Sunday, December 7, 2014

Gender Inequities in Cardiac Care-You Must Advocate for Yourself

I started this blog to work through the why of my heart attack at 42.  I started it just for me and in the beginning, I only shared it with a very small group of longtime dear friends because they wanted updates on how I was doing.   Surprisingly there is much emotion surrounding a cardiac event.  Blogging is a great way to work through this.  It also has a funny way of connecting you to others that are walking the same path as you. I found great relief when I found the blogs of Jen Thorson (My Life In Red) and Carolyn Thomas (Heart Sisters). Just knowing I wasn't alone and other women had experienced this and lived was an amazing truth to find. Still, it is a great surprise to me that people actually find my blog and read it. That I have the same impact on women that Jen and Carolyn had on me makes me smile.  I know I do because I often receive emails from women reaching out to me in an attempt to find the why in their own cardiac events.  It makes being out on the web worth it.

Not long ago, I received a particularly striking email from a woman in Georgia who had a heart attack over the summer.  She is older than me by almost 20 years and her experience really infuriated me.  She found Jen's blog and that was the first she knew of cardiac rehab.  She also said she feels  that her doctor dismisses her because she is older and therefore not that important.  She feels young and she was very put off by this treatment.  I have been sitting on this and stewing over it not sure what to write.  I find it unconscionable that in this day and age of modern medicine and technology that this kind of gender and age inequity exists.  

I was referred to cardiac rehab however my insurance would not cover it so I only went a few times. I found this to be so odd because my bill from my STEMI was about $250,000.00  That they would cover this and not the recovery and prevention of the next one leaves me scratching my head.  I work managing medical billing so I am not sure why this was so surprising to me but it was.  With all of the studies surrounding the benefits of cardiac rehab it just seems so ridiculous.

According to The American College of Cardiology, "Women with coronary artery disease who completed a 12-week cardiac rehabilitation program were two-thirds less likely to die compared to those who were not referred to the program. In addition, the mortality benefit derived from this evidence-based program appears to be much more striking in women than men with the same condition, yet referrals and attendance among women fall short, according to research being presented at the American College of Cardiology's 62nd Annual Scientific Session."( Rehab Associated with Reduced Risk of Death in Women with CAD)

The World Heart Federation states, "Despite the fact that half of the 17.3 million deaths from cardiovascular disease (CVD) each year happen in females , women are still discriminated against when it comes to the management and treatment of this disease. Women are more likely than men to be under-diagnosed and under-treated, mostly because the presentation, progression and outcomes of the disease are different and less understood in women than in men.  Although there has been progress in raising awareness about CVD in women and studying the specifics of the disease, as well as in adapting CVD treatment and care for women, the gap is still too wide." (HEART TO HEART: EXPERTS CALL FOR AN END TO GENDER BIAS IN CARDIOVASCULAR DISEASE)

A study published in The European Journal of Preventative Cardiology concludes, "CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies." (Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.)

According to the American Heart Association, "There is ample evidence on the proven benefits of CR/SPPs on CHD risk factors and exercise capacity.3 Moreover, recent data demonstrate that participation in CR/SPP is associated with a reduction in mortality after percutaneous coronary interventions4 and with a dose-dependent reduction in both mortality and recurrent MI for those patients with stable angina or patients after MI or coronary artery bypass surgery.5 Given the significant benefits that CR/SPPs bring to CVD prevention, every recent major evidence-based guideline from the American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) about the management and prevention of CHD provides a Class I–level recommendation (ie, procedure/treatment should be performed/administered) for referral to a CR/SPP6 for those patients with recent MI or acute coronary syndrome, chronic stable angina, heart failure, or after coronary artery bypass surgery or percutaneous coronary intervention. CR/SPPs are also indicated for those patients after valve surgery or cardiac transplantation.6
Despite the clear benefits of cardiac rehabilitation, the use of such programs remains dismally low. Of eligible patients, only 14% to 35% of heart attack survivors7,8 and ≈31% of patients after coronary bypass grafting surgery7 participate in a CR/SPP. Lack of accessibility to program sites and lack of insurance coverage contribute to the vast underuse of cardiac rehabilitation services.3 Another major factor is a low patient referral rate, particularly of women, older adults, and ethnic minorities, to CR/SPP services.3 Accordingly, patients in these latter groups are the least likely to participate in cardiac rehabilitation.7 This is especially noteworthy because women and minorities are significantly more likely to die within 5 years after a first MI compared with white male patients.1
The remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable." (

Women should find it outrageous that despite the research by major well respected outlets they still receive sub-par treatment when compared to men. In my estimation, the only way to change this is for women to take their healthcare seriously and advocate on behalf of themselves. I told the woman that emailed me from Georgia to go to a different cardiologist.  Keep going to a different doctor until you find the one that will take you seriously and will provide you the level of care that you deserve.  I am on my 4th cardiologist and have finally found the one.

I was fortunate that in my situation, I called 911, had a cardiac team waiting on me when I arrived at the hospital, received very quick treatment and was referred to cardiac rehab.  I had no idea that this was not the norm until I started meeting other women who were sent home from the hospital mid heart attack.  They were sent home because they had the flu, they had pulled a back muscle, were having an asthma attack or had indigestion--anything but a heart attack. Once they finally received proper cardiac care, they aren't referred to cardiac rehab. Unimaginable!

 As a woman, you must know that heart disease is your number one killer.  You must make yourself aware of the signs and symptoms of heart attack and stroke.  You must pay attention and you must advocate for yourself when you know something isn't right. Your life may depend on it.


  1. Wow, Jodi! Great minds think alike - how ironic (and fabulous!) that each of us, on the same day - without even double-checking with the other! - happened to be independently blogging about the appalling failure of physicians to refer their female heart patients to cardiac rehab despite the wealth of evidence (well-cited in both our respective articles) suggesting that such referrals will actually save lives.

    What especially galls me was the 2012 American Heart Association report that claimed: "... the benefits of cardiac rehabilitation are greatly under-appreciated in the medical community" and furthermore: "greater efforts are needed to educate healthcare providers" about these benefits.

    This makes me insane. And don't even get me started on the reality that when docs do refer their patients to rehab, they are overwhelmingly their male patients, not females. And as I wrote:

    "I have yet to hear of any physician who fails to routinely prescribe statins or beta blockers or other heart drugs to their freshly-diagnosed heart patients. Most docs seem extremely well-educated about the benefits of pharmaceuticals in cardiac care."

    I'm hopeful that maybe, just maybe, between me and you and a small army of other heart patient/advocates, people with the letters M.D. after their names will become "educated" about doing the right thing.

    Big hugs to you

    1. Carolyn-

      Great minds do think alike! I couldn't believe when I read your blog today and we had the same topic! I am hopeful too that between us and other advocates, M.D.'s will become educated. Maybe they will start to think about this education in medical school. In the interim, women need to step up and insist on the best care and change doctors if they don't feel like they are getting it. To do this, they must recognize how at risk they really are of heart disease including heart attacks.

      Read Carolyn's blog today "Failure to refer: why are doctors ignoring cardiac rehab?" ( )

      Hugs back!

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