Cardiologist C. Noel Bairey Merz, AB’77, minds—and mends—the gender gap in women’s heart health.
A man clutches his arm and keels over, agony etched into his face. He’s having a heart attack, brought on by a clogged artery in a diseased heart. The symptoms are so familiar from movies and TV that cardiologist C. Noel Bairey Merz, AB’77, calls it the “Hollywood heart attack.” There’s just one problem with this scene, a bias shared by cardiac research and many Hollywood productions: men always seem to be the stars.
By the numbers, America’s leading cause of death is at least as much a woman’s disease as it is a man’s. Since the mid-1980s, more women have died from cardiovascular disease—it killed about 65,000 more women than men in 2000. Yet their symptoms still routinely go undetected by tests designed to catch signs of heart disease common in men, says Bairey Merz, director of Cedars-Sinai Heart Institute’s Barbra Streisand Women’s Heart Center and scientific chair of the National Institutes of Health’s women-specific heart disease study, the Women’s Ischemia Syndrome Evaluation (WISE).
The man clutching his arm is having what we call a coronary, the male pattern of heart disease that doctors focused on for years, ignoring another pattern, whose prevalence in women Bairey Merz and WISE colleagues identified about 15 years ago: coronary microvascular disease. This heart disease afflicts smaller blood vessels in the heart rather than the large arteries and causes atypical symptoms that are easy to miss: overwhelming fatigue, indigestion, or pain in the jaw or the back, for example.
Medicine has made great strides since then. Today the American Heart Association clearly differentiates between coronary microvascular disease, which affects many more women than men, and coronary heart disease, which is predominant in male heart patients.
Warm and commanding, Bairey Merz talks about these breakthroughs on a May afternoon in her diploma-decked office at Cedars-Sinai in Los Angeles, a few miles from Hollywood. Her research has found that up to 40 percent of women with heart disease, plus some men, have the coronary microvascular variety.
Also known as cardiac syndrome X, the disease narrows the small arteries of the heart, reducing blood flow to the heart muscle but not producing the telltale lumpy plaque deposits that coronary heart disease causes and that doctors look for. “Women are pretty good at putting the fatty plaque into the wall” of the coronary arteries, Bairey Merz says. While there isn’t a strict split, it’s roughly true that when it comes to heart disease, “women erode, men explode,” as Bairey Merz puts it in a 2011 TEDxWomen talk that’s been viewed online more than 600,000 times.
Doctors still turn away patients presenting with microvascular heart disease thinking there’s nothing wrong, Bairey Merz says. They do so less frequently now, though, thanks to the pioneering work of another cardiologist, former NIH director Bernadine Healy.
In 1991, newly appointed as the first woman to head the medical research agency, Healy wrote a New England Journal of Medicine op-ed about gender bias in heart disease research and treatment. The article was titled “The Yentl Syndrome,” after Isaac Bashevis Singer’s fictional young woman who has to dress like a man in order to study a Jewish holy text.
Two studies published in the same issue showed that men were screened and treated for coronary heart disease more aggressively than women with similar symptoms. “Once a woman showed that she was just like a man, by having severe coronary artery disease or a myocardial infarction, then she was treated as a man would be,” Healy wrote. But that usually came when she was lying in a hospital bed; women and doctors didn’t seem to recognize that heart disease was the leading cause of death among women, “not a man’s disease in disguise.”
This call to action was a watershed moment in women’s health care, and in Bairey Merz’s own career. The editorial “really rang true,” she says. In her own research as a young fellow and assistant clinical professor at Cedars-Sinai and UCLA, she had been finding unexplained differences between cardiac disease in men and in women, with worse outcomes for women. She’d brought up these results with her mentors, but found little encouragement.
Healy’s op-ed “consolidated what I had been seeing in my research and what I had been trying to explain” to those senior doctors—whom today she credits mainly with not getting in her way as she began to investigate gender bias in cardiac medicine.
Bairey Merz had been part of another women’s equality movement as a teenager. A year after Title IX was passed, she received a full-ride academic-athletic scholarship for swimming to the University of Chicago—an achievement that landed her on the cover of Parade Magazine in September 1973. “If it hadn’t been for the scholarship, I sincerely doubt I’d have been able to go to Chicago,” she told Parade.
After college Bairey Merz attended Harvard Medical School and then completed an internal medicine residency at the University of California’s San Francisco campus. While she studied and began her career, the percentage of US medical doctorate degrees awarded to women kept rising. When she began college, only one woman earned an MD, DDS, or similar degree for every 10 men, according to the Department of Education. By 1984, when Bairey Merz became chief resident at UCSF, women were earning nearly one-third of medical degrees (they overtook men in 2003). Bairey Merz credits the influx of women into the field for much of the progress in closing the heart health gender gap.
Bairey Merz has chaired the WISE study since 1996. The project has yielded more than 200 publications, including her team’s groundbreaking work into coronary microvascular disease. “Everything that we do is like Christmas,” she says, “because so little was done before.”
With her TEDx talk and appearances on shows like 20/20 and Good Morning America, Bairey Merz hopes to draw the kind of attention and funding that earned breast cancer a whole month of pink-tinged NFL games to remind women to get screened. Current spending on research into heart disease and women amounts to less than 10 percent of what is spent on breast cancer, she says, “despite the fact that heart disease kills 10 times more women than breast cancer every day.” Meanwhile, in her day-to-day work at UCLA and Cedars-Sinai she spends about half her time on cardiac research and the rest teaching medical students and seeing patients. One of her patients, Danielle Burgener, is a case study in what more doctors can do for women’s heart disease and what women need to learn.
When she awoke in the middle of the night, 25 years old, fit, and feeling terrible chest pain, Burgener waited for hours before going to a hospital, thinking a vitamin pill she swallowed was caught in her chest. “You are much too young to be having a heart attack,” the on-call cardiologist scoffed.” Luckily she was stuck in the hospital while another doctor’s tests were completed. They came back positive for heart disease, and the cardiologist returned to apologize, Burgener says.
She found a much more willing ear when she was referred to the Women’s Heart Clinic, where Bairey Merz and her team put her on a treatment plan designed for coronary microvascular dysfunction. Burgener was relieved to find doctors who weren’t bewildered by her symptoms. “I had a physician that listened to me and understood the impact that this disease would have on my life.” Six years later, she’s alive, fit, and so thankful for the treatment she received that she has become an educator and advocate herself, working to keep other women from waiting as long to get help as she did.
Enrolls at UChicago on new Gertrude Dudley Scholarship for women scholar-athletes
Joins Cedars-Sinai Department of Cardiology, following Harvard Medical School and residency at UCSF
Begins the National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation as chair
Named director of Cedars-Sinai’s Women’s Heart Center, later named for donor Barbra Streisand
Named the inaugural Dr. Carolyn McCue Woman Cardiologist of the Year
Receives the Alumni Professional Achievement Award from the UChicago Alumni Association