Heart Attack Symptoms in Women, Not Always Same as in Men (podcast)

Dr. Adams: They can be more subtle. But it’s important that women recognize the classic symptoms, such as left sided chest pressure. A lot of patients will also say it’s pressure, shortness of breath.

The subtler symptoms are epigastric pain, unusual fatigue, shortness of breath. Women have higher pain thresholds. Typically, we’ll say, “Oh, it’s not this.”

We’re also not taught that heart disease is a woman’s disease. Typically it’s been taught, even with physicians, that this is more of a male-dominant disease. Since women have higher pain thresholds, we kind of negate the symptoms.

Dr. Uddin: Some people will say, “Oh, well I always have indigestion. I’ve had it for years.” But all of a sudden they’ll come in one day and I’ll ask: “Why did you want to see your doctor today for a symptom you’ve had for years?” Often times, they’ll say: “Well, it was really different today” or “It was worse today.” That’s one presentation, but then other times we see somebody who says, “You know, I was perfectly fine until all of a sudden a week ago I started to have all these non-specific or vague symptoms.” That’s the really tricky part about it. Depending upon how active somebody is, what they’re baseline risk factors are, it can be something that just suddenly came on a few days ago or it could be something that’s been going on for months to years unrecognized. That’s where we as doctors come in to help determine: Are these just aches and pains you’ve always had or is there actually something serious going on that needs a little more work up?

Dr. Adams: Two weeks before a heart attack, women are more likely to describe unusual fatigue. The day of presentation, it typically tends to accelerate into more specific symptoms of shortness of breath or chest pain.

If you’re noticing a change in your exercise tolerance, if you notice that your workouts have changed and you can’t do your normal activity — “I used to walk this hill regularly, but now it’s giving me more trouble” — that can be a very early sign that we need to check some things out.

Dr. Uddin: Those are the red flags. What we really want to know is if there is a change from your normal functional routine. It may not be chest pain. It may just be fatigue or shortness of breath. But if somebody says, “Well, normally I can get on the treadmill for 30 minutes, no problem, and this past month I really get tired after 10 minutes or five minutes,” we know something has come up and they don’t necessarily have to use the word chest pain or jaw pain, just something different.

Dr. Adams: The first thing we always tell women is one, know your numbers. Get a baseline good evaluation with your primary care provider. What’s your cholesterol? Do you have diabetes? How is your blood pressure running? Is your weight normal? What’s your family history? Have an idea if I’m a low risk person or am I an intermediate risk person?

The reality is people want to know: Is this heart disease or is this not? There is no magic bullet for diagnosis. In fact, we even know that stress tests don’t necessarily predict heart attacks. They help to restratify: Is this chest pain? Is this cardiac? Is this not cardiac?

Dr. Uddin: For example, when somebody comes in and says, “You know what, I want a cardiovascular workup. I want to make sure my heart is healthy or strong,” there are several different types of tests we can do. We’ll do an EKG. Sometimes we’ll do an echocardiogram, which looks at the walls of the heart, the valves and the structure and the function.

Sometimes, we’ll recommend a stress test and even with stress tests there are several different types depending on what we’re looking for. What I always tell patients is if the stress test is normal, it gives us pretty good confidence in the 90 to 95 percent range that maybe everything is okay. But it can miss things and actually in women it can miss things more often than in men. It can either miss something that’s there or it can over diagnose something. It can actually be what we call a false positive, where it makes it seem like something is there that’s not. What we have to do is put it in the context of what Dr. Adams is saying: Does this person have as strong family history? Do they have a lot of risk factors? Are these symptoms typical or atypical?

Dr. Adams: Listen to your woman’s intution. If it feels weird, if it is concerning — many patients will say, “I don’t know how to explain it, this just doesn’t feel right” — that’s kind of your spidey sense going off and you’re saying: “You know what, let’s check this out.”

Dr. Uddin: As for going to the ER or urgent care, I think it’s whatever is closest to you depending on what you’re feeling. If you’re saying, “Okay, I’ve had this nagging ache for a couple months, I want to get it checked out,” you could call your doctor and see what they say. But if something is new that feels scary and unusual to you, don’t blow it off. If it’s something new and you don’t know what’s happening, call 911, or go to the emergency room. Have somebody drive you there whatever it is.

Dr. Adams: There are some acute blood tests that can be done to make sure that you’re not having an acute event. It doesn’t necessarily mean you’re going to be admitted to the hospital, but women need to be aware of changes in symptoms. They need to know their numbers. They need to say, “These are new symptoms for me, I don’t know what it is. I can’t explain it. Definitely get it checked out.”

Dr. Adams: We definitely know that after menopause some very important things happen with women. The blood pressure tends to go up. The good cholesterol drops. The bad cholesterol goes up. Our metabolism goes down.

That’s why after menopause women tend to catch up with men in regards to heart disease. Women are more likely to be diagnosed with heart disease postmenopausal a decade later then men. The consensus still is we do not use hormones to prevent coronary disease. It’s far more complicated then just saying estrogen is protective. Use hormone replacement therapy if you’re having side effects of menopause or you’re having postmenopausal symptoms.

Dr. Uddin: The guidelines have changed throughout the years. There was a time when women were just using estrogen or progesterone because of menopause symptoms pretty liberally and that’s changed more recently because there’s been some studies that suggest the possible increase risk of stroke, possible blood clots and the truth is it’s not the same for every woman as you could imagine. It depends. Is this somebody who’s had a lot of blood clots before? Is this somebody who’s had cancers that run in the family? The recommendation would actually be different for different women as far as how much hormone replacement therapy they can actually take, whether or not it’s safe. That makes it even more tricky because a lot of women will say, “Well, you know, my neighbor is taking her whatever and she feels great. Can I take the same thing?” And the answer is not necessarily. That makes it tricky, too.

Dr. Adams: What we really want to impress upon women is knowing your risk. If you had breast cancer and you’ve had certain radiation therapies or certain chemotherapeutic agents that may also increase your overall cardiovascular risk. But this is what makes it more complicated because women are presenting at later ages with more comorbidities, meaning they have risk factors. But again, typically with higher pain thresholds, it’s more difficult to really ascertain whether this is cardiac or non-cardiac. Women just need to say, “Hey, I got to get checked out.”

Dr. Uddin: It’s never too soon and the reason is A, you just want to get into those good habits of establishing a relationship with a physician or healthcare provider and knowing your numbers, knowing your personal risk profile, which is very different than your friend or your neighbor.

The other thing is we focus a lot on heart disease, coronary disease, but that doesn’t actually take into account all the other things that could possibly be going on in the cardiovascular system, such as lood pressure, arrhythmias, particularly electrical abnormalities, valvular issues. Those don’t always necessarily come on at later age or menopausal. Some of them are congenital. They can be there from birth. Some can develop in the 20s or 30s. Just like you see a pediatrician when you’re little, I think as people get into their early 20s, it’s time to at least establish care.

Dr. Adams: We tell women pregnancy is a woman’s first stress test. We now know that women who have preeclampsia, high blood pressure, even borderline high blood pressure during pregnancy or gestational diabetes — even if those risks factors completely go away after the delivery of the child — that increases your risk of coronary disease 20 or 30 years down the road. You kind of already have the first glimpse of, “I’ve got to get down that lifestyle. I’m going to get my numbers because I know that is the first glimpse of a cardiovascular risk.”

Dr. Uddin: If you think about it at that point, let’s say the woman is pregnant, then the next several years are spent really focused on the child’s health and the family. If something did come up during pregnancy if it resolves, we don’t think about it. That’s a great time to ignore things, but not really.

Dr. Adams: That’s why cardiovascular disease really should be more of a preventive component. Once you have the heart attack, once you have the stents, it’s really hard to reverse the disease. What we’d prefer is that our culture shifts toward preventing cardiovascular disease.

Dr. Adams: Do you know your numbers? By numbers we mean: What’s your cholesterol, blood pressure, waist circumference, family history? And be specific. What age did mom or dad have a heart attack or have stents? Am I a lifetime nonsmoker? Do I have any other inflammatory diseases, such as lupus, rheumatoid arthritis? We now think that inflammation is an associated risk factor of heart disease. We know patients who have chronic inflammatory states are at increased risks.

Dr. Uddin: The other thing to consider is just regular old stress, just the daily stressors in life. Do you have a very stressful job? How do you cope with stress? Do you have symptoms with stress or anxiety? Are you a caregiver for somebody, like a spouse or an aging parent? Those have actually been shown to contribute significantly. Just from the stress alone, the inflammation, it may keep somebody from exercising or having a proper diet.

Dr. Adams: We know that traumatic events that have even occurred during childhood or young adulthood, we know that does increase the risk.

Dr. Uddin: It’s actually called takotsubo cardiomyopathy. It’s got a Japanese name. It’s named after an octopus trap because that’s the shape that the heart takes when it happens. But really what’s happening is it’s purely an extreme stress response that causes a physiologic response in the body. For example, a woman — and it doesn’t have to be a woman, but it is more common in women — will present with all the symptoms of a classic heart attack, such as chest pain, maybe shortness of breath. They’ll go to the emergency room and their EKG and maybe even their lab work will indicate that they’re having a heart attack. But if you go and look at their coronary arteries, they’re actually wide open. There’s no obvious blockages, but if you look at the shape of their heart it will dilate a little bit like that octopus trap and it’s presumed that it is a physiologic response to extreme stress hormones circulating in the body.

Dr. Adams: It’s one of the greatest examples of the link between the head and the heart.

Dr. Uddin: If you ask those people, “What happened to you?” usually they’ll tell you something really severe like, “I had a really bad car accident,” or “my spouse just passed away,” or “I’m bankrupt.” The good news is that often times it actually does improve and people can go completely back to normal, but as Dr. Adams was saying, it really highlights that just the influence of stress alone, how damaging that can be to the heart.

Dr. Uddin: We mentioned inflammation. Let’s say you’ve got gum disease or something that you’re unaware of. You’ve got a chronic low grade amount of inflammation. That’s enough to cause a systemic response in the body similar to what Dr. Adams was referring to with lupus or other autoimmune issues. That’s one big factor we’ve actually seen in people who have had coronary disease or stents. Sometimes, if they’ve got poor dentition or a lot of inflammation in the mouth or other areas, they tend to form scar faster within those stents that they already have. Let’s say if somebody goes with an uncontrolled tooth infection or something for a while, it can actually increase the risk of endocarditis, which is infection on the heart valves. It can enter the bloodstream and we see that actually quite often.

Dr. Adams: The take away is that we’re learning more and more about the risk factors of heart disease. It’s not always just cholesterol, diabetes, high blood pressure, family history, smoking. There are newer, novel markers that are signs of chronic inflammation. Going back to people that we know have chronic inflammatory states, they have more aggressive coronary disease. They have flares with their inflammatory disease states.

Dr. Uddin: Exercise and diet are huge.

Dr. Adams: An anti-inflammatory diet. An anti-inflammatory diet is also anti-cancer. It’s great for diabetes. It’s getting rid of those simple sugars, the white flour, the white rice, the breads, the pastas. Empty calories.

Dr. Uddin: The more packaging something comes in, probably it’s less good for you. We’re big fans of whole foods, where you can actually understand what it is that you’re eating and recognizing where that food product came from.

Dr. Adams: Because this is the disease of women in America right now. This is a highly preventable disease, but it happens to be the number one killer of women in the United States. We ignore care. We get less aggressive care, historically. We are involved in fewer research studies.

We have different presentations. It needs to be part of our public collective consciousness to say: “This is a disease that I can actually improve upon, and you’re going to be taking better care of your families if you understand your own inherent disease.” Women are always taking care of everyone, but women have to understand this is a woman’s disease. This is the disease that’s killing women in America right now.

Dr. Uddin: We offer the full spectrum, all cardiac care. We’ll take everybody. If somebody just wants to talk about, “Hey, I feel fine but I just want to know what’s my baseline risk,” we’ll sit with them. We’ll figure it out. We’ll determine if there is any need to do any advance testing or stress testing. We’re happy to take care of what we call primary prevention. We’re all cardiologists, board certified in more then a couple of things between all of us. We’ll do whatever our patients need. If somebody wants to come in and if they need a stent, if they need a pacemaker, we are ready to provide help.

Dr. Adams: Before you even come in for your appointment, you will have completed about an 11, 12-page questionnaire, which really gets to the meat of how is your health. What’s the family history? What are your other associated risks? We ask about pregnancy. We ask about hormone therapy. We ask about breast cancer risk.

By the time they come in to their visit, we’ve reviewed their entire profile. We already know them and we’ve discussed it with each other even before the patient comes in. We’ve possibly ordered labs. The idea is to provide a really comprehensive visit, even for women who don’t necessarily need to see a cardiologist but say, “I want to know my overall risk. I want to better understand what I should be looking for.” We want them to leave that visit knowing these are my numbers, these are my goals. This is what I’ve got to look out for and maybe we’ll see them back in a year. Or maybe we’ll see them back in a month depending on what’s going on. It’s about knowledge. It’s about empowerment. It’s about letting women not be so anxious about heart disease, but really having a better understanding.

Dr. Uddin: And not being afraid to discuss, not being afraid to come in and say, “You know what, maybe I do have chest pain. Maybe I do have coronary artery disease.” And that’s okay. We actually have a support group for women and it meets once a month in Rancho Bernardo. We want them to leave as an absolute expert on their overall health.

It doesn’t have to be just cardiology. What we don’t want is somebody walking away saying, “I don’t know what my doctor said.” Unfortunately we find that a lot where people are intimidated to ask their questions or they think they understand and they go home and they realize they actually didn’t really know what we were talking about. Our goal is for them to leave saying, “I totally get it, I have a plan for the next year, the next six months.”