Changing the way we view women's heart attack symptoms

Heart attacks are misdiagnosed more often in young women than in men, and one key way to change that, researchers say, is to think differently about how symptoms can manifest.

For decades, women have been evaluated by a protocol geared toward men. "The historic failings of cardiology to take a balanced approach to research have led to fundamental flaws in the care for women with heart disease and has cost the lives of many women," according to a 2019 editorial in the medical journal The Lancet.

Typically, a heart attack diagnosis begins with a health care provider following a procedure to recognize a classic set of common symptoms. The predominant sign of a heart attack for both men and women is chest pain.

But a new study published in February in Circulation: Cardiovascular Quality and Outcomes found women under age 55 often have more variation in symptom combinations – not just differences in individual symptoms – than men. Physicians have sometimes failed to relate these other, less-obvious symptom combinations to heart attacks and thus refrained from making a heart attack diagnosis.

A growing body of recent research shows women can experience a heart attack differently than men. But Dr. John E. Brush Jr., the new study's lead author, said he and his colleagues were the first to delve into how specific symptoms combine in individual patients as unique symptom combinations.

"As a physician, if you're looking at a woman, you need to think more expansively," said Brush, professor of medicine at Eastern Virginia Medical School in Norfolk and a practicing cardiologist. "She might not have the prototypical combination of features of chest pain, radiating pain down the arm, shortness of breath and sweating, which are often the examples given in textbooks."

In fact, a woman having a heart attack might not have any of those symptoms.

"In women, we have to expand that to include neck pain or sometimes just dizziness and nausea with something that feels like heartburn," said Dr. Jennifer H. Mieres, senior vice president of the Center for Equity of Care at Northwell Health and a professor of cardiology at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. "Jaw, back and arm pain could be the only manifestation for women coming in, and chest discomfort could come later."

Even then, the chest discomfort that many women report could fall far short of the crushing pain men having heart attacks usually experience and might not seem as urgent, experts said. Just being aware of the many combinations and more-subtle signs in women could be the key to quicker diagnoses and treatment.

"Let's say you're at home and you have nausea, jaw pain and heartburn, and you're not thinking this could be a heart attack, even when you know you're at risk," said Mieres, an executive producer of the documentary film Ms. Diagnosed, which focuses on inequities in women's cardiovascular disease care. "We need to remember that the array of symptoms in women is much broader."

When Mieres says "we," she is referring not only to health care professionals — from EMS personnel to emergency room triage nurses to physicians — but women, too.

"We see our patients as partners, and this calls for active participation in their own health," Mieres said. "Health is your most valuable asset. Why would you not do everything you could to protect it? When tax time comes around, you don't show up at the accountant with no receipts and expect to get a refund. You have to be an active participant in maintaining your health."

Dr. Nakela Cook, of the National Heart, Lung, and Blood Institute, warned in a recent Circulation: Cardiovascular Quality and Outcomes editorial that new ways of thinking should bolster, not replace, the current ways.

"The growing focus on recognizing that women are more likely than men to demonstrate an array of symptoms other than chest pain or discomfort when presenting with (heart attack) raises awareness for patients, but may also unintentionally diminish the message that chest pain is the most common symptom for both men and women," Cook wrote.

Brush said people at risk can take comfort knowing "most of the time, the diagnosis is not missed in either women or men."

With more awareness among medical professionals and female patients, he said, "most of the time" can continue to move toward "all of the time."

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