab. But women are half as likely, in some studies a third as likely, to be referred than men."

Since participation in a program is a strong predictor of a positive outcome, it is particularly concerning that such low numbers of women report attending.

Depression, social isolation

Another key finding of the survey is that a large percentage of women report suffering from an undiagnosed mental condition in addition to their cardiac illness, say both women.

Women in general have a higher incidence of depression, and depression and other mental illnesses have been shown to have an adverse effect on overall health and on heart function, says Hayes.

"If you talk to female heart patients, you will find many have been depressed and many were not diagnosed with it," she relates. "It wasn’t until they came out of their fog six or eight months later and realized it."

Since women are two to three times more likely to suffer from depression, it would make sense for physicians to screen for this in women with as serious a health complication as heart disease, she adds.

The different ways society responds to male and female heart patients may have something to do with the phenomenon, also, says Loving. Because heart disease is not seen as a women’s disease, many women feel extremely socially isolated after their diagnosis.

"When it happened to me, the social isolation was more devastating than the heart attack itself," she recalls.

At WomenHeart, women have reported that their families became upset and resentful of the woman after she became ill and her condition affected her ability to perform traditional caretaker roles.

"One woman reported that her husband wasn’t able to deal with her illness and so resorted to blaming her and yelling at her when she was unable to do things she once had done," Loving says.

As a result, many women don’t comply with recommended alterations in diet and lifestyle recommended by their physicians. And many try to return to normal work and household duties too soon and harm their recovery, Loving adds.

WomenHeart has sponsored support groups for women with heart disease that offer some opportunities for information and encouragement. But hospitals and health care providers must do more to address family and social issues with female heart patients in order to improve rates of compliance with treatment recommendations and improve outcomes, she says.


  • Nancy Loving, WomenHeart, 818 18th St. N.W., Suite 730, Washington, DC 20006. Web:
  • Sharonne Hayes, MD, Mayo Clinic Rochester, 200 First St. S.W., Rochester, MN 55905.