May 9, 2008
by Laurence Degelsmith, MD
Coronary heart disease is the primary cause of death for women in the United States.
Women also make up a greater proportion of sudden cardiac death tragedies than men, primarily because women frequently ignore or don’t recognize early warning signs of coronary heart disease.
Medical professionals are complicit in this second statistic because they inadvertently ignore some of the symptoms of coronary heart disease women often present to their doctor or the hospital emergency department.
Women have very different symptoms from men
The dichotomy is basic: men usually get chest pain, or angina, prior to having a heart attack while women frequently do not. The effect of this dichotomy can be tragic, as women are often not treated as quickly or aggressively as men are.
In the emergency department when we hear the words “I’m having chest pain,” we all jump into action with military precision. However, when we hear a female patient complain of fatigue or sweating, we simply don’t move as quickly. The fact of the matter is that extreme fatigue, shortness of breath, abnormal sweating, dizziness and weakness are some of the most common symptoms women have due to angina or a heart attack. Over a third of women presenting with heart attacks have no chest pain at all.
Most women protected until menopause
It is a widely acknowledged fact that women are generally protected from coronary heart disease until they reach menopause. Estrogen seems to prevent the accumulation of plaque in the blood vessels in the heart that can cause angina or a heart attack. In general, I think that this is true since I have rarely seen a female under 50 experience a heart attack.
Those few women under 50 that I have seen or treated have had one or more significant risk factors for coronary heart disease. Diabetes is probably the most significant risk factor but a family history of coronary heart disease before the age of 50 in a close family member is also very important. Smoking, obesity, lack of physical exercise, a hysterectomy, hypertension and hyperlipidemia (an elevation of fats in the blood stream, like cholesterol) round out the remaining common risk factors.
Most frequent symptoms are unusual fatigue and sleep disturbances
As noted in an article in the American Heart Association journal, “Circulation,” published in 2003, it has been documented in past studies that 85 – 90 percent of women presenting with heart attacks had various symptoms for up to six months prior to their heart attack. The two most frequent symptoms include unusual fatigue and “sleep disturbances” followed by shortness of breath, indigestion and anxiety.
If these symptoms included chest pain, it would be easy to identify the presence of coronary heart disease. Even when women do get chest pain it is often not in the usual suspicious area in the center of their chest. Frequently the pain is in the upper left part of the chest. Also, the pain is usually not even described as a pain, but rather an ache, discomfort or pressure.
Back pain is just as frequent as chest pain. Shortness of breath, weakness, nausea and sweating are all more common symptoms of angina or heart attacks than either chest or back pain in women. This is especially true but not limited to diabetics. Some other common symptoms of coronary heart disease in women include indigestion, arm weakness or heaviness and dizziness.
I once saw a patient many years ago who was about 45 years old and presented with burning in her throat and severe pain in her left temple. Her electrocardiogram and blood tests were normal so I sent her home with medication to treat heartburn. She saw her doctor a few days later who continued the medication I started in the emergency department. I saw her again two weeks later in the emergency department with the same symptoms but now she had EKG changes diagnostic of a heart attack. Her primary complaint at this visit was pain in her temple and not chest pain, shortness of breath or sweating.
Women over 50: take your symptoms seriously
In summary, I want to emphasize that it is very uncommon for women under the age of 50 to have a heart attack unless they have risk factors as mentioned above. It is not necessary to run to the doctor’s office or emergency department for every case of nausea or tiredness. However, if unusual symptoms are occurring in an increasing frequency or intensity that is not common to you, it might be prudent to have them checked out. It would also be advisable to take appropriate steps to decrease one’s risk of developing coronary heart disease by engaging in routine exercise, maintaining a healthy diet, treating underlying high blood pressure and hyperlipidemia and not smoking.
Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.
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