A Woman's Guide to Heart Attack

Her Guide to a Heart Attack: Recognizing Female Heart Attack Symptoms
By Katherine Kam
Reviewed by Michael W. Smith, MD

On a Monday morning in April, Merle Rose, a New Jersey woman, experienced what some doctors call "female heart attack symptoms;" a feeling of indigestion and extreme fatigue. Later, she had nausea, vomiting and fainting.

But she never had chest pain-a "typical" male heart attack sign. When she got to the emergency room, doctors couldn't find any sign of heart attack and Rose says, "They would have sent me home."

As Rose's experience shows, many doctors-and women themselves--still don't realize that female heart attack symptoms can look very different than those of men. In fact, according to a study of women's early heart attack signs published in Circulation, women have more unrecognized heart attacks than men and are more likely to be, "mistakenly diagnosed and discharged from emergency departments."

In the emergency room, physicians had assumed she had a gastrointestinal illness. But at the time, no one told Rose that she had suffered a heart attack.

When an outside cardiologist recommended by Rose's regular doctor ordered testing that uncovered major blockages, doctors still made no mention of heart attack, she says.

So when did she finally get word? Not until several months later, when she visited a new female cardiologist. This doctor told her in retrospect that she had suffered a textbook case of undiagnosed female heart attack.

"That's the first I ever heard," Rose says. "This doctor told me, 'They didn't connect the dots.'"
Female Heart Attack Symptoms: What are They?

These chest-related heart attack signs often appear in men, and many women get them, too:

* Pressure, fullness or a squeezing pain in the center of the chest, which may spread to the neck, shoulder or jaw;
* Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath;

But many women don't have chest pain. In the Circulation study on early female heart attack symptoms, researchers found that during a heart attack, 43% of the 515 women studied had no "acute chest pain... a 'hallmark symptom in men,'" according to study authors.

Nevertheless, the study cited evidence that many emergency room doctors still look mainly for chest pain. Only a minority check for the other types of symptoms that women tend to develop. As a result, doctors may miss heart attacks in women.

"Although women can have chest tightness as a symptom of a heart attack, it's also important for women to recognize that might not be their symptom," says Nieca Goldberg, MD, a cardiologist and chief of Women's Cardiac Care at Lenox Hill Hospital in New York City and author of "The Women's Healthy Heart Program."

"Women commonly have symptoms of shortness of breath, unexplained fatigue, or pressure in the lower chest, so they easily mistake it as a stomach ailment."

In the Circulation study, common female heart attack symptoms include:

* shortness of breath (57.9%)
* weakness (54.8%)
* unusual fatigue (42.9%)

Women also had these symptoms:

* Nausea
* Dizziness
* Lower chest discomfort
* Upper abdominal pressure or discomfort that may feel like indigestion
* Back pain
Female Heart Attack Symptoms: Warning Signs That a Heart Attack May Be Coming

In the weeks preceding an actual heart attack, some of these symptoms may even appear as early warning signs, according to the Circulation study.

Goldberg, who is familiar with the study, says, "About six weeks before the actual heart attack, women were more likely to experience shortness of breath, unexplained fatigue or stomach pain as an early warning sign that they might have a blocked artery."

Rose was a prime candidate for a heart attack: a family history of heart disease, high blood pressure, high cholesterol and type 2 diabetes. Long before her heart attack, she had struggled with extreme fatigue.

"I felt like I was being rolled over by a steam engine-couldn't make plans," she says. Doctors put her on antidepressants. She also developed shortness of breath. "I was constantly gasping for breath." But because of the depression diagnosis, "I thought this was an anxiety issue."

"I did have symptoms of heart disease," Rose says. "They just didn't connect it and I didn't connect it."

If you get early warning signs, call your doctor and talk about the possibility of heart disease.

"That's the time to come in for an evaluation," says Goldberg.

On the day of a heart attack, these symptoms can strike without any provocation; for example, shortness of breath may come without physical activity. Symptoms can appear during rest or even awaken a woman from sleep, and they're much worse, Goldberg says.

"They just come on and they're severe. I had one patient describing that she was so short of breath that she could barely talk to the 911 operator."
Female Heart Attack Symptoms: Calling 911

If you believe you're having heart attack symptoms, dial 911 right away for an ambulance to take you to the emergency room. Wait no more than 5 minutes.

"As a doctor, I know from experience that when chest pains or other symptoms occur, most women are reluctant to call 911," Goldberg says. "That's precious time that we could be saving your heart muscle."

Women often worry about being embarrassed if they're not having a heart attack after all, she says. But embarrassment will pass without causing long-term damage; a heart attack may not.

Others don't appreciate the seriousness of the situation. One of Goldberg's patients had heart attack symptoms at age 57 and insisted on straightening up her house before she let her husband call 911. "This delay could have been fatal," Goldberg says.

Calling for an ambulance is better than taking a taxi or having someone else drive you, Goldberg says. And unless you have absolutely no other option, you shouldn't drive yourself. "You don't want to pass out driving your car," she says.

A big advantage to calling 911: emergency medical personnel can start treatment, such as oxygen, heart medication, and pain relievers, as soon as they arrive, says Mohamud Daya, MD, MS, an associate professor of emergency services at Oregon Health and Science University.

One more compelling reason to go by ambulance: "When you come into the emergency room with the [cardiac] monitor hooked up, you're really taken seriously," Goldberg says. "You look the part."
Female Heart Attack Symptoms In the Emergency Room

When you reach the emergency room, describe your symptoms, but don't offer your own conclusions, Goldberg says. "I wouldn't go through this whole dissertation about how, 'Oh, I thought it was a stomachache, I thought it was this.' You should just tell the doctor how you feel. Don't interpret it for them."

If it doesn't occur to the emergency room doctor to check for heart attack, be bold. Goldberg tells women to say outright: "I think I'm having a heart attack." Because many doctors still don't recognize that women's symptoms differ, they may mistake them for arthritis, pulled muscles, indigestion, gastrointestinal problems, or even anxiety and hypochondria.

In short, female heart attack symptoms may be missed-and dismissed. When one of Goldberg's patients entered the emergency room with such symptoms, doctors gave her antacids. "She said, 'Listen, I'm diabetic and women's heart disease symptoms can be different, and unless you give me an EKG, I'm not leaving this place.' And the next day, she had a bypass."

Of course, stomach pain could prove to be nothing more than a bad case of gastrointestinal illness. "But what I tell all my patients is, 'It's best to check out your heart first because a potential heart attack is life-threatening,'" Goldberg says.

And if your fear of heart problems turns out to be unfounded, don't sweat it, she adds. Doctors would much rather diagnose you with indigestion than a heart attack.


SOURCES: Merle Rose.

Nieca Goldberg, MD, chief of Women's Cardiac Care, Lenox Hill Hospital, New York.

Mohamud Daya, MD, MS, associate professor of emergency services at Oregon Health and Science University.

Mayo Clinic.

National Heart, Lung, and Blood Institute.

American Heart Association.

McSweeney, JC et al. "Women's Early Warning Symptoms of Acute Myocardial Infarction," Circulation, 2003 Nov 25;108(21):2619-23.
Reviewed on July 24, 2008