Hardening Arteries

Whether coronary disease develops in a man or a woman, its biological course is the same, says Edgar Haber, Harvard Professor of Biological Sciences. Cholesterol deposits begin to accumulate along the inner walls of the coronary arteries, a process known as atherosclerosis. As these crusty deposits enlarge, they can cause the arterial openings to narrow, pinching off the supply of blood to the heart muscle. The formation of blood clots can choke blood flow off completely. If starved of sufficient blood, heart muscle begins to die, triggering a myocardial infarction, or heart attack.

Despite the underlying similarities, there are important differences in the symptoms that prompt men and women to seek medical attention for coronary problems. The Framingham Heart Study, an ongoing longitudinal study that is one of the few to examine disease rates in both women and men, found that men are more likely to "present" to a physician with a full-blown myocardial infarction, whereas women tend to present with chest pain. When men do present with chest pain, however, it is apt to be the sort of pain classically associated with heart attacks: a sharp pain beneath the breastbone, radiating across the chest. The type of pain that women tend to describe is more diffuse, may be localized in the neck or left arm, and may be confused with nausea.

"Women need to understand that some of their complaints-pains that they may attribute to a gastrointestinal problem-are the equivalent of the substernal [beneath-the-breastbone] pains that men experience," says Elsa-Grace Giardina, professor of medicine at Columbia University's College of Physicians and Surgeons.

Paralleling these differences in presentation are documented differences in the way men and women are treated for coronary disease. In a landmark study published in 1991, Arnold Epstein, associate professor of health care policy at the School, and his colleagues found that women who are hospitalized for coronary heart disease undergo significantly fewer major diagnostic and therapeutic procedures than men.

"We analyzed data on more than 80,000 patients who had been hospitalized in Massachusetts and Maryland for coronary disease and determined how many had received an angiography [a diagnostic procedure in which radioactive dye is injected into the coronary arteries] or coronary-artery bypass surgery," says Epstein, who is also associate professor of medicine at Harvard Medical School. "We found that the odds of receiving an angiography were 28 percent and 15 percent higher for men than for women in Massachusetts and Maryland, respectively. For bypass surgery, the odds were 45 percent and 27 percent higher, in favor of men," Epstein says.

Whether there are sound medical reasons for this disparity, or whether they reflect a pattern of discrimination, is unknown. Doctors also are unsure whether the disparity actually works to women's detriment.

"It's possible that we're treating women appropriately and overtreating men," says Epstein. "Alternatively, differences in treatment may reflect differing preferences for care. Perhaps women are more willing to make lifestyle changes-such as eating better and exercising more-so they can avoid surgery."

To answer these questions, Epstein has embarked on a multi-year, multimillion dollar study that will study patterns of care in more than 5,000 patients across the country. "We're trying to discover what the differences in procedure use between women and men mean in terms of quality and appropriateness of care," says Epstein. "Are women getting too few procedures? Are men getting too many?"

There is a suspicion among some experts in women's health that disparities in treatment of heart disease are less a reflection of hidebound sexism than of ageism. Heart disease generally strikes women later in life than it does men, and "diseases that appear in old age may get less attention," says Marcia Angell, executive editor of the New England Journal of Medicine.

Giardina concurs: "There's a great sense of urgency when a 45-year-old man, who's at the peak of his earning power and may have children entering college, is struck down prematurely with a myocardial infarction. But that sense of urgency may not be as acute if the patient is a 65- or 70-year-old woman."

Still, a female coronary patient presents doctors with a rather different set of variables than a male patient does. For one, women's coronary arteries tend to be smaller than men's, making bypass surgery more difficult and risky. (Fortunately, new techniques have begun to improve surgical outcomes for women.) For another, older patients-male or female-are apt to have other health problems that complicate treating them for heart diseases. They may be diabetic or have high blood pressure. They may have impaired kidney function or respiratory problems or any of a host of "co-morbidities" that make treatment for heart disease even dicier.

"Patients with untreated high blood pressure, for example, usually cannot be given the clot-dissolving medication that heart-attack patients receive, because it could increase the chance of stroke," Giardina remarks.

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