Warning Sign for Heart Attack Goes Unheeded in Women

Women who experience chest pain with no other signs of heart disease are at elevated risk for heart attack or stroke.

May 18, 2009

Listen to your heart: Chest pain should be taken seriously by woman and their doctors.

05-18-09 RODALE NEWS, EMMAUS, PA—Some women who have chest pain may not be getting the medical care they need, a new study suggests. File this under little-known medical facts: It isn’t uncommon for women complaining of chest pain to be found to have no plaque buildup inside their coronary arteries (a classic sign of heart disease, which is checked via angiogram) and to be sent home without treatment. “Actually, it’s quite common,” confirms Martha Gulati, MD, associate director of the Center for Women’s Cardiovascular Health at Northwestern Memorial’s Bluhm Cardiovascular Institute in Chicago, and lead author of a study that confirms that women with symptoms of heart disease often present differently than men.


“Women who have had a heart attack have a 20 to 30 percent chance of having normal coronary arteries,” she says. “Asymptomatic women (or, women with no symptoms of heart disease who have not had a heart attack) who undergo angiography because of an abnormal stress test have a 40 to 60 percent chance of having normal coronary arteries, despite symptoms and signs of ischemia [reduced blood flow to the heart]. This probably translates to more than 3 million women a year in the U.S. with this problem. Not a small issue at all.”

THE DETAILS: Dr. Gulati helmed a team of physicians who analyzed two previous studies of heart disease in women; the first group was followed for an average of 5 years, the second, up to 10 years. The five-year annualized rate for heart attacks was 16 percent among women with some coronary artery obstruction, 7.9 percent among women with normal coronary arteries, and 2.4 percent women with no previous symptoms of heart disease. Their conclusion: “Women with symptoms and signs of ischemia [reduced blood flow to the heart], including pain/chest pressure at rest or with exertion, relief with rest, shortness of breath on exertion, neck or jaw pain, or an abnormal stress test, are at elevated risk for heart attacks and stroke—even if an angiogram comes back clean.”

WHAT IT MEANS: “Women’s heart attack symptoms are often more subtle than men’s,” says Noel Bairey Merz, MD, director of the Women’s Heart Center at the Cedars-Sinai Heart Institute, and chair of one of the studies Dr. Gulati’s team used in their research. Subtle symptoms are still symptoms and should be thoroughly checked out. “For instance, men might complain about tingling in the arm, which is widely recognized as a sign of a heart attack,” says Dr. Bairey Merz, “whereas a woman might present with symptoms such as exhaustion or overwhelming fatigue. A physician who knows how men and women manifest heart disease differently would recognize that symptom as an indication to look further.”

Here’s what women should do to make sure their hearts get the proper care:

• Know the female-specific symptoms. The classic symptoms of a heart attack (read: the symptoms most commonly seen in men having a heart attack) are squeezing chest pain or pressure, shortness of breath, sweating, tightness in the chest, and pain spreading to the shoulders, neck, and/or arm. What women having a heart attack are more likely to experience, says Dr. Bairey Merz, is indigestion or gaslike pain; dizziness, nausea or vomiting; discomfort or pain between the shoulder blades; recurring chest discomfort; and a sense of impending doom.

• Don’t dismiss any symptoms. “Symptoms are symptoms,” says Dr. Gulati. “Some symptoms are more classically associated with heart disease, but for women more so than men, symptoms can also be atypical, and all symptoms should be evaluated.”

• Don’t let your doc dismiss them, either. “There still exists some bias among doctors to not think about heart disease in women, despite an educational push to help physicians recognize that heart disease is the number one killer of women,” says Dr. Gulati. “Many women with angina still don’t get a cardiac assessment; it is a major issue.” If you’ve had chest pain but an angiogram comes back normal, ask for further evaluation, she says. Dr. Bairey Merz seconds that: “Push back,” she says. “Insist on a second opinion. Write down your symptoms, present them to your doctor, and tell him or her that you believe these are symptoms consistent with heart disease in women.”

• Search out women’s heart clinics in your area. Go where doctors are trained to recognize the difference in male and female heart disease symptoms, if you can, suggests Dr. Bairey Merz.

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