As a trial lawyer, Rosa K has never been afraid to ask
tough questions. When her 71-year-old mother Lydia passed
away of a heart attack last year, Rosa demanded to know
why she wasn't diagnosed earlier and if everything was
done to prevent her death. No one could give her a straight
answer, but a study published in the February issue of
Heart may shed some light on the question. It's
old news that women get the short end of the clinical
stick when it comes to being diagnosed with heart attack
and in receiving subsequent treatment. Up until now, the
belief has been that this inequity somehow reflected the
fact that women with bad tickers tend to be older than
men, and so are more apt to die. But this latest study
throws cold water on this view and implicates gender bias
as the real root of the problem.
TNT
WARNS OF MI
Researchers at the Hull Royal Infirmary in the UK, headed
by Dr Eric Kilpatrick, examined the issue of gender
bias in light of new diagnostic criteria published in
2000 by the European Society of Cardiology and the American
College of Cardiology. The guidelines placed a greater
emphasis on markers of cardiac health. Specifically,
elevation of the levels of cardiac troponin T (cTnT)
above a set level was deemed to be one diagnostic feature
of myocardial infarction (MI). A subsequent study showed
that adoption of these benchmark alert levels would
greatly increase the diagnosis of MI.
The Heart study was done
in 2002, a full year after the introduction of the guidelines,
so that the new criteria would have had ample time to
be put in place by clinicians. Patients treated at the
Hull and East Yorkshire Hospital Trust in northeast
England during 2002 formed the study population, with
almost 5,000 patients providing over 6,000 cTnT samples.
The patients included 2,505 men with a median age of
66 years and 2,323 women with a median age of 74 years.
Of the 561 heart attacks that were
actually recorded, 93% displayed the elevated cTnT levels
that, according to the guidelines, would have triggered
the diagnostic alarm. Some other patients, 743 in all,
had elevated cTnT levels but no record of an attack.
Of these 1,304 people with elevated
cTnT levels only 40% were diagnosed with a MI. Though
overall this is a dismally low rate, men fared better
than women with 46% obtaining a diagnosis of MI compared
to only 33% of women.
This diagnostic gender inequity
held true over a range of cTnT concentrations. Indeed,
near the top end of the concentration scale, where the
guidelines would trigger a diagnosis of MI, 40% of the
men were correctly diagnosed, compared to a measly 15%
of affected women.
The large sample size of this study
provided it with some hefty statistical weight indicating
that gender was a predictor of MI diagnosis, while age
was not. The bottom line: women got a raw diagnosis
deal.
The big question, of course, is
why? The conventional wisdom that age is the culprit
seems not to be the case here. Thus, as the study's
authors write, "other factors, such as the perception
that women have a lower pre-test probability of infarction,
must influence a clinician's discharge decision."
Heart Feb, 2005;91:237-8
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