Understanding heart disease in female patients: the standard model for diagnosis of cardiovascular disease often doesn't fit women. Here are some common medical missteps to look for in a malpractice case.

What is a woman's medical malpractice case? Most people think of a failure to diagnose breast cancer, delayed cesarean section, or the unnecessary removal of a woman's uterus.

But what about cases beyond a woman's reproductive organs? Does malpractice occur because of medical bias? Do doctors treat men and women differently when they display the same set of symptoms? Do men and women ever experience different symptoms of the same disease? The answer to these questions is a resounding yes. Doctors' gender-based assumptions about their female patients can lead to errors in diagnosis and treatment--and life-threatening consequences for women. This problem is perhaps most evident in cases involving women with heart disease.

Imagine a 51-year-old woman driving home from work. She's had a nagging heaviness in her chest all day, accompanied by an intense burning sensation. Her regular doctor's office has already closed for the day, so she stops at the nearby emergency room. She receives a cursory examination, and her symptoms are attributed to indigestion and menopause. She's told to go home, take some Maalox, and call her doctor if the symptoms persist.

Now imagine a 51 year-old man driving home from work. He's had a nagging heaviness in his chest all day, accompanied by an intense burning sensation. He, too, drives to the nearest ER. He undergoes a battery of tests, is diagnosed as having had a heart attack, and is promptly treated. Meanwhile, the woman returns to work the next day, where she dies of cardiac arrest.

It has long been assumed that men's and women's physiology is basically the same: A cell is a cell is a cell, and that cell is male unless performing a female reproductive function. But the last 10 years of research have shattered this myth. Researchers have learned that, from hearts to hair follicles, men and women are astonishingly different. In 1991, the American Medical Association published a council report titled Gender Disparities in Clinical Decisions, which expressed concern that medical treatments for women are based on a male model, no matter that some diseases manifest themselves differently in each gender, or that women and men may react differently to treatments. (1)

When doctors work from gender-biased stereotypes, significant errors in medical practice can occur. Likewise, when lawyers base their work on a standard male medical model, they may find that women don't always fit. Lawyers who understand the stereotypes about women and heart disease--and develop strategies for addressing them--will be more effective in selecting cases.

Spotting the symptoms

Coronary artery disease (CAD) is an equal opportunity killer, yet studies show that women who have it are treated less aggressively than men. A woman is more likely to be undertreated for an acute coronary event than a man, and when a woman suffers a coronary event, she is more likely to die than a man. This disparity in treatment and outcome typifies the gender differences in medical care. (2)

A medical revolution was launched in 1987, when researchers at the Albert Einstein College of Medicine in New York City studied patterns of referrals for patients suspected of having CAD. In the process, they inadvertently made the disturbing discovery that cardiologists were treating the complaints of men and women very differently.

Given the same abnormalities, men were 2.5 times as likely to be referred for cardiac catheterization, and men underwent bypass surgery almost four times as often as women for the same complaints. Also, doctors were twice as likely to attribute a woman's symptoms to noncardiac causes, such as hysteria or indigestion. (3)

Other studies established that these were not errant results. One frequently cited study used male and female actors who read identical scripts detailing their symptoms to doctors. The study found that the gender of the patient independently influenced how the doctors managed chest pain and whether they referred the patient for cardiac catheterization.

Assuming that these studies reflect medical treatment performed across the country, and recognizing that cardiac catheterization is the gold standard for diagnosing coronary artery disease, women may be suffering and dying from cardiac disease unnecessarily. (4)

Knowing the atypical symptoms of CAD in women is critical when you evaluate whether to take a case. What are the signs of a heart attack? The classic male case includes severe, burning pain; pain radiating down the left arm; or a crushing, "elephant standing on my chest" type of pain. A woman's symptoms may appear more benign, and therefore are more likely to be misdiagnosed or dismissed.

One of the major preliminary findings of the National Institute of Health's Women's Ischemia Syndrome Evaluations (WISE) is that the traditional predictive model of CAD--which was based on research on men, and includes chest pain and the relief of chest pain with rest or nitroglycerine--accurately identifies coronary artery disease in men, but not so accurately in women.

The WISE results confirm that chest pain alone is not an adequate predictor of CAD in women. (5) Women with CAD most often initially present with symptoms of stable angina--a condition that occurs when the heart is not getting enough oxygen, usually due to clogged arteries--which is typically announced by transient chest pain that can be brought on by emotion or exertion. (6)

Additionally, a significant 20 percent of women experiencing a heart attack will experience upper abdominal pain, back pain, intense nausea, sweating, and shortness of breath. (7) These women are likely to be discharged from the emergency room with a diagnosis of anxiety, gallbladder disease, or gastrointestinal ("acid") reflux. Disputing the common belief that heart attacks are more serious in men than in women, Dr. Marianne Legato, a pioneer in gender-specific medicine, has stated that the "first heart attack is much more dangerous for women than for men." And a woman's chances of a second attack within the next six years are greater. (8)

Case preparation

Once you've committed to a case, carefully evaluate the records for clues. The doctor's responsibility is to gather information by listening closely, observing the patient, and putting the pieces of the puzzle together. If the doctor worked from a traditional male model of heart disease, he or she may have overlooked important medical factors.

Did the doctor take an adequate history? In time-pressed HMO practices and emergency rooms, taking time to ask the right questions and listening carefully to the responses is difficult. A scanty chart often reflects a scanty exam. During the deposition, ask the physician to explain the purpose of a medical chart and, in general, the information it should contain. Confirm that the timing of events is important and that an incomplete or inaccurate chart can result in treatment errors that cost a patient her life.

In depositions, learn how the doctor took the patient's history: Did he or she work from a standard checklist? Note the patient's risk factors for heart disease? Rule out other causes of the symptoms? Ask whether the patient had taken any antacids, and whether they worked? If the doctor diagnosed a cardiac condition as gastrointestinal, what in the patient's history supported this diagnosis? Did the doctor ask about the patient's diet or prior episodes? Ask for the doctor's differential diagnosis--that is, what conditions he or she considered as possible causes of the patient's symptoms. Of those conditions, which diagnosis posed the greatest threat, and how were the various conditions on the list ruled out? Were her complaints dismissed because they didn't fit a standard male model?

The risk factors for CAD--age, a history of smoking, high blood pressure, serum cholesterol, low HDL cholesterol, diabetes, obesity, and a family history of heart disease--are generally the same for men and women, but there are certain important differences. The risk of CAD increases four-to sixfold in women with diabetes, and diabetes removes the protection that a pre-menopausal woman has by virtue of her age. In an obese woman (one who weighs 30 percent more than her ideal body weight), how is the fat distributed? A woman with a "spare tire" around her midsection is at greater risk than one with a pear shape. Safe cholesterol levels are also different for women and men. (9) If you handle a woman's cardiac case, find out whether these distinctions were factored into the doctor's analysis.

The best tests

What are the diagnostic tools doctors should use when a woman complains of symptoms such as burning chest pain, dizziness, or palpitations? If the doctor suspects that a heart attack has occurred recently, a blood test to measure elevated cardiac enzymes should be ordered. A positive test always means a heart attack has occurred, although a negative test does not mean a heart attack has not occurred or is not occurring.

An electrocardiogram (EKG) is a snapshot of the heart's electrical activity at the time of the reading and can reveal cardiac injury or irregularities in rhythm. Although the EKG is a useful diagnostic tool and can diagnose whether a woman is at greater risk of a future heart attack, the reading will be normal in 50 percent of all women who suffer from angina caused by CAD. The exercise stress test combines vigorous exercise with an EKG to evaluate the heart's response to stress.

Another type of diagnostic tool is the echocardiogram, a noninvasive test similar to an ultrasound that provides a picture of the heart based on sounds waves. Malfunctions in the contractions of the heart's chambers will be visible on the image, but disease or narrowing of the arteries will not.

Cardiac catheterization is the best way to study the coronary arteries and diagnose CAD. The test is performed by threading a catheter into a vessel and through the veins, arteries, and chambers of the heart. Dye is injected into the arteries and traced by X-ray, showing whether and where vessels are damaged and narrowed by disease. Use discovery to find out which, if any, of these steps the doctor took in your client's case.

During jury selection in a case involving gender-specific medical issues, learn whether the jurors believe that, medically, women are simply small men. Ask if they know whether cardiac disease presents the same symptoms in women as in men. It is often helpful to find a juror who knows that there are differences between a female heart attack and a male heart attack. Use that juror to educate the others.

As in every case, determine whether the jurors are receptive to new information that may run counter to ideas they bring to court. Ask them if they ever research medical issues on the Internet and why. Ask if they have ever changed their opinions about a medical issue based on research they found on the Web or learned about in the media. Ask how they felt about revising their opinion.

From referrals to diagnosis to treatment, assumptions based on gender can affect the kind of treatment a patient suffering from CAD receives. The challenge for lawyers handling these cases is to show the harm these gender-based patterns of care have caused.

To learn more about women and heart disease

The Internet, bookstores, and libraries house a trove of information on women and heart disease, from tips for preventing it to guidelines for recognizing symptoms and discussion of how gender affects the heart, Here are some starting points.

Online resources American Heart Association 

Facts About Women and Cardiovascular Diseases

www.americanheart.org/presenter.jhtml?identifier=2876

Contains a wealth of educational resources; surveys of women's perceptions about heart disease and stroke: information on preventive programs; source material for physicians and other health care professionals, including statistics and links to scientific publications; a clinician's guide to caring for women with heart disease and stroke; and an extensive section on coronary disease, including various types, anatomy and physiology, and patient evaluation information.

Lori Mosca et al., Cardiovascular Disease in Women: A Statement for Health Care Professionals from the American Heart

Association

circ.ahajournals.org

Discusses epidemiology, risk factors, prevention, diagnosis, prognosis, and treatment of coronary heart disease, stroke, and peripheral artery disease.

Cardiovascular Institute of the South

Women and Heart Disease

www.cardio.com/categories/womenarticles.htm#top

Offers five articles that discuss how estrogen, exercise habits, weight, calcium, and pregnancy affect heart health.

Centers for Disease Control and Prevention 

Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Heart Disease Mortality Among Women

www.cdc.gov/cvh/womensatlas/index.htm

Contains data about geographic, racial, and ethnic disparities in women's heart disease mortality. Includes links to interactive state maps, state fact sheets, and the CDC-sponsored Cardiovascular Health Program.

International Academy of Cardiology

www.cardiologyonline.com

Features links to medical journals, research guidelines, discussion groups, and additional online resources, as well as lists of medical centers that specialize in treating cardiac diseases.

National Coalition for Women with Heart Disease

www.womenheart.org

Contains heart disease fact sheets, research and treatment updates, fitness and wellness information, and heart news resources, including a list of women's heart centers

Women's Heart Foundation, Inc.

Judith Hsia. Gender Differences in the Diagnosis and Management of Heart Disease

www.womensheartfoundation.org/content/ HeartDisease/gender_differences.asp

Examines the gender gap in diagnosis and treatment of heart disease.

Print resources

Nieca Goldberg, Women Are Not Small Men: Life-Saving Strategies for Preventing and Healing Heart Disease in Women (Ballantine Books 2003).

Offers a step-by-step approach to understanding, preventing, and managing heart disease in women, including risk factors, treatments, and diagnostic tests.

Marianne J. Legato and Carol Colman, The Female Heart: The Truth About Women and Coronary Artery Disease (Simon & Schuster 1992).

Explains how hormones, pregnancy, menopause, and other factors unique to women affect heart health. Identifies risk factors and gives practical information on self-care and prevention, understanding medical tests, recognizing the symptoms of heart disease, and recovering from a heart attack. Also provides insight on what a woman should expect from a cardiologist.

Theresa M. Wizemann and Mary Lou Pardue, eds., Exploring the Biological Contributions to Human Health: Does Sex Matter? (National Academy Press 2001).

Discusses basic biochemical differences in the cells of men and women, as well as health variability between the sexes. Identifies key research needs and opportunities and addresses barriers to research.

--Compiled by Kathleen Maguire TRIAL legal researcher

Notes

(1.) Council on Ethical and Judicial Affairs, American Medical Ass'n, Gender Disparities in Clinical Decision Making, 266 JAMA 559-62 (1991).

(2.) MARIANNE J. LEGATO, THE FEMALE HEART xvi (1991). See also MARIANNE J. LEGATO, EVE'S RIB 90-91 (2002).

(3.) Jonathan N. Tobin, Sex Bias in Considering Coronary Bypass Surgery, 107 ANN. INTERN. MED. 19-25 (1987).

(4.) Kevin A. Schulman et al., The Effect of Race and Sex on Physicians' Recommendations tar Cardiac Catheterization, 340 NEW ENG. J. MED. 618 (1999). See also R.M. Steingart, Sex Differences in Management of Coronary Artery Disease, 325 NEW ENG. J. MED. 226 (1991); LEGATO, EVE'S RIB, supra note 2, at 90-114.

(5.) B.D. Johnson et al., Chest Pain Evaluation for Prediction of Coronary Disease in Women: Pilot Results of the NHLBI-Sponsored WISE Study (submitted for publication).

(6.) LEGATO, EVE'S RIB, supra note 2, at 99; LEGATO, THE FEMALE HEART, supra note 2, at 73-76.

(7.) LEGATO, EVE'S RIB, supra note 2, at 189.

(8.) Id. at 106. See also Kevin. J. Malloy, Cardiovascular Disease and Arrhythmias: Unique Risks in Women, 2 J. GENDER-SPECIFIC MED. 37 (1999).

(9.) Am. Heart Ass'n, Primary Prevention of Coronary Heart Disease: Guidance from Framingham, 97 CIRCULATION 1876 (1998), available at circ. ahajournals.org/cgi/content/full/97/18/1876.

Susan Dennehy practices law in New York City.