Ask Dr. Pat · Health

Heart Disease in Women Is Still Under-Diagnosed

One main reason for the delay in treatment and diagnosis of heart disease is likely due to the fact that women present atypically. Like men, the most common heart attack symptom in women is some type of pain, pressure or discomfort in the chest. However, unlike men, women are more likely to have heart attack symptoms unrelated to chest pain such as neck pain, jaw pain, shortness of breath, nausea, vomiting, lightheadedness and dizziness. These symptoms may be subtler than the obvious crushing chest pain most people know about. Because of this atypical presentation in women, it can be difficult to recognize that a woman is having a heart attack. In addition, women often downplay their symptoms. A woman having a heart attack will wait longer before presenting to the emergency room. She will be less likely to have a diagnostic electrocardiogram upon arrival and she will be much less likely to be diagnosed correctly.  Even if she is diagnosed correctly, she will be less likely to receive all the life-saving treatments we have today. In addition, when she is diagnosed correctly, life-saving therapies for heart disease will be given an average of a 10-minute time delay compared to a man. This is a big difference because morbidity and mortality are directly linked to a delay in initial treatment.

One recent observational study observed 217 patients as they presented to the emergency room of Yale-New Haven Hospital diagnosed with coronary heart disease (acute coronary ischemia or myocardial infarction). Chest pain was the most frequently reported symptom in women (70%) and men (71%). However, women were more likely than men to present with mid back pain, nausea or vomiting palpitations or indigestion. In these women presenting with atypical symptoms, morbidity and mortality were increased likely due to initial delay in recognizing presenting symptoms of a heart attack. It is important for not just the doctor but the patient to understand that women present atypically so a heart attack can be recognized and diagnosed early and treated promptly.

It is important that we further increase awareness of heart disease by identifying what constitutes higher risk for coronary artery disease so women with these risk factors can be identified early and followed closely. The classic modifiable risk factors of coronary artery disease include smoking, hypertension, high cholesterol, obesity and diabetes. In general women have the same classic risk factors for developing coronary artery disease as men. However, some risk factors may affect women differently than men. For example, diabetes raises the risk of coronary artery disease more in women. Perhaps this is because women with diabetes more often have added risk factors, like obesity, hypertension and high cholesterol. Although women typically develop heart disease ten years later than men, diabetes erases that advantage. Women who smoke are twice as likely to have a heart attack as male smokers. Women are also less likely to succeed in quitting and women who do quit are more likely to start again. The use of birth control pills can increase the risk for the development of coronary disease, especially in women older than 35. Women who smoke and take birth control pills are at a much higher risk.  If women choose to smoke, then birth control pills should be discontinued, and another form of contraception instituted.

In addition to an atypical presentation of a heart attack, about 10% of women who experience a heart attack have no obvious blockages seen on cardiac catheterization. This is a substantially higher percentage than in men. Women are much more likely to develop certain conditions such as coronary vasospasm, which is a temporary tightening of the muscle wall of the coronary arteries that with time can lead to a heart attack. Spontaneous coronary dissection (SCAD) is an uncommon occurrence that develops when a tear forms in one of the main coronary arteries or the smaller branches. This dissection can disrupt blood flow to the heart causing a heart attack and sudden death. It most commonly occurs in healthy women in their 40s and this condition needs to be diagnosed and treated quickly.

Increased awareness and early detection of risk factors and presentation of heart disease are very important but prevention of heart disease in women can perhaps have the biggest impact. Smoking cessation is critical! Your chance of a heart attack doubles if you smoke one or more cigarettes a day. A healthy diet of whole grains, fruits and vegetables and poly and monounsaturated fats are key as well as daily exercise and stress management. It is important to “know your numbers” —maintain weight, cholesterol and blood pressure at appropriate levels.  Most importantly be proactive about your health. Discuss your cardiac risk with your doctor and the appropriateness of certain testing such as calcium score and CT scans of the heart, stress testing and other imaging modalities. Be your own advocate: It may save your life!


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  • Kirsten Healy July 9, 2018 at 11:17 pm

    To clarify, Men and women often have different symptoms. However I want to point out that men and woman most often present with “typical symptoms” and their presentations are similar. I use the term “atypical” to describe the constellation of symptoms that a woman more frequently presents with in comparison to men.

  • Walker Thornton July 9, 2018 at 8:49 am

    Note that Dr. Healy refers to a woman’s heart attack symptoms as “atypical” which just reinforces the idea that the male symptomatology is considered the norm. Another example of gender differences or bias, even as she writes about the differences and the need for awareness. This kind of thinking reinforces the idea that women are ‘other’ and continues to lead to a lag in diagnosis and treatment time.