Ann and Andy, both 48 years of age, go into ERs having suffered what they think are heart attacks. You would assume that each of them would get the same treatment within the "benchmark" time guidelines set by hospitals for treating heart attacks. But you would be wrong.
According to a new study, released today in the Canadian Medical Association Journal, among younger adults who have suffered heart attacks, younger men received faster care for heart attacks and angina compared with women of the same age. In fact, gender-related factors affected access to care for both sexes.
This study is the first of its kind to look at sex-related differences in and determinants of access to care within a population of younger people who have had heart attacks, McGill University psychologist Dr. Roxanne Pelletier, lead author, told me. "In the last decade the incidence of heart attacks have been increasing in younger people and even more quickly in women compared to men. Our team thinks that gender-related characteristics play a role in that."
In the multicentre study, 1123 patients, aged 18 to 55, were recruited from 24 centres across Canada, one in the United States and one in Switzerland. The median age for women was 50 and for men 49 years. Within 24 hours of admission to hospital, each patient completed a survey that asked about gender-related issues such as "traditional" masculine and feminine personality traits, housework responsibility, education level and health status before the cardiac event. Researchers then looked at benchmark times -- guidelines set by the American Heart Association and the American Cardiology Association which spell out the maximum delays a patient should experience in getting the necessary treatment.
What they found was that men received faster access to ECGs and fibrinolysis (an injection to unblock the arteries) than women, with door-to-ECG and door-to-needle times of 15 and 21 minutes and 28 and 36 minutes respectively. Surprisingly, the researchers also found that both men and women with feminine character traits were less likely to receive timely care than patients with masculine traits; those who reported being the person at home mainly responsible for housework were also less likely to undergo invasive procedures.
"We were partly surprised by our findings," said Dr. Pelletier. "Those with typically feminine traits or roles were more likely to experience delays for some procedures and were also less likely to receive some procedures."
When the researchers dug further to try to explain why some patients had longer delays to treatment, they found that how patients communicated had an impact on their treatment timelines. For instance, women who presented with anxiety had longer delays. "It is well known that anxious patients tend to over-use ERs and a lot of these are due to panic attacks," surmised Dr. Pelletier. Most of these patients are women. And because the incidence of heart attack is lower in younger women than men, the triage nurse may initially dismiss a cardiac event in a younger woman thinking that it's anxiety instead. "If you have a panic attack you can have chest pain."
But they also found that when men expressed particular traits of femininity (such as being compassionate or sensitive to the needs of others) they too experienced delays. The study's authors wrote that "results also highlight that both men and women with no chest pain and those with anxiety, several traditional risk factors and feminine personality traits were at increased risk of poorer access to care."
So why is all this important?
For one thing, among those who suffer a serious heart attack, failure to meet benchmark times has been associated with a fourfold risk of having another heart attack or dying within a month of that heart attack. "Patients should know that the way they report and present their symptoms and express their needs can influence their access of care," says Dr. Pelletier. "Men and women have to be assertive, specific and concise when they report their symptoms and needs.
"Also, when they experience chest pain, this should be the first symptom they mention and they should emphasize this. They should not be lost in their description of their symptom, you know, like 'I have this and I have that and a bit of this...' They have to say, 'I have chest pain!' It should be the first symptom to disclose and it should be emphasized."
Dr. Pelletier also hopes that medical personnel become more aware of the gender-related factors influencing access to care. "Even though a patient is young, reserved, anxious or a woman, medical personnel need to be careful not to dismiss a suspected cardiac event."