San Diego Union-Tribune

HEART ATTACK Symptoms for women different

- This article originally appeared in The New York Times.

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Most studies suggest that a major reason women delay seeking care — and are often misdiagnos­ed — is because of the symptoms they develop. While chest pain or discomfort is the most common sign of a heart attack in both sexes, women who have heart attacks are far less likely than men to have any chest pain at all. Instead, they often have symptoms that can be harder to associate with cardiac trouble, like shortness of breath, cold sweats, malaise, fatigue, and jaw and back pain. A report by the American Heart Associatio­n found that heart attacks are deadlier in women who do not exhibit chest pain, in part because it means both patients and doctors take longer to identify the problem.

But when women suspect they are having a heart attack, they still have a harder time getting treated than men do. Studies show they are more likely to be told that their symptoms are not cardiovasc­ular-related. Many women are told by doctors that their symptoms are all in their head. One study found that women complainin­g of symptoms consistent with heart disease — including chest pain — were twice as likely to be diagnosed with a mental illness compared with men who complained of identical symptoms.

Longer waits, slower diagnosis

In a study published in May in the Journal of the American Heart Associatio­n, researcher­s analyzed data on millions of emergency room visits before the pandemic and found that women — and especially women of color — who complained of chest pain had to wait an average of 11 minutes longer to see a doctor or nurse than men who complained of similar symptoms. Women were less likely to be admitted to the hospital, they received less thorough evaluation­s and they were less likely to be administer­ed tests like an electrocar­diogram, or EKG, which can detect cardiac problems.

Dr. Alexandra Lansky, a cardiologi­st at Yale-New Haven Hospital, recalled one patient who had gone to multiple doctors complainin­g of jaw pain, only to be referred to a dentist, who extracted two molars. When the jaw pain didn’t go away, the woman went to see Lansky, who discovered the problem was heart-related.

“She ended up having bypass surgery because the jaw pain was heart disease,” said Lansky, who directs the Yale Cardiovasc­ular Research Center.

Over the years, health authoritie­s have tried to address the gender gap in cardiovasc­ular care through a variety of public service campaigns. The federal government and the American Heart Associatio­n launched campaigns to increase awareness of heart disease and its symptoms among women, as did the Women’s Heart Alliance, which started placing ads last year on Facebook, Instagram, and thousands of radio and television stations. Set to music from Lady Gaga, the group’s ads urge women to “know the signs” of a heart attack, which it cautions can be as vague as sweating, dizziness or unusual fatigue.

In January, a group of scientists published a study that delved into the factors that drive women to delay seeking care for their cardiac troubles. They found that the absence of chest pain or discomfort was a major reason. The study, published in the journal Therapeuti­cs and Clinical Risk Management, looked at 218 men and women who were treated for heart attacks at four hospitals in New York before the pandemic. It found that 62 percent of the women did not have chest pain or discomfort, compared with just 36 percent of the men. Many women reported shortness of breath as well as gastrointe­stinal symptoms like nausea and indigestio­n. About one-quarter of the men also reported having either shortness of breath or gastrointe­stinal distress.

Ultimately, 72 percent of women who had a heart attack waited more than 90 minutes to go to a hospital or call 911, compared with 54 percent of men. Slightly more than half of the women called a relative or a friend before dialing 911 or going to a hospital, compared with 36 percent of the men.

Heart disease rising in younger women

“There’s a lack of understand­ing in both women and men that a heart attack does not have to cause chest pain or these incredible movie-like symptoms,” said Dr. Jacqueline Tamis-Holland, an author of the January study and a cardiologi­st at Mount Sinai Morningsid­e in New York.

Tamis-Holland said there were other reasons for the delays. One is that women don’t consider themselves to be as vulnerable to heart disease as men. Previous studies have shown that they are more likely to dismiss their symptoms as stress or anxiety. They also tend to develop heart disease at later ages than men. In Tamis-Holland’s study, the women who had heart attacks were, on average, 69 years old, while the average age of the men was 61.

But younger women are not immune to heart disease. In fact, recent studies have found that heart attacks and deaths from heart disease have been rising among women between ages 35 and 54, in part because of an increase in cardiometa­bolic risk factors like high blood pressure and obesity.

“I think a lot of young women cannot believe they have heart disease because it’s never been labeled as a disease of young women,” said Lansky at Yale-New Haven Hospital. “Second, the symptoms in younger women are even less typical — there’s less of the elephant-on-the-chest feeling and more indigestio­n, shortness of breath, malaise, fatigue and nausea — things that are not very specific. That makes it difficult for them to identify it as a problem.”

Experts say that more outreach and education is needed to help women and men recognize the signs and risk factors for heart disease. But Lansky said she also wants to empower people to become advocates for themselves. If you suspect something is wrong with your health, then do not let a health care provider turn you away until you have answers, she said.

“If you’re not feeling right and you think that in the realm of possibilit­ies is an issue with your heart, then you should spell it out,” she said. “Say: ‘I am concerned I may be having a heart attack, and I want an EKG just to be sure.’ Nobody in the emergency department is going to say you can’t have it. But sometimes they’re just not thinking about it, so it’s good to flag it.”

Lansky recommende­d that people be as detailed as possible when describing their symptoms, which can lead to better diagnoses. She also pointed out that the Hollywood depictions of people clutching their chests during a heart attack can be misleading: Often people experience chest pressure or tightness because of heart disease, rather than pain. They may also feel unusually fatigued or short of breath in response to slight exertion. “If you used to go up and down the steps and now you have to stop to catch your breath, that should raise a red flag,” she said.

Lansky urged women to join clinical trials focused on cardiovasc­ular medicine. She pointed out that much of what is known about heart disease comes from studies involving men. Women represent just 20 to 25 percent of the participan­ts in clinical trials related to heart attacks and interventi­onal treatments, she said. One reason is that for many years health authoritie­s excluded women, fearing that if they became pregnant or experience­d hormonal fluctuatio­ns it could influence trial results.

“In many cases, our recommenda­tions are based on evidence that’s derived from male patients,” Lansky said. “In cardiovasc­ular medicine, it’s challengin­g to get more women involved. There are a million obstacles, but it’s just so important to encourage enrollment in clinical studies. If you want to do something for humankind, that’s a big one.”

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