Scott Webb (Host): Although women suffer from cardiovascular disease at the same rate as men, there are disparities in diagnosis and treatment for women that can lead to worse outcomes for these patients. And joining me for a second time today to help us to understand the disparities and offer some solutions is Dr. Steven Cook. He's a board-certified cardiologist, subspecializing in non-invasive cardiology at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's great to have you back on the podcast. Today, we're talking about women, equity, and access to care, and the disparities, and what we can do about it. So, let's start there. Talk to me a little bit-- and the listeners-- about the disparities in diagnosis and treatment for women.

Dr. Stephen Cook: When I think about cardiovascular disease, we know that this is the leading cause of death among women in the United States. More lives are actually lost from cardiovascular disease compared to lives lost from cancer and chronic lung disease. And half of the 27 million Americans living with cardiovascular disease are women, but yet it remains underdiagnosed, undertreated, and often portends worse outcomes in women compared to men. And so, I'm still confused as to why this often happens.

I think it's really important for us to kind of start to begin to review cardiovascular risk factors and disparities in management of ischemic heart disease and heart failure that can really help us highlight some of these disparities in healthcare between men and women.

Host: I'm wondering, Doctor, I wanted to just jump in here, because I've spoken with other experts. What I've heard is-- and I'm just a lay person here, so, you know, bear with me. But what I've heard basically is that oftentimes it is the presentation that is different between men and women in terms of heart issues, heart attacks, whatever it might be. And I'm just wondering, is that a part of the reason? Is it just it doesn't present the same way? It isn't as obvious when women, the symptoms they're experiencing, are heart-related or cardiovascular-related?

Dr. Stephen Cook: So, that is a great myth that I would like to debunk.

Host: Okay, good.

Dr. Stephen Cook: It's interesting when you think about diagnosis of ischemic heart disease, you know, many people believe that women have atypical symptoms when it comes to chest pain.

Host: Okay.

Dr. Stephen Cook: At the time of presentation, women and men are equally likely to report chest pain. However, women are more likely to endorse additional symptoms and may complicate the clinical picture; and therefore, I believe that this leads to delay in presentations to the emergency department. There's been studies that show that women are less likely to undergo cardiac catheterization. In addition, women are less likely to receive optimal medical therapy for myocardial infarction as well as secondary prevention.

So as a result of all of these factors, women with acute coronary syndrome often lead to worse in-hospital outcomes than men, including a higher risk for heart failure, shock, and stroke. So, I think, you know, if we continue to perpetuate this myth that women should present with stomach discomfort or GERD-like symptoms or atypical pain, it's taking the right history and understanding that women are just as likely to show up with chest pain as men and providing them with the same exact care, and not being kind of going through this and taking off our blinders that, you know, women and men should not be receiving the same care is incredibly important.

Host: Yeah, I'm wondering, Doctor, then, is one of the answers or one of the solutions to this problem, is it better or more community outreach, better education efforts, like what we're doing today, podcasts like this and other things? Is that one of the keys to solving this?

Dr. Stephen Cook: Yeah. This is a very challenging problem to kind of address. You know, one of probably the most important thing to address is recognizing sex-specific risk factors. I think that compared to men, and we've talked about this already, women have very specific sex-specific risk factors that are deeply interconnected throughout their lifespan.

So for example, early menopause are highly associated with a higher risk of coronary disease, stroke, and heart failure. Again, the mechanisms driving for these risks are deficiencies in endogenous hormones. We talked about adverse pregnancy outcomes. We talked about hypertensive disorders of pregnancy, gestational diabetes. If you don't take the time to understand this history, you're going to completely miss patients that are at a higher risk for the development of cardiovascular disease.

And I think that many cardiologists are unaware of these risk factors. And I think it takes people who are interested in women's health, and I think it takes people who are advocates for people who are interested in women's health, and if we have more people who are trained in this subspecialty of cardiovascular medicine, this is what's going to change the tide for people who are being more aggressive with taking care of women in general, equal to or not better than men.

Host: Right. Right. That's well said. Equal to, but not better. Just equal, right? Yeah. So then, million-dollar question, Doctor, as we get close to wrapping up here, how can healthcare systems do better? What are some of the things that they need to know in order, you know, to improve care, diagnosis, treatment outcomes, all that?

Dr. Stephen Cook: You know, it's multi-pronged, right? And I think This is already starting to happen. It has to happen, you know, at an academic level, right? In academics now, there are institutions that actually have formalized women's cardiovascular fellowship training programs that are uniquely tailored to address the unique aspects of women's cardiovascular health. And I think that will certainly pull the trigger to kind of help identify what are barriers, why are we not caring for women similarly to men.

You know, I think another big problem is really diversification of the workforce when you compare the number of women compared to men in the cardiovascular workforce, it's much less. And I think this is why there's been a such a drag in even enrolling women into cardiovascular research studies. So, I think those are two things that'll hopefully change the tide in the future. I think at an institutional level, it's identifying barriers to, you know, getting women into the cardiology clinic. Is there transportation barriers? Is there childcare barriers? Are there language barriers? So, there's a lot of things that could happen at an institutional level as well to make it easy for women to receive cardiovascular care.

Host: Yeah, it's so interesting. And I just am listening to you and I'm thinking about the women in my life, right? My mom, of course, my wife, my daughter, and just wanting, as you say, like equal treatment for all. Not better, just equal. And education seems like such a big part of this on so many levels. I'm glad we did this today. I appreciated having you on both times. I'm sure we'll speak again in the future. So, thank you so much.

Dr. Stephen Cook: It's my pleasure.

Host: And to learn more, visit franciscanhealth.org/herheart. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.