Why Are Women’s Heart Attack Symptoms Overlooked?
Gender differences in warning signs mean women are often misdiagnosed, despite heart disease being their number-one killer.
It was August 2017, and Lashawnda Walker hadn’t been feeling like herself for nearly five months. She’d seen numerous doctors about the terrible fatigue that plagued her—on some days, she felt like she couldn’t even move her body out of bed.
From April on, her primary doctor had chalked it up to working long hours as a newborn hearing screener—she was running on too little sleep and too much stress. By July, Walker was having fainting spells. She went to the ER where an attending physician told her she had dysautonomia, a dysfunction of the nerves that regulate heart rate and blood pressure. That’s what was causing Walker’s blood pressure to plummet, which was making her faint, the doctor said. Walker got a medication that would normalize her blood pressure and stop the fainting—yet she continued to faint, anyway.
Next, doctors implanted a heart monitor to see what was happening with her heart each time she fainted. The monitor revealed that she had a relatively slow heart rate that slowed even more right before she fainted. So they prescribed a medication that would bring it up to speed.
“Even after they gave me all this medication, it seemed like everything was making me more tired. It was paralyzing me even more,” Walker recalls.
In August, as she stood in her garage in Cedar Park, TX, packing boxes to send her son off to college, she felt another fainting spell coming on. “I thought, ‘Oh no, I’m going to pass out on this concrete floor.’” Then she felt a crushing pain in her chest that radiated into one arm. She lowered herself down and crawled to the doorway into the house, where she yelled for her son. When he saw her, he called 911.
Walker was having a heart attack.
If you know the statistics on women and heart attacks, you'll know that Walker’s story is far from unique. She represents an ongoing crisis when it comes to the medical community's ability to correctly predict and prevent cardiac events in women. It begs the question: Why are women’s symptoms misunderstood? What causes them to be misdiagnosed, or—worse—dismissed?
Women Can Develop “More Diffuse Disease”
In the months leading up to her heart attack, Walker had a battery of tests done—and none found a blockage in her arteries for her doctors to treat. Turns out, in her case that was the problem.
“Women are more likely than men to have the type of heart attack where there’s no obstruction,” explains Janet Wei, M.D., a cardiologist in the Barbra Streisand Women’s Heart Center at Cedars Sinai in Los Angeles. In classic heart disease—“classic” being defined as how symptoms generally present in male bodies, which have been significantly overrepresented in clinical studies—plaque builds up in an artery, causing it to narrow in one spot. The plaque can eventually block off that part of the artery, arresting blood flow to the heart and causing a heart attack.
However, for women the picture is often different.
“Women get more diffuse disease, so the artery doesn’t look narrowed in one place. The whole thing is narrowed,” says Gina Lundberg, M.D., clinical director of Emory Women’s Heart Center in Atlanta. This could explain, she says, why doctors don’t find blockages in some women who complain of chest discomfort, and why women can have heart attacks without blockages. “It's also harder to treat because you can’t put 10 stints down the whole artery," she adds.
Women may also be more likely to have artery spasms. These episodes usually last less than 15 minutes and block blood flow to the heart. A rare condition called spontaneous coronary artery dissection, in which a blood vessel in the heart tears and triggers a heart attack, might also happen to women more often than men.
What’s more, “women can have conditions that make their blood more likely to clot,” says Dr. Wei, “and those little clots—or embolisms—can cause a heart attack.”
A Familiar Refrain
That’s what happened to Tamika Reeves, a therapist in private practice in Detroit who was just 34 when she started having pain and numbness in her left arm followed by excruciating chest pains in March 2019. The pain would take hold of her for three to four minutes, and she could do nothing but curl up in a ball and cry. Then it would be over. It happened once or twice a week for the next eight months, but Reeves could never peg it to any triggering event. “It felt like mini-heart attacks,” she says now.
Over the course of those months, Reeves first saw her primary care doctor and next her OB/GYN, then finally she went to a cardiologist, who gave her a stress test on a treadmill, an EKG to search for any heart rhythm abnormalities, and an echocardiogram to review her heart’s chambers and pumping abilities.
None of these doctors found anything wrong—“It’s just anxiety” became a familiar refrain—but Reeves now knows that each of those three to four-minute bouts of crushing chest pain she was experiencing represented a small blood clot passing through her heart.
What happened next? Eight months after that first episode of chest pain, Reeves had a massive heart attack, and only then did her doctors discover what was really going on. Reeves had just sat down with a new client when she felt the recurring chest pain coming on. Knowing it would only last a few minutes, she excused herself to use the restroom. As she sat in the stairwell watching the time and waiting for the pain to pass, the pain grew worse. She knew she needed help. She tried to stand up and walk back into her office, but she could only crawl.
“I mustered enough strength to stand at the door of the other therapist. All I could do was say, ‘Help me,’ and grab my chest and fall down,” Reeves recalls.
Reeves’ coworker and her client carried her out of the building and drove her to hospital on the same block. Reeves soon learned she had a genetic mutation that causes her blood to clot more easily—her main artery was completely blocked.
“I had the widow maker,” she says. “Throughout the whole thing, they were telling my husband they didn’t know if I would make it.” A far cry from months of hearing, “It’s just anxiety.”
Getting to Know Female Symptoms
It’s not just that women can have different symptoms and even different types of heart attacks. They often describe their experiences differently, too. Where men might describe that classic, crushing chest pain, “Women rarely say ‘pain.’ They’ll say heaviness, tightness, squeezing, pressure. A lot of them will say, ‘My bra feels too tight,’” Dr. Lundberg says.
While pain or discomfort in the chest is still the leading symptom of an imminent heart attack for both men and women, women are more likely to describe a handful of other symptoms. More than 70% of women report “unusual fatigue,” like Walker did, in the month leading up to a heart attack. Shortness of breath and indigestion are high on the list, too.
“With women, the story ends up being far more detailed, including symptoms like shortness of breath, nausea, and discomfort between the shoulder blades,” adds Rekha Mankad, M.D., a cardiologist at Mayo Clinic in Rochester, MN, who specializes in women with heart disease.
Conversely, women may not mention any chest-related symptoms at all. They might instead feel pain in their jaw, neck, back, either arm, or the abdomen.
Research shows that these less obvious symptoms of heart disease or heart attack are a top reason that many women put off seeing a doctor. One study found that even when a woman is having a heart attack, she may take up to 37 minutes longer to get medical attention than a man. The study’s authors suggest that women may think their symptoms don’t warrant a doctor’s care, or falsely believe they are not at risk for a heart attack. (Only about half of women know that heart disease is the number-one killer of women, per a study published in Journal of the American College of Cardiology). Those crucial minutes can mean the difference between life and death: In that study, 6% of women who had a heart attack died in the hospital compared to 4.5% of men.
It’s these more nebulous pains and discomforts that may cause doctors to send women in the wrong direction, too. They may look into GI problems, for example, such as acid reflux or stomach ulcers, before checking out the heart. In a study of nearly 1,000 men and women who were hospitalized for a heart attack, women and their health care providers were less likely to attribute the signs leading up to their heart attack to heart disease.
Women Have Unique Risk Factors
The typical risk factors for heart disease that everyone knows about—smoking, obesity, unhealthy diet, diabetes, high cholesterol, and high blood pressure—may raise women’s risk more than men’s. Aside from that, women face some unique risk factors of their own.
Problems during pregnancy, for starters, can reveal a lot about a woman’s risk for future heart problems. Women who develop high blood pressure (preeclampsia) or gestational diabetes during pregnancy are at increased risk for heart disease later on, according to the American Heart Association. Multiple miscarriages can be a sign of clotting disorders that could lead to heart problems. And, preterm labor is also a sign of heart troubles to come, Dr. Lundberg says.
In an analysis of 28 studies that included more than nearly six million women, those who delivered pre-term were more likely to have heart disease or stroke later in life. They were twice as likely as other women to die of heart disease. Researchers don’t fully understand the link between pre-term birth and heart disease, but they say that both share some risk factors, such as inflammation and dyslipidemia.
“About a third of all pregnant women have these adverse pregnancy outcomes,” Dr. Wei says. “We now know they are associated with future heart disease. It's like the pregnancy is a woman's first stress test, and is a window into their future cardiovascular health.”
A study of 116,430 women found that those who had endometriosis before the age of 40 were three times more likely to later have a heart attack, chest pain, or a blocked artery that required treatment. In about 40% of the women, later heart troubles were also correlated with total hysterectomies, a not-uncommon procedure for women with endometriosis. But researchers say that doesn’t explain the heart troubles in the women who didn’t have a hysterectomy. One possible explanation is the chronic inflammation endometriosis brings about.
Disparity in After-Care
Reeves now takes seven pills a day, including the typical post-heart attack regimen of blood pressure and cholesterol medications, plus blood thinners related to the genetic clotting condition.
Given that she had a massive heart attack with a complete blockage, Reeves was also referred to cardiac rehab. Designed to improve heart health after a major cardiac event, such programs include exercise training plus counseling on fitness, stress reduction, and healthy living. But post-heart attack care is another area where women don’t get the same treatment as men. Studies show far fewer women are referred to cardiac rehabs than men. And that’s not all.
“It takes longer for women to get to the cath lab to get, for example, a stent,” Dr. Wei says. “Even once they are diagnosed, fewer women are prescribed life-saving therapy, such as cholesterol-lowering medication, than men.”
Researchers say there may be several reasons that women are less likely to get these treatments. For one, their unique symptoms seem to lead some docs to believe that the medications men get wouldn’t be as effective for them. That seems to be part of the disconnect when it comes to cardiac rehab, too.
“Because women’s heart disease looks different from men’s,” Dr. Mankad says, “some doctors think that that person shouldn’t be referred for those same treatments and rehab, which is completely wrong because data from Mayo has shown that cardiac rehab is critical for these women, too.”
Finally, when women do get a referral, they are less likely to complete the program. Some experts attribute women’s lack of follow-through to their putting their family’s needs before their own. “Maybe we will see improvement now that we’ve been doing virtual cardiac rehab because of COVID,” Dr. Mankad says.
Prevention Is the Best Medicine
The vast majority of heart disease is a result of the typical risk factors, but gender differences do exist. Knowing that women have additional, unique risk factors can help them better understand their own risk levels, spot warning signs earlier, and even prompt a talk with a cardiologist to help prevent the worst from happening.
“Do your genetics homework,” Walker advises other women. She didn’t learn until after her heart attack that her father was diagnosed with heart disease in his 30s, had a heart attack in his 50s, and had a pacemaker implanted. Walker now has a pacemaker, too.
If you feel you are having the symptoms of heart trouble, speak up until you are heard. “Advocate for yourself,” Reeves says. “It’s OK to go for a second opinion, a third opinion. It’s OK to say, ‘This is not anxiety. What else can you check?’”
Women’s heart centers are now available across the country. You don’t necessarily need a gender-specific clinic to get care. But, if you have ongoing symptoms that your local cardiologist can’t explain, a women’s center might be worth a look.
The bottom line, Dr. Lundberg says, is that “heart disease is preventable, and you can get care. Let’s empower women to get that care.”
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