Colleen M. Norris is a women’s heart health researcher, the associate dean of research of the University of Alberta’s faculty of nursing, and the scientific director of Alberta Health Services’ Cardiovascular Health and Stroke Strategic Clinical Network.
Every 20 minutes, a woman in Canada dies from heart disease. Sadly, the longstanding view of the condition as a man’s disease means there is a lack of awareness of its risk in women. This continues to be reflected in the lack of research, policies, programs and clinical protocols for women with heart-health issues.
Research has shown us that, compared with men, women having a heart attack are more likely to present with chest pain and discomfort, and with additional subtle symptoms such as unusual fatigue, sudden sweating or shortness of breath, and neck, jaw or back pain.
More importantly, however, even if women recognize and talk about their symptoms as “heart-related,” research tells us that they are more likely to be dismissed by medical professionals. Women who have had a heart attack and arrive at a hospital emergency department or primary-care clinic often describe being “stopped at the gate,” and feeling misunderstood, misinterpreted, misdiagnosed and mistreated. In fact, heart-attack symptoms are not recognized in more than 50 per cent of women.
As the variation of female-specific symptoms makes it difficult for women and clinicians to identify them as heart-related, and because of a historical lack of women in clinical trials, there is a dearth of female-specific guidelines for the diagnosis and treatment of heart disease, and so women continue to be misdiagnosed and mistreated.
In my home province of Alberta and across the rest of the Prairies, there are no dedicated clinical programs for women’s heart health. This stark reality leaves the majority of Albertan women and their caregivers scrambling to provide care that is not necessarily evidence-based – nor, for that matter, appropriate. My own research at the University of Alberta has identified that close to 300 women a year in the province who arrive at an emergency department, with signs and symptoms of heart-health issues, are discharged home but readmitted within 30 days – having had a heart attack.
A small group of women in Alberta have used their own considerable resources to secure an appointment at the women’s heart-health program in Vancouver. They must independently arrange for and pay for all the related expenses to be diagnosed and treated for heart-related issues. Furthermore, even when they get a diagnosis and treatment strategy in that city, they may not be able to access the recommended treatments because they are not presently available in Alberta.
It is important to reiterate this is not unique to Alberta. Only four of Canada’s 13 provinces and territories have established a women’s heart-health program over the last five years. Vancouver is joined by Halifax, Montreal, Ottawa and Toronto in hosting such programs, which have incredible and increasing demand. This is a good start, but if you live outside of these five cities, there are no local opportunities for women to obtain appropriate care based on female-specific heart health issues. Furthermore, because of limited resources and the urban-centered locations, these programs are not universal, accessible, nor portable even within the provinces and people they serve.
Fundamentally, the problem is national in scope. Canada utilizes a publicly funded health care system, which in effect provides universal coverage for medically required care. The Canada Health Act stipulates that health care is to be publicly administered, comprehensive, universal, accessible and portable.
Yet provincial and territorial governments have control over how health insurance plans are administered, the planning and funding of care in their hospitals, and the determination of what services are provided. This means that universal access to female-specific heart health care and the integration of female-specific cardiac pathways, protocols or policies, is at the behest of not just the provincial government but the individual health-care facilities within each province or territory.
This lack of any Canada-wide health policy has resulted in an absence of consistent women’s heart health care, from diagnosis to treatment.
Women’s heart health as a field of research has grown significantly in this country. Take the Canadian Women’s Heart Health Alliance, for example. This group of multidisciplinary experts and women with lived experience gathered in 2018 to embark on an in-depth analysis of critical sex and gender-specific issues across the entire spectrum of cardiovascular diseases, throughout the life-cycle of women.
The result was the CWHHA ATLAS, a detailed document providing clinicians with the resources needed to understand the unique aspects of women’s heart health, and aiming to prod policy makers in the right direction for more equitable care.
But despite such research efforts, in Canada there is still a significant lack of evidence driving clinical decisions in women’s heart care. This is compounded by low levels of awareness in the public, among clinicians, and importantly at all levels of government.
While we continue to provide evidence for the development of Canada-wide policies related to women’s heart health, it is time that Alberta follows the example set by others and invests in clinical programming that will bring about much-needed equity.
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