Cardiovascular risks are to some extent a fact of life. After all, everyone’s heart fails at some point. On the other hand, however, most people – of all ages and genders – make some effort to postpone that day, rather than inviting it, and we rely on medical professionals to support us in that effort.
Unfortunately, a longstanding gender gap in cardiac care continues to endanger women’s heart health. Systemic gender biases, in combination with inadequate training in sex-dependent differences in the development of heart conditions, contribute to the frequent misdiagnosis of heart disease in women. Overlooked symptoms and overly conservative treatments, in turn, show a strong correlation to worsened health outcomes, which disadvantage women heart patients compared to men.
As advocacy groups like Go Red for Women work to raise awareness of women’s cardiovascular risks, informed patients are speaking up on another front and seeking to hold healthcare providers to account for medical malpractice when they fail to treat female patients with the same standard of care they give to men. These legal cases are often challenging, but they play an important role in the public conversation around gender bias in the medical profession.
To schedule a private, no-obligation consultation with an experienced women’s health advocate, call the legal professionals at Erin Marshall Law today. You can reach our office in Albuquerque, New Mexico at 505-218-9949.
Charting the Gender Gap in Heart Health
In 2024, as part of its year-long centennial celebration, the American Heart Association (AHA) issued a press release announcing a new medical research venture fund in connection with the publication of a report produced in cooperation with the McKinsey Health Institute (MHI). The release describes the persistent gender gap in heart health, and points to researchers’ efforts to identify both major causes of that gap and some possible avenues for addressing them.
The Invisible Half of the Population
As published to Go Red for Women (a women’s heart health advocacy initiative founded by the AHA in the early 2000s), “The State of US Women’s Heart Health: A Path to Improved Health and Financial Outcomes” paints an alarming picture, concluding that one of the most important factors in the long-running equity was a basic lack of knowledge among medical professionals regarding the development and manifestation of heart disease in women. Researchers found particular gaps in understanding when it came to signs and types of cardiovascular disease (CVD) linked to puberty or menopause, or to the many cardiovascular changes that take place during pregnancy.
This knowledge gap – between clinicians’ understanding of male heart health and their grasp of cardiovascular functions and concerns in bodies subject to the changes of menarche, pregnancy, and menopause – may be attributable, in part, to the under-representation of women in clinical trials and other forms of medical research. Without a greater representation of women in the research on which healthcare providers are trained, and on which they base both their diagnoses and their treatment recommendations, doctors and other medical professionals are often working from inadequate information, erroneous assumptions, or both.
Female Physiology and Heart Health
Failure to adequately account for the impacts of the reproductive life cycle on heart disease risk may be especially problematic. Some of the limited research available has shown that both early menarche (first menstrual cycle) and early onset of menopause are associated with increased risk of heart disease later in life, yet questions about when patients got their first periods – or when they had their last periods – are not routinely included in the assessments used in estimating individual CVD risk or in screenings for heart disease.
A 2018 study – available through the National Library of Medicine’s PubMed – conducted using the United Kingdom’s “Biobank” to draw correlations between life factors associated with female reproduction and lifetime risk of cardiovascular disease. Notably, this study found that each of the following sex-specific factors was independently associated with an increased lifetime risk of CVD:
- History of miscarriage, stillbirth, or hysterectomy
- Early age at first birth
- Early menarche
- Early menopause
Separately, the strong correlation between pregnancy-related heart conditions like preeclampsia and gestational diabetes with the chance of developing cardiac complications later in life also remains under-examined; many women visiting a heart specialist may not even be asked about their history of past pregnancies. Without collecting information on those factors for female patients, healthcare providers are totally unable to account for their cumulative effects on individual heart disease risk.
Pregnancy-Related Heart Conditions and Lifetime Risk
That pregnancy-related cardiac complications are so poorly understood and so little examined is especially troubling. Yale Medicine reports that heart disease and, relatedly, stroke, are leading causes of maternal mortality, while cardiomyopathy (a weakening of the heart muscle) is the most common cause of death in women during the period from one week to one year after childbirth. Even after a pregnancy itself is long past, a woman’s lifetime risk of CVD is higher if she experienced any of the following reproductive health complications, according to the National Heart, Lung, and Blood Institute:
- Anemia (increase in risk is greater if anemia occurs during pregnancy)
- Endometriosis
- Use of hormonal contraceptives
- Gestational diabetes (also associated with increased risk of developing type 2 diabetes later in life)
- Polycystic ovarian syndrome (PCOS)
- Eclampsia or preeclampsia
Importantly, even some risk factors that occur in both men and women are “weighted” differently in terms of their total impact on individual risk profiles, according to a 2010 study in the Netherlands Heart Journal, available through PubMed Central. The authors of the 2010 study reference a meta-analysis, published in 2006 (also available through PubMed Central, or PMC), which found that diabetes type 2 increased the risk of heart disease in women 50% more than in male patients with the same diagnosis.
Pregnancy-Related Cardiac Complications and Preventable Deaths
Pregnancy-related heart complications can, of course, pose an immediate risk as well as contributing to cumulative lifetime risk factors for heart disease. A 2022 press release from the Centers for Disease Control and Prevention (CDC) that highlights the most common causes of maternal death attributes roughly 38% of these fatalities to conditions related to the cardiovascular system, from cardiomyopathy to blood clots. When excessive bleeding (usually during or shortly after delivery) is included, a staggering 52% of maternal deaths are related to a woman’s heart and the blood that pumps through it. Even more concerning, the same press release announces that some 75% of maternal deaths are preventable – a grim statistic that suggests competent, timely medical intervention could have saved a woman’s life, but such intervention was absent.
Quality of Life and Economic Participation
The AHA’s release summarizing the results of its centennial collaboration with MHI quotes one of the study’s co-authors, Lucy Pérez, as remarking on “the disproportionate impact that cardiovascular health has on women.” The context of Pérez’s quote suggests she may have been – as medical researchers sometimes do – referring to what members of the general public would more often call “cardiovascular conditions” or “cardiovascular health problems,” as researchers in biomedical fields, much more than most patients, are apt to view organ and systemic “health” as the total range of factors involved in both function and pathology, rather than drawing a distinction between “healthy” and “unhealthy.”
Cumulative Risk Factors and Burden on Quality of Life
Taken in this sense, cardiovascular “health” does indeed disproportionately affect women. A quick comparison of two charts from the CDC, displaying the percentage of male vs. female deaths attributed to non-specific heart disease in 2021, shows minimal (less than 2%) difference between the sexes in terms of their incidence of heart-related deaths. However, this overall similarity in the final outcome overlooks the fact that women are generally diagnosed with heart disease after having accumulated a greater number (on average) of risk factors, according to the 2010 study in the Netherlands Heart Journal. Many of these risk factors and underlying conditions impose their own burdens on individual health and quality of life.
Economic Impacts of Chronic Conditions
Quality of life, as the AHA’s centennial venture fund announcement points out, has a substantial impact not just on the personal experiences of individual patients, but on their participation in the local and global economies – both as producers and as consumers. The organization estimates that closing the gender gap in heart health could add up to $28 billion annually to the United States economy by the year 2040 – but how much of the projected increase is realized will likely depend to a large extent on whether, and how rapidly, the American healthcare system is able to close that gap.
Gender Bias and Medical Malpractice in Women’s Heart Health
Individual medical professionals are not usually understood to be personally responsible for the systemic bias that leads to – among other concerns – their own under-education in sex-specific differences in the symptoms and disease progression of common heart conditions. At the same time, however, physicians and others working in healthcare have a responsibility to treat all patients with equal care appropriate to their medical needs.
When medical professionals fail in this duty of care, they may be held liable for medical malpractice. The legal and financial dimensions of medical malpractice lawsuits mean both that women and their families may be able to recover compensation for damages suffered due to negligent medical care and that healthcare providers have substantial incentive – whether they are fully aware of it or not – to reduce any gender gap in their own knowledge and decision-making processes that could lead them to provide substandard care to female patients.
Understanding Negligence
Probably most American adults are at least loosely familiar with the concept of negligence. In legal contexts, according to Cornell Law School’s Legal Information Institute (LII), “negligence” typically refers to a failure to take the degree of care a reasonable person would be expected to take under similar circumstances to prevent foreseeable harm. Negligence is one of the three types of civil torts recognized in American jurisprudence, and is the type of tort most commonly alleged in personal injury lawsuits.
Proving Negligence
Generally speaking, to prevail at law in a civil torts case alleging negligence, the plaintiff will need to prove, by the “preponderance of evidence,” each of the following elements:
- The defendant owed the plaintiff a duty of care.
- The duty of care (that the defendant owed the plaintiff) was breached.
- The plaintiff suffered damages (usually in the form of physical injuries or financial losses).
- The damages the plaintiff suffered were caused by the defendant’s breach in the duty of care they owed the plaintiff.
The concept of malpractice is related to negligence, but malpractice only applies when there are certain parameters in place that structure the defendant’s duty of care toward the plaintiff and set professional standards for the degree of care required.
Medical Negligence as Malpractice
Generally speaking, malpractice allegations can only be applied in situations where the party accused of negligence can be said to have had a professional duty of care toward the party alleging negligence at the time when the alleged tort occurred. Another way of looking at this issue is to say that malpractice is typically framed as a specific kind of negligence, based on the breach of a professional duty, and usually one which imposes a higher standard for duty of care than would apply to an average person who had no established professional obligation to the plaintiff.
The parameters that define that professional duty will vary by profession, but in a malpractice case founded on allegations of medical negligence usually the plaintiff will try to show that the defendant failed to follow the medical standard of care (distinct from the “duty” of care) in their diagnosis and treatment. In considering how medical malpractice may impact women’s heart health, therefore, a key consideration will often be whether gender bias led a medical professional to deviate from the generally accepted standard of care that they would typically apply in diagnosing and treating a male patient.
Understanding the Standard of Care
The National Cancer Institute (NCI) defines “standard of care” as any course of treatment that is widely used by professionals in the medical field and that experts generally recognize as appropriate for the type of disease to which it is being applied in a given circumstance. The NCI also gives possible synonyms:
- Best practice
- Standard medical care
- Standard therapy
Other medical sources follow generally similar definitions. A 2021 opinion column in the medical journal Innovations in Clinical Neuroscience observes that “standard of care” is more a legal term than a medical one, and suggests that it sets the legally required degree of care at that which “a prudent and reasonable” person would normally use under the same kind of circumstances. The “prudent” qualifier can become especially relevant in legal cases where there is some question over whether early misdiagnosis may have unnecessarily increased a woman’s cardiovascular risks, as prudence will frequently recommend testing to rule out possible health threats when a patient’s presentation of symptoms is ambiguous.
Standard of Care vs. Standard Treatment Guidelines
Precisely because standard of care is used in legal contexts that address medical decisions, rather than in the medical contexts where those decisions are made, the column also observes that the criteria for meeting that standard varies somewhat from state to state. A 2011 overview of United States case law in the Western Journal of Emergency Medicine notes that the “clinical practice guidelines,” or CPGs, on which medical professionals frequently rely in determining what course of treatment they should pursue in cases where the choice may not be immediately obvious, may be considered inadmissible in some courts as hearsay (since the CPGs author or authors will likely not be available to speak to the recommendations as the first-hand authority).
Professional Responsibility and the Physician-Patient Relationship
Given all these complexities, it is no surprise that individuals who are contemplating possible action for medical malpractice often choose to confer with attorneys who have experience in handling medical negligence cases. As a broad “rule of thumb,” however, medical professionals who have followed the CPGs for a particular condition or set of symptoms are likely (not guaranteed) to be found to have fulfilled the standard of care in a particular case, even though varying from those standard guidelines based on peculiarities present in a particular patient’s situation may not necessarily indicate medical negligence. In considering the intersection of medical malpractice and women’s heart health, when there is a deviation from CPGs in a specific case, an attorney with Erin Marshall Law will often look to determine whether it appears that the deviation was made in order to rule out additional complications, or to apply a level of caution beyond what is most commonly recommended, as opposed to on the other hand that deviating in a way that provides less aggressive treatment and suggests a reduced level of precautionary measures compared with the generally accepted guidance.
Systemic Gender Bias and Medical Negligence in Women’s Heart Health
A number of complications can arise in any case of acute myocardial infarction – otherwise known as a heart attack. One of the more common such complications is cardiogenic shock, a condition in which the volume of blood the heart is able to circulate decreases sharply in the wake of an attack, dropping below the minimum amount necessary to sustain the body’s other vital organs. Cardiogenic shock can, for obvious reasons, quickly become fatal, and so prompt, aggressive treatment is needed to restore critical blood circulation, especially and most immediately to the brain.
Less Aggressive Treatment, Higher Mortality
Unfortunately, a 2020 news release from the AHA that summarized the results of a study published that year in the medical journal Circulation: Heart Failure reports that the Circulation study found women ages 18-55 who suffered cardiogenic shock while in the hospital received less aggressive treatment to restore circulation than that given to men of the same age. This gender disparity in treatment is correlated with a commensurate gender gap in cardiogenic shock survival: The study results, as reported by the AHA, showed that women were 11% more likely to die from post-infarction cardiogenic shock than were men in their age group who suffered the same complication.
Age-Adjusted Impacts
One impetus behind the study was the researchers’ observation of a general trend in previous research that had shown women hospitalized for heart-related complications received less aggressive treatment, and achieved higher mortality rates, than did men with the same conditions. Those earlier studies had generally focused on older patients (of both sexes), prompting researchers to wonder whether the gender gap, in treatment and outcomes, would persist among young men and young women.
After reviewing data from over 90,000 hospitalizations in which the patient experienced cardiogenic shock after admission for a heart attack, the researchers found:
- Doctors were less likely to order a coronary angiography, a diagnostic procedure used to detect arterial blockages, for women than for men.
- Women were 4.8% less likely than men to receive medical interventions such as the introduction of balloons or stents to open arterial blockages, once diagnosed.
- Healthcare providers were nearly 10% more likely to provide temporary mechanical assistance to the heart’s pumping action when the patient was a man.
The disparity in care was reflected in the cost of post-infarction hospital stays for female vs. male patients; while both men and women spent an average of about 10 days as an inpatient following a heart attack, women’s average cost for inpatient care was about $10,000 lower than for men. The study authors attribute the gender gap in hospitalization costs to the fact that less care – in the form of diagnostic procedures and medical interventions – was provided to women over the same number of days.
Combatting Malpractice in Women’s Heart Health
The emergence of multiple studies drawing attention to the negative impacts of gender bias on women’s heart health forms a good start toward addressing the systemic problems that have historically disadvantaged women seeking diagnosis and treatment for CVD. At the same time, however, the fact that the publication dates for these studies span more than a decade suggests that women’s health care advocacy has considerably more ground to gain.
As is so often the case in addressing systemic biases and ingrained institutional norms, the push to improve cardiac care for women will have to advance along more than one front to be truly effective. Advocacy groups like Go Red for Women are already working, in cooperation with the American Heart Association, to raise awareness of women’s cardiovascular risks among both doctors and patients. Some patients are turning to experienced attorneys to draw attention to instances of medical malpractice in women’s healthcare through legal cases that shine a spotlight on misdiagnosis and under-treatment of heart disease symptoms in women.
Speak With a New Mexico Women’s Health Lawyer
Closing the gender gap in heart health will be an incremental process, but at Erin Marshall Law we are proud to carry the torch each time it is handed to us, and advance women’s healthcare advocacy through our work on legal cases. Reach out to our New Mexico team today to schedule a confidential appointment to discuss your personal concerns about misdiagnosis, medical malpractice, or the cardiovascular risks gender bias poses to women’s heart health. You can reach our office in Albuquerque at 505-218-9949.
