Why is it more difficult to ID heart attacks in women?

Young women presenting to the hospital with acute myocardial infarction (AMI) report more non-chest related symptoms than men. Perhaps as a result of this complexity, patients and physicians are less likely to perceive those early symptoms as heart-related, according to a study published Feb. 19 in Circulation.

“The presentation of multiple non–chest pain symptoms may influence the decision of the physician on initiating a workup for ischemic heart disease, in particular if chest pain or the various ways chest pressure is described is not the primary or most emphasized symptom at the time of clinical presentation,” wrote lead author Judith H. Lichtman, PhD, MPH, with Yale School of Public Health, and colleagues.

“In light of our findings and those of others, physicians should listen carefully and consider the diagnosis of heart disease in young patients, in particular those with multiple cardiac risk factors who mention chest pain, pressure, tightness, or discomfort in a history.”

The researchers interviewed 2,009 women and 976 men aged 18 to 55 who were hospitalized for AMI across 103 U.S. hospitals. Patients were 47 years old on average and 76 percent of them were white.

Between 85 and 90 percent of patients in both sexes presented with chest pain, but women were more likely to have at least three associated symptoms such as epigastric symptoms, palpitations and pain or discomfort in the jaw, neck, arms or between the shoulder blades. Women were more likely to attribute the symptoms to stress or anxiety compared to men (20.9 percent versus 11.8 percent) but less likely to blame muscle pain (15.4 percent versus 21.2 percent).

Notably, 53 percent of women reported their provider did not think their symptoms were heart-related compared to just 37 percent of men. More than half of all patients initially attributed their symptoms to other causes as well, most often indigestion or acid reflux.

“This underscores an important gap in the recognition of heart disease in young patients, in particular young women who are typically thought to be a low-risk population,” the authors wrote.

Lichtman et al. said it is important for physicians to elicit all symptoms from patients and “prioritize potential heart disease” if a patient mentions chest pain or tightness among other symptoms, even if they are young and considered at low risk for heart disease. It is also important to identify the 13 percent of women with AMI in their study who didn’t report chest pain, they wrote.

“It is interesting to note that women without chest pain were more likely to have a higher prevalence of diabetes mellitus, prior stroke or transient ischemic attack, chronic kidney disease, and chronic lung disease than women presenting with chest pain,” Lichtman and colleagues wrote. “Thus, young women who present with comorbid conditions along the vascular pathway and atypical symptoms may warrant further testing and careful consideration for cardiac risk even in the absence of traditional chest pain, in particular if they have a family history of heart disease.”

The researchers didn’t interview providers about their perception of symptoms and were unable to identify which symptom patients gave to the providers as the primary symptom. Another limitation is the potential for recall bias from the patients, although the interviews were conducted during the index hospitalization.

In an accompanying editorial, Nanette K. Wenger, MD, pointed out the educational gaps are “substantial” regarding women’s risk of cardiovascular disease (CVD) for both healthcare professionals and patients. CVD was previously thought to be a “man’s disease” but public awareness campaigns over the last 15 years have worked to change that narrative.

While they’ve made some progress, Wenger wrote, the gains in awareness seem to have leveled off in recent years.

Going forward, Wenger said selective educational programs should be administered, especially for women in racial and ethnic minorities, where awareness of risk factors remains lowest.

And to guide professionals in their treatment, Wenger challenged cardiovascular researchers to enroll more women in their trials and include data on attributes unique to women, such as hormonal status, oral contraceptive use and the use of menopausal hormone therapy.