Why heart disease in women is so often missed or dismissed

Researchers have found that women often hesitate to get help because they tend to have more subtle heart attack symptoms than men

Heart disease is the leading cause of death among men and women in the United States, killing nearly 700,000 people a year. But studies have long shown that women are more likely than men to dismiss the warning signs of a heart attack, sometimes waiting hours or longer to call 911 or go to a hospital.

Now researchers are trying to figure out why. They have found that women often hesitate to get help because they tend to have more subtle heart attack symptoms than men — but even when they do go to the hospital, health care providers are more likely to downplay their symptoms or delay treating them. Health authorities say that heart disease in women remains widely underdiagnosed and undertreated and that these factors contribute to worse outcomes among women and heightened rates of death from the disease.

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 to men who complained of identical symptoms.

Women face longer waits and slower diagnoses

In a study published this month in the Journal of the American Heart Association, researchers analysed 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 different hospitals in New York before the pandemic. It found that 62 per cent of the women did not have any chest pain or discomfort, compared with just 36 per cent 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 per cent of women who had a heart attack waited more than 90 minutes to go to a hospital or call 911, compared with 54 per cent 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 per cent of the men.

Heart disease is 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 recognise 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 per cent to 25 per cent 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.”