Heart Biases That Can Kill

Millions of Americans experience heart attack symptoms each year. So why do some get better treatment than others?

By Sid Kirchheimer
WebMD Feature

Reviewed By Brunilda Nazario

If you're having one of the 700,000 heart attacks that occur each year in the U.S. -- or even symptoms suggesting that possibility -- it helps to be rich, white, and male.

Studies indicate that it's those patients who get faster and better care in emergency and follow-up treatment for heart attack than do people with less money, darker skin, or a different sex -- even when symptoms or medical insurance are the same.

While ethnic, socioeconomic, and sex disparities have been well documented across a range of conditions -- from routine prostate screenings to potentially lifesaving lung cancer surgery -- these biases are especially noticeable and troubling when dealing with heart attack, the nation's leading cause of death.

Research shows that blacks and other minorities, women, the poor, and the elderly consistently have to wait longer to get hospital emergency room treatment -- a place where minutes count. Afterward, they are offered therapies less often, including aspirin -- an inexpensive drug proven to prevent a second attack.

Even their complaints and descriptions of pain from heart attacks and stroke symptoms are more likely to be ignored by doctors, say researchers.

Who's to Blame?

"Some of it is due to cultural reasons," says cardiologist Charles L. Curry, MD, professor of medicine emeritus at Howard University College of Medicine in Washington, D.C., and a member of the National Heart Attack Alert Program. "African Americans and other minorities don't seek care as often as whites, and they don't seek it as early. They may be more likely to believe that Mother Nature will take care of problems or try nontraditional forms of medicine."

Another reason: Those getting the best treatment -- wealthier white men -- typically have a better handle on the extent of their problem.

"It's pretty clear from numerous studies that ethnic minority groups in the U.S. have less knowledge of heart attack symptoms, and that leads to their own delays in getting proper treatment," says David Goff, MD, of Wake Forest University School of Medicine, who led several of those studies.

Different Symptoms?

In one study, Goff found that white men are more likely to have a higher number of correct symptoms of heart attack and that they respond more quickly. "That may be because it's also clear from the literature that women and minorities either experience symptoms somewhat differently, or they describe them differently to their doctors than white men," Goff tells WebMD.

For instance, when women have a heart attack, they often complain of back pain, not chest pain. "So physicians may not clue into heart disease as quickly with a woman as when men come in complaining of chest pain," he says.

Minorities have also been found to downplay their pain as compared with whites. "You get a black man in the emergency room and ask him what's wrong, and he'll say, 'I have some indigestion,'" says Curry. "He has no idea he may be having a heart attack. Many minorities, as well as women, I think, are more likely to mistakenly think you have to have chest pain to be having a heart attack."

Unconscious Prejudice?

Still, doctors get their share of blame, says Curry, who served as Howard's chief of cardiology and in 1999 was named the American Heart Association's "Physician of the Year."

"I think there is probably a bit of unconscious prejudice going on that may explain why there's a better level of care given by doctors if you're white, male, and well-incomed than if you're a minority, female, or poor," he tells WebMD.

He cites one event two decades ago when the 70-year-old mother of one his staff members developed heart disease. "After learning about her condition, it was my estimation that she needed a pacemaker," says Curry.

But the woman wasn't getting one from her doctor. "The reason I was given by her doctor was that she was old and didn't have long to live. We talked about it and she did get her pacemaker. That was 20 years ago, and she's still living. But I believe because she was an old black woman, she would have died if I hadn't intervened and the doctor had used his normal instinct. I think if she were white she would have gotten the pacemaker sooner."

That "instinct" may result from past medical training, he says.

"There was a time when physicians were taught in medical school that blacks do not usually have heart attacks, so some of these treatment inequities may be a holdover from that," Curry tells WebMD. "Of course, they don't teach that anymore, since it's the most common cause of death among African Americans."

Wealth Allows Heart-Healthy Lifestyle

Doctors may also believe that poorer people are less likely -- or even able -- to follow a lifestyle that can prevent heart attacks.

"If you go 10 blocks south of my hospital, you're in one of the wealthiest neighborhoods in the U.S., but if you go 10 blocks north, you're in one of the poorest," says cardiologist Ira Nash, MD, of Mount Sinai School of Medicine in New York City and a spokesman for the American Heart Association.

"The difference of food available is those two neighborhoods is striking. You cannot find fresh foods or even fresh milk in the poor neighborhood, which is populated primarily by minorities. All there is available is fast food and prepackaged, highly processed carbs," he says. "When people talk about the role of stress in heart disease, many think of the high-pressured executive. I think it's a lot more stressful to be a welfare mother."

That may explain what Curry has seen in his own hospital.

"I've never known a doctor who met a poor man and would say, 'I'm not going to do all I can do to save his life,'" he says. "But in my hospital, we treat everyone from congressmen to homeless people, and I have seen that some doctors do not spend as much time with that homeless man as they would with a congressman."

What You Can Do

So how can you get better care for a potential heart attack, no matter your race, income level, or sex?

  • Get wise to all the symptoms. In addition to chest pain or difficulty breathing, heart attack symptoms can also include an unexplained feeling of fullness; indigestion, gas, or nausea; lightheadedness; sweating; or pain in the arms, jaw, neck, or back. "Doctors have to be aware that if discomfort occurs from the navel to the nose, they should think of a heart attack first," says Curry.
  • Call 911. That ensures you'll get an ambulance to take you to the hospital and therefore be cared for more quickly. Guidelines for hospital accreditation require that ambulance-arriving patients suspected of having heart attacks must get an EKG within 10 minutes after arrival and a doctor's exam within 30; those arriving on their own don't fall under these guidelines, says Curry.
  • Bring an advocate. A friend or family member can better serve as the doctor's eyes and ears. "The patient may talk about some pain, but a spouse will be more likely to describe other symptoms. Your spouse is probably more likely to tell the doctor of sweating or other symptoms."

Published Oct. 5, 2004.


SOURCES: Charles L. Curry, MD, professor of medicine emeritus, Howard University College of Medicine, Washington, D.C.; member, National Heart Attack Alert Program. David Goff, MD, professor of public health sciences and internal medicine, Wake Forest University School of Medicine, Winston-Salem, N.C. Ira Nash, MD, associate professor of medicine, Mount Sinai School of Medicine, New York; spokesman, American Heart Association. Rathore, S. Circulation, Aug. 8, 2000; vol 102: pp 642-648. Goff, D. American Heart Journal, December 1999; vol 138. Goff, D. Archives of Internal Medicine, Nov. 23, 1998; vol 158: pp 2329-2338. Meshack, A. American Journal of Cardiology, December 1998; vol 82: pp 1329-1332.

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