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Women’s Signs of Heart Disease Often Missed in Testing

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Women’s Signs of Heart Disease Often Missed in Tes

Women’s Signs of Heart Disease Often Missed in Testing

February 22, 2006

By: Diana Barnes-Brown for Veins1

When most of us hear the words heart attack, what comes to mind is the images of men, clutching their chests, falling to the ground and gasping for air before being rushed to the hospital. While such images do represent a large proportion of heart attacks in men, they fail to include the group whose risk of death may be highest: Women.

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Preventing Women’s Heart Disease and Attacks

Women should watch for: shortness of breath and chest pain (even if mild or intermittent), stomach symptoms, fatigue, and any sudden or sharp pain, pressure, crushing sensation and difficulty breathing are all potential signs of heart disease or attack, and should be taken seriously.

Seek out doctors and care centers that view men’s and women’s heart care and diagnoses as separate processes with separate requirements.

Women’s heart disease symptoms may be far subtler, with occasional chest pain, fatigue, or other seemingly mild symptoms that could also be connected to other factors, such as a cold or flu or simply the stress of day-to-day life.

If you or a woman you know has symptoms that may be related to heart disease or heart attack, don’t gamble, trust your instincts. Go to the doctor immediately and push for testing and treatment.


Heart disease is the number one killer of women in the U.S., and in the past several years women’s and national health initiatives have taken steps to tackle the problem and start saving lives. Still, a recent study published by the National Institutes of Health noted that as many as 50 percent of women who die of heart attacks present no clinical symptoms.

Some of the most surprising – and potentially helpful – new findings come from researchers at the Women’s Ischemia Syndrome Evaluation (WISE) program at the University of Pittsburgh. The WISE program began in 1996 with a comprehensive database intended to study the medical outcomes for 936 women who had been referred for coronary angiography (a non-invasive cardiac imaging test used to assess risk factors for heart attack and other heart problems) due to suspected cardiac ischemia (lack of adequate blood flow). The women were enrolled in the program from 1996 to 2000 and the study is now in its sixth year of follow-up.

The researchers of the WISE program have found that many women were sent home with their doctors’ blessings and a clean bill of health only to suffer serious heart attacks or other heart symptoms later on. This is because in women, the signs of serious heart disease can be much harder to see and to interpret.

In a recent interview on NPR’s All Things Considered, Dr. C. Noel Bairey Merz, medical director of the Women's Health Program and Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center and a lead researcher on the WISE program explained some of the key differences between signs of women’s and men’s heart disease.

In women, the fatty deposits, or plaque, responsible for heart attacks do not often show up on angiograms, while in men, they show up fairly predictably as large, unmistakable blockages. When doctors who are trained to read angiograms by looking for these blockages find nothing that fits the description, they may send women home, even if they have reported symptoms consistent with heart distress or a heart attack.

But according to Dr. Merz and her co-researchers, women deposit plaque more diffusely than men, so the signs of fatty deposits may be a lot more subtle, showing up as small irregularities or scallops on traditional angiogram tests. Additionally, women’s arteries often react to plaque damage by a process called “negative remodeling,” where arteries continue to shrink in response to plaque buildup.

Differences in how women build up plaque cause different symptoms. This likely contributes to women’s tendency towards heart attacks and symptoms caused by plaque erosion, as compared to the plaque explosion that causes many heart attacks in men.

In her All Things Considered interview, Dr. Merz noted, “two thirds of men will have what we call a standard Hollywood heart attack, clutching of the chest, chest pain, shortness of breath, perhaps even collapsing and becoming sweaty.” On the other hand, she added, “only one third of women will present with these symptoms; two thirds of women will have atypical symptoms, such as severe fatigue, isolated shortness of breath, or even stomach upset.”

It is also common for women to come to doctors with multiple complaints, such as both heart symptoms and psychosocial symptoms like depression and anxiety, which may contribute to cases of misdiagnosis, with women being sent home to get anti-anxiety prescriptions filled rather than receiving crucial cardiac care that could prolong or even save their lives.

The good news is that, with proper training that incorporates these gender differences in the interpretive process of reading angiograms, doctors can see and respond to these smaller abnormalities. They can also learn to attribute more significance to cofactors of arterial or heart disease (such as injury to heart muscle and symptoms of cardiac distress such as abnormal stress tests) in the absence of traditional large blockages.

Now that the findings have been verified and made public, there is a great deal that women and concerned healthcare providers can do to prevent chronic misdiagnosis of women’s heart disease. In particular, the WISE program advises women to seek out care at a center that can evaluate them for small vessel disease, the kind of vascular disease that most frequently seems to precipitate serious heart problems in women. If women are found to have evidence of plaque buildup, they can be treated with any of a number of successful modalities for preventing and reversing damage, including aspirin, beta-blockers, and inhibitors.

The WISE program’s findings have been reported in the American Heart Journal, the Journal of the American Medical Association, Women’s Health, and the International Journal of Obesity, among others.

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