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The Real Gender Gap in Heart Disease

Because I’m that guy, I took a poll at the recent family barbecue.

“Heart disease—who has it worse? Men or women?” I asked. The answers came quickly. My mother-in-law and sister-in-law said, “Women.” My father-in-law, arms crossed, said confidently, “Men.”

My mother-in-law remembered hearing about how heart disease affected women more than men during the February American Heart Association (AHA) “Go Red for Women” campaign. Apparently, the message wasn’t heard by the men at this family gathering. They were moved by stories of men—fathers, brothers, friends—they knew who died from heart disease. We are taught that facts should trump feelings, evidence should trump anecdotes, and at first glance it would appear the men are too in touch with their feelings.

It is the mission of advocacy organizations like the AHA to raise awareness. Charts like this one are widely disseminated and used in countless presentations on the topic:

Figure 1

The graph demonstrates that over the last few decades the number of women dying from heart disease has been significantly higher than men dying from heart disease. In the year 2000 alone the gap is the most impressive, with 70,000 more women dying than men. The problem with this chart is that it is completely misleading.

Mortality in this case is best judged by death rates that take into account age and the population at risk rather than the crude number of deaths. The following table assembled from the CDC database for heart disease deaths by gender and age group for the year 2000 paints a more descriptive picture. The number of men dying from heart disease exceeds women in almost every age group. It’s not even close.

Figure 2

The absolute number of men dying in the prime of their lives is staggering. Between the ages of 35 and 64, 92,000 men die every year, which is twice as many men as women, and equivalent to those who died in the Korean War and Vietnam War combined. Even after the age of 75 when more women die than men in total, men die at higher rates because there simply are far fewer men left alive. The gap in numeric deaths in 2000 only exists because of the over-85 age group, where many more women than men die. Put another way, when elderly women eventually die, they die of heart disease.

A better way of representing mortality data to avoid this type of misinterpretation is to use the age adjusted mortality rate—a weighted average that takes into account mortality within age groups and the important denominator of people at risk of dying.

The following chart plotting the age adjusted mortality rate by sex is more accurate, though less politically convenient. Men have been dying at higher rates than women over time, and the gap appears to be constant.

Figure 3

To be clear, heart disease in women is well-deserving of attention. While the large portion of deaths do occur in women in later years, cardiovascular disease remains an important contributor to female mortality even at younger ages. As noted in the chart and graph below, cardiac disease is the second leading cause of death even among women aged 35 to 64, though again, at absolute rates far lower than their male counterparts. The wider public certainly needs to be aware that men have no particular ownership of cardiovascular disease, but the messaging to try to raise awareness of cardiac disease in women is misleading.

Figure 4

A good clinician chooses a diagnostic path based on an understanding of underlying risk. The 20-year-old with chest pain gets a different workup than the 55-year-old with chest pain. If the risk of death between men and women varies by a factor of two in the 35 to 64 age group, is it cause for alarm if men are worked up for heart disease at different rates by their doctors?

This wouldn’t be some sort of controversial sexist departure from standard practice. Every day, cardiologists use risk calculators with the difference in cardiac disease rates by sex baked into the algorithms to help decide if patients may be candidates for drug therapy like lipid lowering statins. The higher the risk of a heart attack, the higher the yield of drug treatment.

As an example, the commonly used cardiac risk calculator below was used to calculate risk on two patients. The only difference between the two patients is their sex. The man meets the threshold for therapy with a statin, the woman does not. Is the algorithm sexist?

Figure 5

Since it is the mission of professional organizations like the American College of Cardiology and the AHA to promote the importance of the disease they represent, messaging campaigns to identify lower risk groups that should be screened less aggressively are likely not to be on the menu in the foreseeable future. But the peculiar trend as reflected in remarks by prominent cardiologists is to specifically accentuate both screening for cardiac disease in women, and the possibility that the care women receive is inferior to men.

Examining a few of the pillars this claim rests on is revealing. One commonly held notion is that women may not have the hallmark symptoms of a heart attack—chest pain or discomfort—that has typically defined the disease. The theory goes that approaching women’s complaints with a typical “male-derived” framework of expected symptoms of heart disease may result in delays and subsequently poorer outcomes. But an attempt to source the frequency of atypical presentations by sex suggests that the complaints of women and men when it comes to heart attacks may not be that different.

Figure 6

A summary of a number of large trials that included the clinical presentation of heart attacks by sex demonstrates that 28 percent of men and 37 percent of women presented without chest pain. A difference to be sure, but not enough to recommend a different and more aggressive screening strategy for women when the underlying disease being screened for appears to be more indolent in women. Curiously, the same crowd that finger wags about overtesting and overdiagnosis is silent here. The hallmark of this genre of research seems to be that the message matters more than the evidence.

Honing the Evidence to Match the Message

Consider a recent article published in the Journal of the American Heart Association that seeks to study differences in the treatment between men and women. The article focuses on two important times—the time from symptom onset to a blocked artery being opened, and the time from arriving at the hospital to opening the problem artery. The article is presented as more proof of a sex-based difference in treatment of cardiac disease because it finds a statistically significant delay in time to treatment women.

The path to statistical significance in this case is courtesy of log transformation of the raw data that is notable only because its need arises from the treatment times between men and women being clustered in such close proximity to one another.

It’s no surprise then, that the statistically significant delay in the time between hitting the doors of the hospital to opening the blocked artery amounted to just seven minutes. The time between symptom onset to therapy was longer, approaching 30 minutes for women. The study implies that delays for women result in worse outcomes. But while these times are statistically significantly different, no correlation between these time delays and poorer outcomes was found, arguing against the delays being clinically meaningful. Only in passing does the study mention that the delays are not correlated with poorer outcomes, a fact that would suggest other mechanisms account for the gender outcome gap. For example, women presenting with heart attacks are certainly older and may be sicker in ways that can’t completely be adjusted for.

There are also two types of heart attacks (STEMI/NSTEMI) that were studied—the more serious kind identified by electrocardiogram (STEMI), and the other kind typically identified by cardiac enzyme markers found in the blood (NSTEMI). Interestingly, only the more serious type of heart attack observed a delay in treatment by gender. If gender really does have such a powerful impact on delays in getting appropriate care, it seems strange that the effect is not seen with the less serious type of heart attack, especially as there’s more room for variation in the treatment of these heart attacks.

The paper, like many in this genre, is a masterpiece of confirming bias while glossing over the fact that, in the three years of study, more than three times as many men presented with heart attacks. And perhaps the most important information in the paper also gets lost: only 65 percent of women and 69 percent of men were treated within the widely accepted 90-minute target time for the opening of an artery. Instead of a call to action to improve these numbers for all, the authors choose to focus on the “statistically significant” four percent difference between men and women.

In a twist of black comedy, despite the fact that one reason proffered for the longer time for women between symptom onset and a health system encounter is that women live alone at higher rates without a companion to activate emergency services, there is no mention that a potential solution might be to try and keep more male companions alive. This is not a message likely to find currency in a paper meant to highlight female disadvantage.

Politicians and salesmen have long understood persuasion is the art of bending facts to support a side. The surprise here is that this pablum is coming from within the academic class, a venerated and trusted group. The facts don’t stand a chance against those who see the world through a lens of patriarchy and male privilege. At the very least, one would expect the intelligent designers of this one-note world to recognize a failure of the male patriarchy when it occurs in as spectacular a fashion as happens with men and heart disease. In what can only be described as a landslide victory for the matriarchy, men turning 35 are half as likely to make it to 45 as their female counterparts. The same dismal statistic awaits men who make it to 45, and those who make it to 55. Inexplicably the messaging on cardiovascular disease somehow white-washes all of this.

The story of historical female systemic disadvantage is a very real one but the presence of a long list of bonafide grievances gives no license for the creation of new grievances based on bad analysis. Men die of heart disease at rates that are well beyond women.  Full stop. The roots of this gap are likely rooted in biology; controlling for traditional cardiac risk factors like serum lipid levels, blood pressure and smoking seem to have no impact on the poorer outcomes seen in men.

In the end, the decision on testing and therapy is a tricky one. I recently took care of a physician’s wife who had developed exertional dyspnea and fatigue. Despite negative initial testing pointing away from her heart being the culprit, the knowledge she belonged to a relatively lower risk group didn’t stop her from getting a coronary CT scan that was prompted in part by an anxious and loving husband who knew all too well about women and their atypical presentation. I ordered it with some misgivings about the cascade of further diagnostics and treatment that carry their own very real harms when one proceeds down a path of testing low risk patients. Luckily, the odds being in her favor, the test was clean.

But played out on a larger scale with an anxiety ridden populace and their physicians searching furiously to stamp out the epidemic that isn’t, we may very well end up doing more harm than good. In the battle between biology and created “truths” that arise from the perceived grievances peddled by a coterie of motivated academics, I have a simple recommendation: Choose biology. It’s the best thing for men. And women.

 

Dr. Anish Koka is a board-certified internist and cardiologist practicing in Philadelphia. He can be followed on Twitter @anish_koka.

 

 

48 Comments

  1. The story of historical female systemic disadvantage is a very real one
    No it is not. It is completely false.
    Women have always been protected and advantaged compared to men as is obvious when you look at historic life expectanies. This is true at least as far back a Roman times and I suspect for as long as humanity has existed. The truth is in fact one of systematic disadvantage of men. They take on harsher conditions with less support and less healthcare resources. This makes sense from a biological perspective and it seems likely it is an intrinsic part of humanity that women are sheltered, protected and supported to an extent that men are not, and that men are exposed to dangers and risks women are not subject to. I can accept that, even though I am disadvantaged by it, but what is annoying and leads to poor decisions is the ubiquitous misinformation that men are advantaged.

    • David of Kirkland says

      Well, if you equate life with lifespan, perhaps. A caged animal in the zoo lives older than in the wild, so the best thing we can do is put all animals in zoos?

    • Nakatomi Plaza says

      “Women have always been protected and advantaged compared to men.”

      Only a guy would write something this stupid. It’s just so damn intellectually lazy. And the moment a woman actually gets an institutional advantage, guys like you are the first people to begin crying about what victims men are because you lost your big advantage.

      • Jairo Melchor says

        @Nakatomi Plaza I can’t comprehend the complain of his comment being “intelectually lazy” mere seconds before writing an argument that would very well be summed up as “Male fragile ego wa waaa”.

        He’s not wrong. I would assume people often conflate “disadvantage” with “lack of choice”. Women were often the subjects of acts such as rape and physical violence, but they were also subjects of reverence by these very same culture, pretty much treated as goddess by men in one way or the other. It sounds weird at first, but that’s pretty much the history of women for the most part.

        “And the moment a woman actually gets an institutional advantage, guys like you are the first people to begin crying”

        I assume this statement of yours is in support of any kind of bias as long it is made towards women? Or am i wrong?

      • Walter Fox says

        I always appreciate careful reasoning free of generalities and slogans,

  2. Not PC, but occasionally correct anyway says

    Thank you for the informative and important article!!!

    There is absolutely no place for “politically correct” ideology in any branch of science, and it should be called out wherever it’s found. Politically driven science is a particularly insidious form of corruption which undermines our basis for understanding the world as it is, not as we wish it were.

    Which is why the SJW types are targeting the hard sciences so aggressively now. They’ve already successfully perverted the soft sciences and are actively using them as weapons for furthering their various ideologies. Now they’re going after the hard sciences.

    The history of the 20th century has amply demonstrated that science driven by political ideology is a powerful tool of authoritarian governments. There is no reason to think the outcome would be any different in the 21st century.

  3. Robin says

    “The roots of this gap are likely rooted in biology; controlling for traditional cardiac risk factors like serum lipid levels, blood pressure and smoking seem to have no impact on the poorer outcomes seen in men.”

    Excellent article overall Dr. Koka but I disagree with your above statement. You don’t need to speculate about different outcomes when there are so many concrete and testable reasons why you would be seeing differences. It would be like trying to explain the differences between the male and female suicide rate as being due to “biology”. That would mean completely ignoring the social, legal, economic and political environment men exist in. The APA has declared all men “toxic”, as has Gillette and many others… the culture is in point of fact, anti-male.

    What are the leading causes of heart disease? Poor diet, lack of exercise, stress, smoking, self-medicating… why would men possibly be engaging in those activities in increasing numbers? Obviously I don’t know for a fact but like you I can speculate. Divorce leads to a massive increase in male suicide. I’m sure the pressures that are inherent in that would also cause heart disease. What about Diversity, Inclusion and Equity? (“DIE”) The current political mantra. That so-called diversity doesn’t include heterosexual CIS men. “Inclusivity” excludes White men. Equality means equality of outcome and preferential treatment for demographics that don’t include men. At it’s essence it is government sponsored legal structural discrimination.

    What about other stressors like the legions of men who are homeless? All existing support services go to single mothers and homeless men get nothing. That’s true of all welfare programs in general. Might that not also lead to poor health outcomes?

    I could go on but there is already a lot of information available on this topic elsewhere. I will add though, if you want to argue a biological component, personally I think it is more to do with ‘evolutionary biology’ than biology per se.

  4. Ray Andrews says

    “men turning 35 are half as likely to make it to 45 as their female counterparts”

    I’m having trouble with that. It seems to say that even if 100% of women survived 35 > 45, that half of men would die in the same time, which is obviously incorrect. Does the author mean that men are twice as likely to die? If 1% of women died and 2% of men, then the men’s death rate would be twice as great, but their survival rate — 99% vs. 98% — would be almost identical.

    • E. Olson says

      Ray – its like compound interest – small initial differences become big over time. I remember getting the lesson in school based on a question about accepting a job for a month that started by paying you 1 cent per day, but doubled the pay each day. The correct answer is yes you would want that job.

    • OleK says

      ^Ditto. Thanks for asking. I have a Bachelor in Stats and this sounded odd to me as well.

    • Tx for reading Ray. I was referring to the death rates of men and women by age. So if you use the year 2000 as an example (as I did in the Table in figure 2) the crude rate of death (# deaths/total) for women aged 35-44 is ~25/100,000, but its ~50/100,000 for men in that same age range. For women aged 45-54 its 69/100k, 160/100k for men. That same multiple applies in the next age range (55-64) as well. So yes, it would appear men are twice as likely to die than women. I phrased it as ‘half as likely to make it’ to the next age range.

      • “Twice as likely not to make it” is very different from “half as likely to make it”!

        If 95% of women make it, “twice as likely not to make it” would mean 90% of men make it. “Half as likely to make it” would mean 47.5% make it.

        • Closed Range says

          Coel

          You beat me to it – yes indeed, there is a huge difference between “twice as likely to die” versus “half as likely to survive”. It sent off alarm bells in my mind.

          I think the author didn’t think it through. Can we get a correction? This should be corrected (for an article about what the data does say) but still the article remains solid.

  5. Asenath Waite says

    Very interesting! Thanks for that analysis. It still strikes me as amazing how statistics can basically be used to promote any desired narrative. I no longer trust any statistic that I read in a news article. I have to go the primary source in order to understand what the data are truly saying. It would be nice the the media could actually just be intellectually honest and save me the trouble, but I guess that’s too much to ask. Strange that this would be promoted by the AHA. I guess the idea is just to stress that women also need to be concerned about heart disease, in addition to men, but intellectual dishonesty is not the right way to go about that, in my opinion.

    • E. Olson says

      AW – very good idea to not believe statistics in the media, because not only are journalists biased towards the Left, they also tend to have the statistics and math skills that give them trouble with anything more complicated than page numbers.

      • Asenath Waite says

        @E. Olson

        I guess I might be too quick to attribute to intellectual dishonesty that which can be explained by stupidity. Multivariate analysis seems to be kryptonite to journalists.

    • Ray Andrews says

      @Asenath Waite

      “statistics can basically be used to promote any desired narrative”

      It is a Twain said. And folks should be taught that from their mother’s knee and never be allowed to forget it. My one and only college credit (apart from welding which hardly counts) is in logic and it’s easily the most important thing I ever learned — how to make a good argument and how to detect/refute a bad argument. Why is it not mandatory in high school? Imagine if the electorate had more savvy than a smart dog? Imagine if we could cut thru politok so effectively that no one would even try to insult us with it?

      • Asenath Waite says

        @Ray Andrews

        Yes, although it’s hard to apply logic when we are only given a small portion of the information necessary to understand a situation.

    • Morgan Foster says

      @Asenath Waite

      “I no longer trust any statistic that I read in a news article.”

      I often check primary sources on any statistic that I read in a Quillette article, too.

      • Asenath Waite says

        @Morgan Foster

        Quillette is not exempt. Although I think they are generally more trustworthy than the MSM, and this article in particular does a pretty thorough analysis and seems like an earnest attempt to put the data into relevant context, including references and links to primary literature. Alarms really go off when an article just provides like a single percentage comparison between two groups and expects us to concede the point they’re trying to make because they showed us two numbers and one was bigger than the other.

        • Morgan Foster says

          @Asenath Waite

          Agree that contributors to Quillette are generally more trustworthy. They’ll certainly be held to a higher standard of accuracy by the readers here than at other sites.

  6. E. Olson says

    Great article except for the sexist assumption that there are only 2 genders. Before we go jumping to conclusions about the true victimhood of women we also should know the heart disease rates for the other 297 human and near human genders.

    The article content also reminds me of the recent 75th anniversary of D-Day. I wonder how many politicians gave speeches commemorating “the gallant men and women who gave their lives on the fascist held beaches of Normandy”?

    • Ray Andrews says

      @E. Olson

      As usual Orwell explained it very well. 2+2=5, except for the military and their engineers, where an exception could be made. But not advertised. There was no official permission, but you could get away with 2+2=4 in the service of accurate ballistics tables and so on. Thus medical people blithely refer to humans as if they only have two genders, and they can get away with it so long as they don’t openly proclaim it. Doing medical testing on all 299 ‘real’ genders would after all be so expensive that not even the most woke contemplates that. For the same reason I’ll not be demanding testing on two legged dolphins like myself — I trust that my numbers can be extrapolated from male monkeys closely enough.

  7. Max says

    “In what can only be described as a landslide victory for the matriarchy, men turning 35 are half as likely to make it to 45 as their female counterparts. The same dismal statistic awaits men who make it to 45, and those who make it to 55. Inexplicably the messaging on cardiovascular disease somehow white-washes all of this.”

    Without having seen the data, I can assure that’s very unlikely to be true. It would imply that even if 100% of all women turning 35 make it to 45, only 50% of all men turning 35 can expect to survive the next 10 years. In other words, at least 50% die. What you probably mean is the men are twice as likely to die (which probably will still be in the single digits). Big difference.

    • Thanks Max – Figure 2 is a snapshot of the year 2000 that’s provided. There’s a background rate of heart disease related deaths that is twice as high for men as it is for women. Men don’t have a 50% chance of dying once they hit 35, but their rate of death is double what it is for women. Sorry for the confusion.

  8. Max says

    Otherwise, really liked the article. It’s infuriating how much time and energy has to be spent by scientists to debunk these agenda driven claims. Time that could otherwise be used to enhance the wellbeing of mankind.

  9. Albigensian says

    “Women have always been the primary victims of heart disease. Women lose their husbands, their fathers, their sons to this scourge. Sometimes women even have to leave their own homes. Women are often left with the responsibility, alone, of raising the children.”

    — edited somewhat, from a statement from a former candidate for President of the United States.

    • TarsTarkas says

      Goddamn men. Always dying on us and leaving us in the lurch.

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  11. Joe says

    “The problem with this chart is that it is completely misleading.”

    A terrific example of Simpson’s Paradox.

  12. The intellectually lazyy thing to do is simply assert something is true without any evidence or argument, follow that with an admission that in fact women are advantaged and then denigrate the person making the opposing argument, again without any evidence.

    In all but recent history almost everyone had nasty hard brutal lifes. It was only a small elite for whom that was not true and that elite consisted of men and women. My argument is that amongst the mas sof people just as today women ere shielded and spared the very worst of a hard brutal life because they were women and the evidence of this is that they lived longer despite the risks of childbirth.

    As to whether a short free life is worth more than a long life imprisoned. That is irrelevant because the bulk of men and women had a similar lack of effective freedom.

  13. Jochen Schmidt says

    Great article! Thank you very much!

    Question: Is the misleading representation of the chart by the American Heart Association (AHA) “Go Red for Women” campaign an instance of the so-called Simpson Paradox?

  14. Bradley L Fisher says

    Good article. Thanks. However I had a lot of trouble reading the graphs. A real negative given that this is a discussion about data. I’d like to see bigger fonts, properly formatted data (with commas), extraneous data removed, etc.

  15. Matt says

    “My mother-in-law remembered hearing about how heart disease affected women more than men during the February American Heart Association (AHA) “Go Red for Women” campaign.”

    Curious that the AHA would feel the need to mislead about this issue. It reminds me of the pay gap issue which is also misleading.

  16. Don Collins says

    Theres lies, damn lies, then there are statistics and polls. But if you make it a political issue for women then it means something…right? No it means they know women are dumb enough to beg government to fund medical care and thus give government the power over them, thus their vote because it feels right.

    The problem with that tactic is that it doesn’t actually care who is dying, just who gets the money and when government gets it that is generally lobbyist, corporate pharma, and colleges for research that goes on forever as that is how the money made, not in getting to the cause which in the case of heart disease is smoking and a fork

    In the field of medicine you can actually fix yourself by not killing yourself with your diets and addictions

    • Bill Zorn says

      in my medical practice, i found many who had excellent diets, no addictions, and still died. it’s complicated, but males will have difficulty attaining the hormonal benefits of females.

      and i’m not sure what alternative you’d put forth for society funding research via our government. but i see our government less simplistically than some who see it as separate from the citizenry.

  17. Bill Zorn says

    we can’t have biology discriminating like this. a movement is needed.

  18. David K says

    This is sort of an aside to the issue discussed in the article, but one of the reasons for men dying more of heart disease may be that men tend to consume more meat and animal products than women. For many men, meat eating is part of their identity and they would rather take medications, get multiple bypass surgeries or even die than to change their diet.

    A plant-based diet is the only diet proven to prevent and reverse heart disease. This has nothing to do with politics or culture wars, it’s simply about being healthy so you can continue to be a part of your kids and families lives rather than dying due to misguided ideas about masculinity. You’re not more of a man if you eat a lot of meat but can’t climb a flight of stairs or get an erection. Be masculine by being healthy.

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