Kate Johnson

April 29, 2012

April 29, 2012 (Arlington, Virginia) — Although primary care physicians are equally attentive to men and women who present with textbook symptoms of coronary heart disease (CHD), the addition of stress and anxiety symptoms to the clinical picture reveals strong sex bias, new research shows.

"For female patients, when stress is present, it precludes the investigation of heart disease. They're not ruling out heart disease in women, and they need to," investigator Gabrielle Chiaramonte, PhD, a psychologist at Weill Cornell Medical College of Cornell University, in New York City, told Medscape Medical News.

The findings, she added, suggest the need for physician education about sex differences in symptom presentation, given "the likelihood that women with CHD will also discuss life stressors and report symptoms of anxiety," she noted.

The study, which was presented here at the Anxiety Disorders Association of America (ADAA) 32nd Annual Conference, included 230 primary care physicians (54% women) in a survey delivered by regular or electronic mail.

Physicians were told that the purpose of the survey was to measure memory and symptom recall. They were given 1 of 4 vignettes describing either a woman or a man presenting either with CHD symptoms alone or in combination with a life stressor and anxiety.

Female patients were aged 57 years, and male patients were aged 48 years, putting them at equivalent risk for CHD. The cardiac symptoms described were textbook descriptions of CHD, said Dr. Chiaramonte.

Anxiety Reduces Suspicion of CHD in Women

All case histories included a multitude of CHD symptoms, such as chest tightness, chest pain, shortness of breath on exertion, fatigue, and chest pressure, as well as standard CHD risk factors, such as overweight, hypertension, smoking, and sedentary lifestyle that should have been identified as CHD by most medical professionals, Dr. Chiaramonte said.

One half of the case histories included information indicating that the patient had experienced a life stressor, such as job stress and financial difficulties, and that they had some anxiety symptoms, such as difficulty sleeping.

After reading the case history, each physician was presented with a memory test to support the cover story, followed by 30 statements for which they indicated their level of agreement on a scale of 0 (strongly disagree) to 10 (strongly agree).

The statements dealt with patient management, including the need to order further tests, and the consideration of either cardiac or anxiolytic medications.

The researchers hypothesized that when CHD symptoms were mentioned alone, there would be no sex difference in patient management, and their findings confirmed that a similar percentage of physicians would consider cardiac medication for women as well as for men (64% vs 66%; average score, 6.05 vs 6.51, respectively).

However, when CHD symptoms were put in the context of stress and anxiety, physician suspicion of heart disease in women "plummeted," Dr. Chiaramonte said.

In that setting, only 14% of physicians would consider cardiac medication for women, compared with 48% for men (average score, 2.44 vs 5.51, respectively; P < .001).

Delayed Care

In the context of anxiety, there was no sex bias in the consideration of anxiolytic medication (average score, 8.06 for women vs 8.36 for men).

"What we found is that for men, physicians believe that heart disease and anxiety can coexist. They're given anxiety medication but also cardiac medication. But women are given only anxiety medication," she said.

"Because we presented a patient with textbook typical symptoms, the likelihood of those symptoms being heart disease was very high — so they should have ruled out heart disease before anything else," she added.

Dr. Chiaramonte said the bias is not an irrational one because women are up to 7 times more likely to present with anxiety, and the presentation of CHD and anxiety can be similar.

"Given prevalence rates for anxiety disorders, it's understandable that they would give more 'weight' to anxiety in women. The problem is that there is a lot of research showing that women may not be getting cardiac care in a timely manner. "

She noted that by the time women are treated for CHD, the disease has progressed, leading to a less favorable prognosis.

She also pointed out that more women than men die of heart disease on an annual basis, "so it is critical for physicians to understand gender differences in symptom presentation so that cardiac symptoms are not neglected."

Differing Interpretations

Sex-specific symptom presentation is central to bias in CHD management, agreed Stefan Bösner, MD, from the Department of General Practice/Family Medicine at the University of Marburg, in Germany.

Dr. Bösner recently published a prospective study of 1212 consecutive chest pain patients from 74 primary care offices that showed a similar sex bias among general practitioners: 7.3% of men were sent for exercise testing, compared with 4.1% of women (P = .02), and 6.6% of men were referred to the hospital, compared with 2.9% of women (P < .01).

However, after adjusting for "typicality," the study showed that all evidence of sex bias disappeared.

"Typicality relates to the clinical presentation of CHD," he told Medscape Medical News.

"CHD often presents in women in an untypical manner with not as clearcut clinical symptoms as in men." This is largely because women tend to present earlier and, therefore, with milder symptoms than men, he said.

Dr. Bösner's group has developed a tool called the Marburg Heart Score that adjusts for this typicality. It uses 5 predictors to help primary care physicians rule out CHD: age/sex, known clinical vascular disease, pain worse with exercise, patient assumes cardiac origin of pain, and pain not reproduced with palpitation.

However, it does not specifically address the issue of anxiety, even though psychogenic disorders in his cohort were more common in women (11.2%) than in men (7.3%; P = .02).

"I would say that women are rather more fearful than men and therefore present earlier, which is linked to anxiety," he said, adding that it is also clinically plausible that their CHD symptoms could be interpreted as anxiety.

Studies also show that women's self-perception is different from men's, he noted. "Women rated their pain as more intense using more affective words and report more often bodily symptoms than men," he wrote in his article.

But although Dr. Chiaramonte and Dr. Bösner agree that sex bias exists, they see different clinical implications. Whereas Dr. Chiaramonte is concerned that sex bias may result in the underdiagnosis of CHD in women, Dr. Bösner's research suggests that this bias may lead to overinvestigation of cardiac symptoms in men, rather than underinvestigation in women.

Dr. Chiaramonte and Dr. Bösner have disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 32nd Annual Conference. Poster 226, presented April 14, 2012.

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