Heart disease is a silent killer for women. RI’s female cardiologists want to change that

• Heart disease is the leading cause of death in the U.S. for men and women, but diagnostic and treatment protocols are overwhelmingly based on men.
• Women with heart disease often present with different symptoms, owing to physiological differences, so they are frequently misdiagnosed, leading to poorer outcomes.
• Lifespan’s Cardiovascular Institute is bucking the trend of a male-dominated field, with women making up 26% of their 62 cardiologists, many in leadership roles.
• Lifespan also continues to invest in its Women’s Cardiac Center at Miriam Hospital to treat women-specific cardiac disease and serve as a center of research.

You often hear that representation matters, be it in education, the workplace or politics. But what about when it comes to your health? Take, for instance, heart disease. It’s the leading cause of death in the United States for both men and women. Yet, our knowledge of telltale symptoms and effective treatments are overwhelmingly based on men.

In recent years, studies – from the National Institutes of Health to the American College of Cardiology and beyond – have investigated why women who are experiencing heart failure are routinely misdiagnosed. Their symptoms are often dismissed as atypical and unrelated, or even psychological in nature. The research points to decades-long gender bias in clinical trials as a main factor. While women make up roughly half the U.S. population, they’ve typically accounted for just 20% to 30% of patients in clinical and pharmaceutical studies. 

“Historically, women have actually had higher rates of mortality related to cardiovascular disease,” said Kate French, a cardiologist at Lifespan. “Women, for a long time, were being left out of clinical research looking at how to reduce that mortality.”

Bucking the trend of a male-dominated medical specialty

Women haven’t only been underrepresented in research. Cardiology remains a male-dominated field. While half of medical school students are female, only 10% to 15% of practicing cardiologists across the country are women. Lifespan’s Cardiovascular Institute is bucking that trend. Of their 62 cardiologists, sixteen are women (26%), and many of them hold leadership positions.

Take Dr. Athena Poppas, director of Lifespan’s Cardiovascular Institute and chief of cardiology at Lifespan and Brown University. She gravitated towards cardiology after studying at the University of Wisconsin Medical School and zeroed in on an important area of investigation.

Women in Action:Hispanic families in crisis call this RI psychologist an ‘angel.’ How she’s saving lives.

“I did research early on in heart disease and pregnancy, because it wasn’t a well-studied area, and found there were a lot of knowledge gaps,” she said.

When she was hired by Lifespan and Brown in 1997, she was one of only two female faculty members in cardiology.

“I remember being on rounds pregnant, and the medical residents were like, “Wow! We’ve never seen that before,” she said.

Since then, Poppas has been active in expanding the pipelines for women into her field, many of whom still face discrimination.

“For the last 10 to 15 years, I’ve spent a lot of time working on why there were so few women in cardiology,” she said. “There’s a lot of intentionality in terms of making a workplace more welcoming and free of bias.” 

Becoming chief of cardiology in 2018 gave Poppas an even greater platform to showcase that women can be effective leaders, keynote speakers and panelists at medical conferences, cutting-edge researchers and mentors.

“It’s a way to break down barriers and reduce bias,” she said. “What I’ve tried to do is be upfront about it, even in our recruitment. When we’re looking at trainees, the new residents and health staff coming in, to say we want a diverse workforce. To say that out loud. And, then they can see it’s not just talk.”

Why does heart disease present differently in women?

On the patient side, Lifespan continues to invest in its Women’s Cardiac Center, housed at Miriam Hospital in Providence. Dr. Kate French has been its director since its inception in 2016. 

“When I first started at the center, I encountered a little bit of resistance – even amongst my male colleagues – questioning the need for a women’s cardiac center,” French said. “But, I think with the expansion of the cardiac centers, both here and nationally, we’ve learned so much more about women’s cardiovascular physiology and pathology. We’ve really created these epicenters for the concentration in expertise related to particular conditions that disproportionately affect women. And, they provide a focus and a center for research to expand our knowledge on women-specific cardiac disease.”

Women in Action:How is this RI foster care innovator transforming young lives and gaining national praise?

While some women may present with chest pain and shortness of breath as men do, they are more prone to have atypical symptoms. As French explained, that’s because, ”women are more likely to have heart attacks that are not related to blockages in the big coronary arteries that you can fix with balloons and stents [as are more common in men]. They’re more likely to have problems with the small vessels in their heart, or with the coronary arteries that are not related to cholesterol blockages.” Which is why traditional testing and treatment protocols often fail when it comes to detecting and treating heart disease in women.

To bolster their diagnostic tools, Lifespan recently purchased state-of-the-art machines called CoroFlow and IntraSight, the first of their kind in Rhode Island. As part of the cardiac catheterization lab, they will be used to diagnose small vessel disease, known as coronary microvascular dysfunction (up to 75% of people who suffer from this are women). Lifespan’s cath lab is run by another female cardiologist, Dr. Dawn Abbott. 

‘Care for women, by women, is really important’

“I think care for women, by women, is really important,” said Janine Lairmore, head of cardiovascular services at Lifespan. “I think as a female you want to be treated by women who can empathize with what you’re experiencing because they’ve lived it.”

The same can be true on the practitioner side. Lairmore credits the unique makeup of the cardiovascular institute with attracting even more women to the practice, in what is typically a male-dominated field.  

“Coming up through the process and into leadership, sometimes you were the only woman at the table,” she said. “You don’t want to come across too hard, because that’s perceived a certain way. You won’t want to come across too weak because then you’re not strong enough. Trying to navigate that all the time is somewhat difficult. But I do think that in the past years, women have owned their voice.”

Lairmore, a Rhode Island native, took over business operations for the institute in March 2020. She has been instrumental in increasing access to care for both women and men. By building out the care team – with the hiring of more physicians, nurse practitioners and technicians – new patient access is up by 80%. She’s also added personnel to streamline ambulatory care and medications and even brought down wait times at the call center. 

“It’s a problem across the country: There seems to be more patients than providers can manage,” she said. “So, everything we’re doing is really focused on how to get patients in, how do we triage folks? The more access you can open up on the outpatient side, the more you can help free up the hospitals,” she said. “That’s the model we’re really working towards.”

Getting the word out to women: If you feel something is wrong, seek medical care

The cardiology team is also working constantly to educate women about the importance of seeking medical attention if they feel something is wrong. “Oftentimes women’s symptoms can be vague, non-specific and dismissed,” said French. 

In the case of Pat Colonies, a retired cardiac nurse, a sharp pain in her right shoulder years ago was perplexing.

“I thought I must have slept wrong,” she said. But as the day wore on and the pain persisted, she saw her doctor, who recommended she go to the emergency room. Tests failed to find any problems. But before she could be discharged, her case had to be cleared by the cardiac care unit. Additional blood work revealed she was having a heart attack, even though her symptom was not typical of heart failure.

“If it wasn’t for the [cardiac care unit], I would’ve been out of the hospital, and who knows what would have happened to me?” Colonies said. “I had a blockage in one of my vessels.”

It’s cases like Colonies’, involving an initial misdiagnosis – and women’s tendency to brush off symptoms rather than seek immediate medical care – that pose a challenge to the Lifespan team. They’re focused on educating both patients and providers to be attuned to the different symptoms a woman may experience, and training providers in newer diagnostic tools.

“Women do tend to present later,” Poppas said. “So, they get treated later and the outcomes aren’t as good. The later you wait to come in, the worse the outcome. If you think you’re having symptoms, I’d rather see you in the ER every month or two than miss something.” 

— Patricia Andreu, a freelance journalist living in Providence, writes Women In Action, a periodic column. Reach her at [email protected] and follow her on Twitter: @ri_women.