Heart Problems After Stressful Event More Likely to
be Considered Just Anxiety in Women
For women, anxiety appears to have a pervasive
influence on medical judgments regardless of gender of health care
provider doing evaluation
Oct.
13, 2008 When women complain of having symptoms of heart problems
after a stressful event, it is more likely their complaints will be
interpreted as being due to emotional or mental stress, than for men.
This may help explain why there is often a delay in the assessment of
women with heart disease, according to research presented yesterday at
the 20th annual Transcatheter Cardiovascular Therapeutics (TCT)
scientific symposium.
"We know that there is a delay in diagnosing CHD
(coronary heart disease) 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 New
York-Presbyterian Hospital/Columbia University Medical Center, and
associate professor, clinical medicine, Columbia University College of
Physicians and Surgeons.
The investigation was led by Gabrielle R.
Chiaramonte, Ph.D., postdoctoral associate at the Weill Medical College
of Cornell University and Clinical Fellow at New York-Presbyterian
Hospital.
The study examined the effects of patients' gender
and the context of how CHD symptoms are presented (with or 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 and anxiety would shift the interpretation of women's
but not men's CHD symptoms, so that these would be perceived to
originate in mental or emotional processes.
"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.
Problems Perceived as Real for Men
By contrast, men's symptoms were perceived as real
physical problems 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."
Dr. Chiaramonte warned that, "Given the overlap of
CHD and anxiety symptoms (e.g., chest tightness common in both) and
given the higher prevalence of anxiety symptoms or disorders in women,
physicians need to be aware of gender differences in symptom
presentation and they need to be especially careful to rule out CHD
before considering an anxiety diagnosis.
In the case of women, anxiety appears to have a
pervasive influence on medical judgments regardless of the gender of the
health care provider making the evaluations."
Ronald Friend, Ph.D., co-investigator, Professor of
Psychology at Stony Brook University and Oregon Health & Sciences
University, School of Nursing, added: "The assessment of women's CHD is
further complicated by evidence that women sometimes present with
'atypical' CHD symptoms and that chest pain, a hallmark symptom in men,
is less common in women.
We recently conducted an additional study with 142
family physicians examining the influence of stress on the assessment of
patients presenting atypical CHD symptoms. Results showed a different
dynamic in this case:
Women were more likely than men to receive a GI
rather than a CHD diagnosis regardless of the presence of stress; the
addition of stress increased GI diagnoses in both men and women. Given
that women are more likely to present with atypical symptoms (and
stress), these preliminary results are cause for concern."
Prior to conducting the two studies reported here,
the researchers had tested their hypothesis with 99 first year medical
students, 82 third and fourth year medical students, and 122 physician
assistant students. The investigators were surprised to find nearly
identical results whether the participants surveyed were first year
medical students or experienced practicing family physicians and
internists.
Dr. Chiaramonte concluded, "The consistent results
observed with participants of varying clinical experience attest to the
strength of the research and the pervasiveness of the effect. Our
results suggest the need for the development of educational initiatives
aimed at improving health care providers' understanding of gender
differences in symptom presentation."
Editors Notes:
The title of the study is "Gender Bias in the
Diagnosis, Treatment, and Interpretation of CHD Symptoms: Two
Experimental Studies with Internists and Family Physicians."
The research team included: Gabrielle R.
Chiaramonte, Ph.D., of Weill Medical College of Cornell University/NewYork-Presbyterian
Hospital; Ronald Friend, Ph.D., of Stony Brook University and Oregon
Health & Sciences University, School of Nursing; Arnold S. Jaffe, Ph.D.,
and Jeffrey S. Trilling, M.D., of Stony Brook University Medical Center;
Gil Weitzman, M.D., B. Robert Meyer, M.D., Susan Evans, Ph.D., and JoAnn
Difede, Ph.D., of Weill Medical College of Cornell University/NewYork-Presbyterian
Hospital; and Alexandra J. Lansky, M.D., of NewYork-Presbyterian
Hospital/Columbia University Medical Center.
About CRF and TCT
The Cardiovascular Research Foundation (CRF),
sponsor of the symposium, is an independent, academically focused
nonprofit organization dedicated to improving the survival and quality
of life for people with cardiovascular disease through research and
education. Since its inception in 1990, CRF has played a major role in
realizing dramatic improvements in the lives of countless numbers of
patients by establishing the safe use of new technologies and therapies
in the subspecialty of interventional cardiology and endovascular
medicine.
Transcatheter Cardiovascular Therapeutics (TCT) is
the annual scientific symposium of the Cardiovascular Research
Foundation. Attended by over 10,000 participants each year, TCT gathers
leading medical researchers and clinicians from around the world to
present and discuss the latest developments in the field of
interventional cardiology and vascular medicine.
Oct.
13, 2008 When women complain of having symptoms of heart problems
after a stressful event, it is more likely their complaints will be
interpreted as being due to emotional or mental stress, than for men.
This may help explain why there is often a delay in the assessment of
women with heart disease, according to research presented yesterday at
the 20th annual Transcatheter Cardiovascular Therapeutics (TCT)
scientific symposium.