Why are women less likely to survive cardiac arrest than men?

For the past 5 years, researchers from the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC), and the European Resuscitation Council (ERC) worked to improve SCA prevention and treatment through the ESCAPE-NET project, which concluded on January 1, 2023.

During this time, more than 100 studies connected to ESCAPE-NET research have been published in peer-reviewed journals.

One study published in the Journal of the American Heart AssociationTrusted Source in December 2021 found that primary careTrusted Source visits rose sharply the weeks before a person experiences SCA.

And another study, published in the European Heart Journal in May 2019, found that women receive less rapid resuscitation careTrusted Source from bystanders noticing they are having cardiac arrest than men, leading to a lower survival rate for women from SCA.

What is sudden cardiac arrest?
SCA occurs when an abnormal heart rhythm called an arrhythmia causes the heart’s electrical system to stop working properly. This causes the heart to unexpectedly stop beating.

SCA is different from a heart attack, where a coronary artery becomes blocked and blood is not able to reach the heart. However, a heart attack can cause SCATrusted Source and puts a person at higher risk for SCA.

Symptoms of SCA include:

fainting or loss of consciousness
dizziness
racing or irregular heartbeat
chest pain
shortness of breath
nausea.
Because SCA occurs so quickly, the first treatment for SCA is normally calling emergency medical services and administering cardiopulmonary resuscitation (CPR) until help arrives.

Previous researchTrusted Source shows that how quickly a person administers CPR has a direct effect on the survival rate and neurologic outcomesTrusted Source of the person with SCA.

SCA and primary care visits
In the study from the Journal of the American Heart Association, ESCAPE-NET researchers found that people who experienced out-of-hospital cardiac arrest (OHCA) were more likely to have visited their primary care doctor in the weeks before having the cardiac arrest incident.

Scientists evaluated data from almost 29,000 patients from the Danish Cardiac Arrest RegistryTrusted Source who had OHCA. Upon analysis, researchers found the weekly percentages of patients meeting with their general care practitioner the year before the OHCA were constant.

However, 1 week before the OCHA, 42% of patients contacted their doctor. The research team also found that 2 weeks before experiencing an OHCA, 57.8% of patients contacted their doctor.

“Contrary to the general assumption, sudden cardiac arrest does not strike entirely unheralded, as ESCAPE-NET data have shown that patients attend primary care more often in the run-up to an arrest compared to usual,” explains Dr. Han Tan, ESCAPE-NET project leader, and cardiologist at the Amsterdam University Medical Centre AMC in the Netherlands.

“This insight may provide a lead for efforts to identify individuals at imminent risk of sudden cardiac arrest so that it can be prevented,” adds Dr. Tan.

Medical News Today also spoke with Dr. Alexandra Lajoie, a noninvasive cardiologist at Providence Saint John’s Health Center in Santa Monica, CA, about this study.

“I hope this research educates both patients and primary providers because the fact that they’re going and seeking care before the cardiac arrest, that’s really unfortunate because somebody saw them and still didn’t prevent this from happening,” she said.

“I think the majority of cardiac arrests are avoidable if the underlying cause is treated quickly prior to the arrest,” Dr. Lajoie continued. “I think that this shows that both patients and primary care providers need to take certain symptoms more seriouslyTrusted Source, be that chest pain, palpitations, lightheadedness, fainting, [or] shortness of breath.”

And Dr. Lajoie said these findings may also be due to limited access to care. “Patients may see their primary care doctor who is concerned about these symptoms appropriately and refers them to cardiology, but they can’t see a cardiologist or can’t have their echocardiogram or stress test due to limited access to care,” she detailed.

Gender differences with SCA
The ESCAPE-NET study published in the European Heart Journal found that women experiencing an OHCA have a lower chance of being resuscitated compared to men.

Researchers analyzed all emergency medical serviceTrusted Source (EMS) treated resuscitation attempts in one province of the Netherlands.

When looking at the data, scientists discovered women with OHCA were less likely than men to receive a resuscitation attempt by a bystander, even when it was obvious they were experiencing cardiac arrest.

Researchers also found women with OCHA who were resuscitated had lower odds of overall survival than men.

“This eye-opener must lead to public awareness campaigns aimed at narrowing the gender gap in sudden cardiac arrest management,” Dr. Tan says.

“A lot of that’s attributed to people being concerned about respect for female anatomy or just gender concerns,” Dr. Lajoie adds. “Someone who’s not well-trained may be concerned about doing deeper chest compressions on women who tend to have a smaller chest. And for effective CPR, you do need to give a good 2-inch deep chest compression.”

Why women face greater risk
Dr. Lajoie also mentioned that while there are no known gender-based reasons why women might be at a higher risk for cardiac arrest, they are also more likely to delay going to get care initially with symptoms:

“[With] cardiac arrest, a lot of people think of it as something that comes out of the blue with no warning, which, unfortunately, sometimes that is the case. But oftentimes, patients do have symptoms leading up. Women are known to delay seeking careTrusted Source longer than men with symptoms, so [they are] less likely to get that care when they’re starting to have cardiac symptoms. And so, therefore, more likely to have the massive myocardial infarctionTrusted Source that causes cardiac arrest.”

“And there still is this myth out there that men are more likely to have cardiac arrest and heart disease, and so a lot of women don’t recognize that, unfortunately,” Dr. Lajoie added.

Women have played a vital role in the improvement of medical care across clinical fields.

Figures such as Dorothea Dix, who helped change the face of mental health care, Rosalind Franklin, who contributed to the discovery of human DNA structure, and Dr. Virginia Apgar, who put together the evaluation criteria assessing the health status of newborn infants, have revolutionized medicine.

Despite this, women and girls across the world still face challenges and discrimination in medical settings.

Only last year, for instance, senior staff from the Tokyo Medical School, as well as from Juntendo and Kitasato Universities in Japan, admitted to manipulating entrance exam scores so that fewer women candidates would qualify for their courses.

These admissions spurred endless debates about the degree to which women who choose medical care as a profession keep on facing waves of discrimination.

Such problems, however, do not stop at women trying to build a career in medical sciences. According to some reports, women also face discrimination as patients. Sometimes, their doctors fail to diagnose conditions they are struggling with, or offer them the wrong diagnosis and consequently, the wrong kind of therapy.

In this Spotlight feature, we will look at some of the conditions that doctors underdiagnosed in women and explore some of the possible reasons behind these lacks in medical care.

1. Endometriosis
One of the chronic conditions that many women struggle with for a long time before they manage to receive a correct diagnosis — if they ever do — is endometriosis.

Endometriosis is a progressive gynecological condition, which doctors currently consider incurable. Endometriosis occurs when the type of tissue that usually only lines the uterus grows in other parts of the body. This can include the ovaries, fallopian tubes, urethra, but also the bowel, kidneys, and other organs.

Symptoms of this condition include debilitating pain in the pelvic area, as well as other parts of the body, heavy and persistent menstrual bleeding, spotting between periods, pain during sex with vaginal penetration, nausea and vomiting, severe headaches, and persistent fatigue.

These symptoms can often have a severe impact on an individual’s quality of life, affecting their productivity, other aspects of their physical and mental health, and their relationships.

Estimates in the journal Fertility and Sterility indicate that 10–15 percent of women of reproductive age live with this condition, and 70 percent of women who experience chronic pelvic pain actually have endometriosis.

As the authors of that study paper write, “The time from the onset of symptoms to diagnosis is disturbingly long.” Two-thirds of the people they spoke to begin to experience symptoms of endometriosis during adolescence. However, most of these people do not seek medical attention immediately, and once they do, it can take doctors 10–12 years to make a correct diagnosis.

Typically, doctors can only diagnose endometriosis by conducting a laparoscopy. This is a minor surgical procedure in which a doctor inserts a tiny camera into the abdomen to look for lesions and abnormalities.

A doctor may prescribe pain relief medication or hormonal therapy for the management of endometriosis, but since this condition is progressive, many people require multiple and regular surgeries to remove the abnormal tissue growth.

‘So validating to know I wasn’t weak or crazy’
One woman, aged 25, who spoke to Medical News Today, explained that she lived with severe endometriosis symptoms for years before she received a correct diagnosis.

Primarily, this was because both she, her family, and the doctors that she consulted, thought that her disabling symptoms were nothing more than “bad period pains,” or else they mistook them for other health problems.

“I thought it was totally normal to have excruciating pain and 10-day-long heavy periods,” she told us. “My mom, aunt, and grandmother all had the same experience, so I was always told ‘that’s just how it is for women in our family,'” she added.

“I thought maybe I was weak and not able to handle the pain as well as other girls. Last year I was diagnosed with deep infiltrating endometriosis and finally had an explanation and, most importantly, a treatment plan. It was so validating to know I wasn’t weak or crazy, just dealing with a chronic condition.”

She also told us that her journey towards a diagnosis was difficult and long-winded. “I’ve gone through three [general practitioners] and two gynecologists in 2 years,” she explained. She added that because her condition affected several organs, she received many different — and incorrect — diagnoses before the doctors eventually identified the real issue.

“I have endometriosis on my bladder, urethra, kidneys, and bowel, so I wound up with many doctors saying ‘you have [irritable bowel syndrome]’ and ‘you have [pelvic inflammatory disease],’ when I knew this wasn’t the case.”

2. Coronary heart disease
Another health problem that doctors often fail to spot in women is coronary (or ischemic) heart disease (CHD). This disease occurs when the arteries that deliver oxygenated blood into the heart, so that the heart can pump it out to the other organs, become unable to “service” the heart effectively.

The symptoms of CHD vary from person to person, which can make the condition challenging for doctors to spot. However, more generally, symptoms also differ between men and women, and more women thus go undiagnosed until the condition becomes exacerbated.

The National Heart, Lung, and Blood Institute explainTrusted Source that symptoms can also vary between different types of CHD, and some people do not experience any symptoms at all. However, some common symptoms include angina (pressure in the chest area, especially during physical activity), neck pain, and fatigue.

They also state that “[h]eart disease is the leading cause of death for women,” and that women are more at risk than men of developing non-obstructive CHD. This condition can occur when the arteries that go into the heart abnormally tighten or are “squeezed” by the surrounding tissue.

Unlike obstructive CHD, which is more likely to be characterized by tell-tale chest pain, non-obstructive CHD is often “silent” and may go unnoticed for a long time.

Past researchTrusted Source published in the BMJ has argued that doctors often miss CHD in women because of the different set of symptoms and because women themselves do not seek medical attention early on.

“Women may have more atypical symptoms than men — such as back pain, burning in the chest, abdominal discomfort, nausea, or fatigue — which makes the diagnosis more difficult,” the researchers write.

Moreover, they add that: “Women are less likely to seek medical help and tend to present late in the process of their disease. They are also less likely to have appropriate investigations, such as coronary angiography and, together with late presentation to hospital, this can delay the start of effective treatment.”

‘Research has focused primarily on men’
Specialists have been trying to find better ways of assessing and diagnosing women with heart problems, but they acknowledgeTrusted Source there is still a long way to go in this respect.

One reviewTrusted Source, which appears in the journal Circulation Research, notes, “For the past 3 decades, dramatic declines in heart disease mortality for both men and women have been observed, especially in the [over] 65 years age group.”

“However,” its authors add, “recent data suggest stagnation in the improvements in incidence and mortality of coronary heart disease, specifically among younger women.”

But why is this the case? The study authors argue that it may all be down to the underrepresentation of female populations in clinical studies for heart and vascular problems. They write:

“For many decades, [cardiovascular disease] research has focused primarily on men, thus leading to an underappreciation of sex differences from an etiologic, diagnostic, and therapeutic perspective. As long as women are underrepresented in clinical trials, we will continue to lack data to make accurate clinical decisions on 51 [percent] of the world’s population.”

3. Attention deficit/hyperactivity disorder
Women do not just miss out on physical health diagnoses; this problem also extends to other conditions, such as behavioral conditions, and more specifically, attention deficit/hyperactivity disorder (ADHD).

The National Institute of Mental Health defineTrusted Source ADHD as “a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.”

Typically, doctors see ADHD as a problem specific to childhood, and the Centers for Disease Control and Prevention (CDC) note that in 2016 — the latest year for which data are available — around 6.1 millionTrusted Source children in the United States had received an ADHD diagnosis.

Furthermore, according to the Anxiety and Depression Association of America, while approximately 60 percent of children with ADHD in the U.S. continue to experience the symptoms of this condition as adults, less than 20 percent of adults with ADHD receive the correct diagnosis.

If adults, in general, struggle to receive a diagnosis, the situation is even worse in the case of women. Research has shown that both families and healthcare professionals are biased towards believing that boys and men are more likely to have ADHD, and they are more likely to ignore similar symptoms in girls and women.

In fact, some sourcesTrusted Source indicate that up to three-quarters of all women with ADHD never receive a diagnosis, and in the case of children, doctors diagnose fewer girls than boys with ADHD.

Moreover, girls have to wait longer than boys to receive a diagnosis of ADHD. While boys, on average, receive a diagnosis at age 7, girls have to wait until they reach the age of 12 to get the same clinical attention.

Some women think ‘it is too late’
In a reviewTrusted Source published in The Primary Care Companion for Central Nervous System Disorders, researchers explain that in boys and men, ADHD manifests as hyperactivity and impulsiveness; in girls and women, this condition takes a different guise. In women and girls, the primary symptom of ADHD is inattentiveness, which doctors may struggle to spot. Often doctors take this less seriously.

The same source also suggests that girls and women with ADHD may develop ways of masking their symptoms. Some may appear to have better coping strategies than boys and men with the same condition.

Also, because people with ADHD sometimes have other mental health problems, such as anxiety, depression, and obsessive-compulsive disorder, the review authors point out that existing evidence indicates that doctors will much more eagerly diagnose women as living with a mental health condition, but deny them an ADHD diagnosis.

One woman — now in her 50s — who spoke to MNT told us that although she fits ADHD criteria and has lived with ADHD symptoms for a long time, she still has not received an official diagnosis.

“Therapists are pretty sure I have ADHD, the [national health services] still do not diagnose ADHD in adults and in particular women, and [only] direct you to do online tests,” she explained, adding:

“[After] reading an article by a man in the United Kingdom that [said] it took years for him to get a diagnosis, I stopped worrying about it. It is too late to take medication for it at my age; as they say, [it would be like] shutting the stable door after the horse has bolted.”

Although medical systems across the globe have come a long way in terms of providing better quality care at an appropriate time, such accounts make one issue very apparent, namely that discrimination is still present in clinical research and health care. To fight it, we must all learn how to listen — really listen.

What is a heart attack?
In the United States, someone has a heart attack every 40 secondsTrusted Source.

A heart attack happens when there is an interruption in the blood supply to the heart. This usually happens when a blood clot blocks one of the coronary arteries.

The heart still pumps blood around the body, but the part of the heart that usually receives blood from the blocked artery begins to die.

A heart attack can cause serious damage to the heart and be fatal.

The most common cause of heart attack is coronary artery disease (CAD), in which the artery walls become clogged with atheroma, a buildup of fatty deposits. If a piece of atheroma breaks off, a clot forms around it, which can block the blood flow.

Symptoms of a heart attack
Although the symptoms of a heart attack can appear suddenly, this is not always the case. Some people’s symptoms are mild and gradual, developing over days to weeksTrusted Source.

The symptoms can differ between the sexes and even among heart attacks in the same person.

However, typical symptoms of a heart attack include:

chest pain or discomfort
heavy or burning pain that spreads to one or both arms or the back, neck, jaw, or stomach
shortness of breath
lightheadedness
nausea
a rapid or irregular heartbeat
sweating
Some people may experience a silent heart attack, which is one that happens either without symptoms or with very mild symptoms. According to one estimate, silent heart attacks account for almost 50%Trusted Source of heart attacks.

Being older and having conditions that cause nerve damage, such as diabetes, can affect how a person experiences pain. As a result, a person may have a heart attack without feeling pain.

Learn how to spot and treat a heart attack.

Heart attack: What to do in an emergency
If a person thinks that they or the person they are with is having a heart attack, they should maximize the chance of a good outcome by:

calling 911 immediately
sitting down and staying calm
chewing and swallowing 325 milligrams of aspirin, if possible
waiting for the emergency medical services (EMS)
The AHATrusted Source suggests calling an ambulance rather than going by car to the emergency room (ER), as EMS staff can begin treatment as soon as they reach the person. Individuals arriving at the ER by ambulance will, therefore, usually receive treatment sooner than those arriving by car. The quicker a person receives treatment, the better their outlook.

What is heart failure?
A person with heart failure has a weakened heart that cannot pump blood around the body properly. The heart can sustain damage during a heart attack or as a result of high blood pressure.

The symptoms of heart failure include:

shortness of breath
fatigue
swelling in the ankles and feet
bloating
exercise intolerance
shortness of breath when lying down
With the right medication and lifestyle changes, a person with heart failure can live a normal, active life.

Learn about congestive heart failure.

Risk factors
The most significantTrusted Source risk factor for cardiac arrest is having CAD, a history of heart attack, or heart failure. A person with CAD may have no symptoms before experiencing cardiac arrest or a heart attack. Sometimes, people have silent heart attacks before they experience cardiac arrest.

The following factors increase a person’s risk of cardiac arrest and heart attack:

Age: The risk increases with age.
Sex: The risk of cardiac arrest is higher for males.
Race: African American people have an increased risk of cardiac arrest. At particular risk are those with conditions such as diabetes, high blood pressure, chronic kidney disease, and heart failure.
Additional risk factors for cardiac arrest and heart attackTrusted Source include:

a personal or family medical history of cardiac arrest
a personal or family medical history of inherited disorders that may cause arrhythmias or cardiomyopathy
drug use disorder
alcohol use disorder
heart failure
tobacco smoking
high blood cholesterol
high blood pressure
physical inactivity
obesity
diabetes
stress
a nonnutritious diet
an electrolyte imbalance
kidney failure
Complications
Heart attack and cardiac arrest can lead to complications that range from mild to fatal.

Heart attack complications
If a person does not get treatment for a heart attack, it can cause cardiac arrest. People may also experience the following complications after a heart attack:

arrhythmia
heart failure
cardiogenic shock
heart rupture
Cardiac arrest complications
If a person does not get immediate treatment following a cardiac arrest, it can lead to permanent brain and organ injury or disability. It can even be fatal. The risk increases the longer the delay in restoring a heart rhythm and blood flow.

During cardiac arrest, the brain can become starved of oxygen, leading to long-term effects that include:

personality changes
memory problems
fatigue
problems with speech and language
dizziness
balance issues
involuntary movements
permanent brain injury
People often have no memory of having a cardiac arrest.

Outlook
People who survive a heart attack have a higher chanceTrusted Source of experiencing another one. About 200,000 people each year have a subsequent heart attack.

With the right medication and lifestyle changes, people can reduce the likelihood of a subsequent heart attack.

The AHATrusted Source notes that out of the 350,000 or so people who have a cardiac arrest outside of a hospital each year, fewer than 12% of people will survive and go home. CPR can double or triple the chances of survival.

Summary
Both heart attack and cardiac arrest are medical emergencies.

A heart attack happens when blood flow to the heart becomes blocked. A person will usually remain conscious during a heart attack unless it is very severe. It is essential to call 911 immediately so that a person can receive treatment. A heart attack can lead to cardiac arrest.

A cardiac arrest happens when the heart stops pumping blood without warning, causing a person to fall unconscious. It is vital to call 911 immediately, give the person CPR, and use an AED to deliver an electric shock to the heart.

A person can manage their risk factors for both events by adopting lifestyle changes and taking medication as a doctor has prescribed it.