As an emergency medicine physician, do you see any differences in men and women who come to the ER with symptoms of a heart attack? Do women tend to have worse outcomes than men? Are patients with a poorer diagnosis receiving fewer interventions?

Men and women can present very differently when they suffer a myocardial infarction (MI) or “heart attack.” Classically, the symptoms are described as substernal chest pressure, shortness of breath, diaphoresis or sweating, and the pain can radiate into one’s arms or jaw. Women can still present with the above mentioned classic symptoms, however, women can also present with less classic symptoms including nausea/vomiting, back or jaw discomfort, pressure in the lower chest or upper abdomen, and dizziness or lightheadedness. It is very important, when evaluating women with acute symptoms in the ER, to be very aware of these atypical presentations.

Studies have shown that women tend to have delays in therapy after MI, and are less likely to receive appropriate therapy. These findings are thought to contribute to poorer outcomes for women who suffer a heart attack.

Women who have myocardial infractions tend to be older in age, have more co-morbid conditions, be non-white race, present with atypical symptoms and delay seeking medical care. This has resulted in delays in perfusion therapy as well as patients being excluded from early perfusion therapies. The Ludeman Center seed grant funding is for your project “Gender Differences in the Decision to Withdraw Life Sustaining Therapy after Cardiac Arrest.”

How did you become interested in this question? Are you finding that families are making different choices with male and female cardiac arrest patients? Are health care providers making different choices?

I became interested in this question during my residency at the University of Pennsylvania. In working with one of the faculty, Dr. Raina Merchant, I found that in a small cohort of comatose cardiac arrest patients, women tended to have earlier establishment of “poor prognosis” documented in the medical chart. Additionally, women had earlier establishment of DNR (Do Not Resuscitate) and “early withdrawal of life” sustaining therapy in comparison to men. Although we had made this observation, we did not have sufficient numbers to make a strong statement regarding this topic, so it has been an interest of mine since that early stage in my research career. 

Our preliminary work out of the California State In-patient Dataset (SID) has shown that women who suffer a cardiac arrest and are admitted to the hospital have a higher incidence of establishment of DNR in the first 24 hours of hospitalization versus men. This indicates that either families or physicians are making different decisions for women versus men, however, the SID is a large data set that does not answer the granular questions that we are addressing in our Ludeman Center pilot regarding physician care of post-arrest patients.

How do you balance your time between your clinical work and your research?

Not very well! It is difficult being a clinician researcher, with the competing demands on your time and efforts. Especially currently, where clinical productivity and efficiency is a must and funding for research endeavors is challenging to come by. On my worst days, I always remember why I went to medical school and what is important to me personally. Being a clinician is all of that, and without my encounters with patients and treating the critically ill, I would have no fire to fuel my research. Clinician researchers are a unique asset to the research endeavor, as we see first-hand the social and medical conundrums that affect our patients daily and can transition that into novel research questions that can directly affect patient outcomes.

What are the long term implications for your research?

Long term, I hope to utilize the findings from the Ludeman Center pilot to further inform larger projects looking to improve upon the quality of decisions post-cardiac arrest and limit the implicit bias that may contribute to varying outcomes for women and racial/ethnic minorities.