Case Example: Ms. Locke, a 45-year-old inmate at your facility seeks medical attention today because of fatigue and shortness of breath. You look at the problem list and note that she was a smoker before incarceration and is being treated for hypertension, hyperlipidemia and diabetes. She is also obese. In your interview and assessment of Ms. Locke, she says that she feels nauseated and has a burning or soreness in her necks and upper arms. She reports experiencing these symptoms intermittently for the last month and being treated for a cold, epigastric distress and anxiety.
Does your differential diagnosis include cardiac disease, particularly ischemia or infarction? She is describing the four most common symptoms experienced by women before an acute cardiac event and there are six risk factors for heart disease in her health history.
The problem: There is still a belief that heart disease is a man’s disease and breast cancer is perceived as a greater threat for women than heart disease. And yet heart disease is the single leading cause of death among women in the United States! While ischemic heart disease is less prevalent among women compared to men; after the age of 45 the risk for women is comparable to men. Since the life expectancy of women is greater than men, as the population ages there is more heart disease among women.
The reason: In a survey of women conducted in 2012 only just over half were aware that cardiovascular disease was the leading cause of death for women and among black and Hispanic women recognition was even lower. In addition, women were not aware of the signs and symptoms of acute myocardial infarction that are more typical for women.
Research also shows that providers minimize the importance of women’s symptoms or disregard their concerns, do not order recommended diagnostic tests for heart disease and are more likely to prescribe treatments for depression or indigestion. Women also have poorer outcomes after diagnosis of ischemic heart disease than men; they are more likely to die the first year after an acute myocardial infarction, more often experience complications after cardiac intervention and have a poorer health related quality of life. While the death rate for younger men (ages 35-44) has decreased with prevention and treatment of heart disease the death rate for young women is increasing. Not knowing prodromal symptoms more typical of women and failure to asses for ischemic heart disease are thought to be the reason for this.
Typical symptom presentation: A meta-analysis of 26 studies concluded that women with acute myocardial infarction were less likely than men to present with chest pain. Women were more like likely to report fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness and syncope than men. Another prospective longitudinal study showed that there were four symptoms that were significantly associated with the likelihood of a woman experiencing a cardiac event: discomfort in the jaw/teeth, unusual fatigue, discomfort in the arms and shortness of breath. Experiencing more than one of these symptoms increased the likelihood of a woman experiencing a cardiac event by four times.
Nursing implications: Here are my suggestions about what nurses should do with this information about the differences between men and women with ischemic heart disease.
- Review the nursing protocols at your facility that pertain to cardiac disease, especially those for emergent and urgent conditions. Do they need to be revised to include information that differentiates how ischemic heart disease typically presents in men and women? I looked at a nursing protocol today for angina and among the risk factors was “male gender”. While it is true that ischemic heart disease is more prevalent among men, women are more likely to present with angina when experiencing a worsening cardiac condition. It also doesn’t list age or menopausal status which are extremely relevant risk factors. The symptom description emphasized chest pain or pressure as intense and discounted the importance of other symptoms independent of chest pain. After the immediate problem is addressed does the nursing protocol provide guidelines for referral to a provider for a more comprehensive cardiac assessment?
- Educate women about the prevalence of heart disease, the risk factors and the symptoms of cardiac disease. Women tend to attribute their symptoms to non-cardiac reasons and are therefore more likely to be treated for non-cardiac disorders. A more knowledgeable patient helps to reduce delays in treatment for heart disease.
- Advocate for patients to receive appropriate diagnostic workups and treatment for heart disease. Unrecognized or “silent” myocardial infarction is more frequent in women and women who experience an MI have a much poorer prognosis than men. Because women are more likely to have their symptoms disregarded or minimized by providers (lack of knowledge by providers about increasing evidence of sex and gender differences in cardiac disease) nurses need to be familiar with diagnostic procedures as well as treatment interventions that are more accurate with women and advocate for these in developing the patient’s plan of care.
- You may be saying “Whew, just another reason why I am glad I don’t work in a women’s correctional facility”. But even at male facilities there are women correctional officers, nurses, other officials and visitors who are women. As a nurse you have the opportunity to educate these women about cardiac disease, its prevention and recognition-doing so may change their life. You may also be called to respond to one of these women in a medical emergency and it would be good to be prepared if they present with symptoms more typical of women in a cardiac event.
Next week we will review how sex and gender characteristics of women affect risk factors for heart disease. In the meantime, it would be interesting to know how the emerging information about women and heart disease might change how health care is provided at your correctional facility. Please let us know your thoughts by replying in the comments section of this post.
To read more about nursing care of women and patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!
McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.
McSweeney, J. C., et al. (2014) Predicting coronary heart disease events in women: a longitudinal cohort study. Journal of Cardiovascular Nursing: 29.
Coventry, L.L., Finn, J., Bremmer, A.P. (2011) Sex differences in symptom presentation in acute myocardial infarction: a systemic review and meta-analysis. Heart Lung: 42.