Heart attack misdiagnosis in women

28 May

woman sad drawing

by Carolyn Thomas  @HeartSisters

A woman attending one of my heart health presentations told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between the (male) doctor and the (male) patient in the bed next door beyond the curtain:

“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.

A male patient is thus kept in hospital for observation in spite of ‘normal’ cardiac test results. But I and countless other females in mid-heart attack are being sent home from Emergency following ‘normal’ test results like his, and with misdiagnoses ranging from indigestion to anxiety attacks to menopause.  Why is this?      

Women (especially younger women) with heart disease are more likely than men to be misdiagnosed.  Research on cardiac misdiagnoses reported in the New England Journal of Medicine* looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with chest pain or other heart attack symptoms. Investigators found that one in every 50 people who had suffered a heart attack was misdiagnosed and sent home from hospital. But women younger than 55 were seven times more likely to be misdiagnosed than men of the same age. The consequences of this were enormous: being sent away from the hospital doubled the chances of dying.

Dr. Jerome Groopman‘s book, How Doctors Think, helps to explain why these misdiagnoses happen in the first place:

“Specialists in particular, are known to demonstrate unwarranted clinical certainty. They have trained for so long that they begin too easily to rely on their vast knowledge and overlook the variability in human biology.”

This so-called “disregard for uncertainty” was what I faced with that Emergency Department physician in 2008 who sent me home from hospital with a misdiagnosis of GERD (gastroesophageal reflux disease), despite the fact that I’d just presented with textbook heart attack symptoms like chest pain, nausea, sweating, and pain radiating down my left arm. His emphatic but unwarranted clinical certainty:

“You’re in the right demographic to be having acid reflux!”

The medical error of misdiagnosis can include:

  • a complete failure to diagnose (totally missing the disease)
  • wrong diagnosis (for example, diagnosing indigestion instead of a heart attack)
  • partial misdiagnosis (diagnosing the wrong subtype of heart disease or the wrong cause of the disease or its complications)
  • delayed diagnosis (when a doctor does not recognize a disease until long after it should have been identified)

There is also still, amazingly, a persistent myth that heart disease is a man’s disease.  Even the name of the type of heart attack I survived (the so-called “widowmaker”) tells you that semantics reflect the medical profession’s assumption that this kind of myocardial infarction hits men, not women. It’s not, after all, called the “widowermaker”, is it?

Doctors may actually be reluctant to consider heart disease when a woman has cardiac symptoms, and instead will look for other causes. A 2005 American Heart Association study showed, in fact, that only 8% of family physicians and 17% of cardiologists were aware that heart disease kills more women than men each year.

And women themselves are less likely than men to realize how vulnerable they are to heart disease.  A number of studies report that women are more likely to delay seeking treatment even when they experience serious cardiac symptoms. A 2009 survey, for example, suggests that only half of women indicated they would call 911 if they thought they were having a heart attack (and that’s down from 80% just five years ago!) and few were even aware of women’s  most common heart attack symptoms.  And those symptoms can be more vague and atypical compared to men’s ‘Hollywood Heart Attack‘ symptoms.  See also: What Does a Girl Have To Do To Get Her Heart Attack Noticed?

Even first-responders like ambulance paramedics are less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to their male counterparts, according to a study at the University of Pennsylvania.

Researchers found significant differences in both aspirin and nitroglycerin therapy offered to women vs. men. In fact, this study showed that of the women transported to hospital by ambulance who were suffering from heart attacks, not one was given aspirin by paramedics en route.  See also: How  Can We Get Heart Patients Past the E.R. Gatekeepers?

Once women do arrive at hospital, both nurses and physicians working in Emergency Departments report a bias towardslooking for heart attack pain symptoms, even though a majority acknowledge that women often present with vague, non-pain symptoms during a cardiac event. About 40%, for example, do not have any chest symptoms at all.

Why don’t diagnostic tests pick these up?  Women are less likely than men to receive some cardiac diagnostic tests in the first place, and some tests don’t work as well in women.   Most tests for diagnosing heart disease have been fine-tuned in studies focused on men. The treadmill stress test, for example, has been found to be far less accurate in women than in men, and particularly for identifying single vessel or non-obstructive heart disease – which are both more common in women.

The ‘gold standard’ test for diagnosing coronary artery disease in both men and women is the angiogram, but studies also show that women are less likely than men to be referred for angiography. And some types of non-obstructive heart disease like Prinzmetal’s Angina do not show up during angiography unless the coronary artery spasm happens to actually occur during the procedure.

How to help yourself get an accurate diagnosis:

  • Know your symptoms
  • Know your facts
  • Be specific
  • Be objective
  • Get results

What to do if you think you’ve been misdiagnosed:

  • Do not feel embarrassed to speak up
  • Get more tests/ask for repeat tests
  • Get a second opinion
  • Keep going back until you are diagnosed accurately!

Dr. Jerome Groopman further recommends that you ask these questions of your doctor:

  • “What else could it be?”  The cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
  • “Is there anything that doesn’t fit?”  This follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
  • “Is it possible I have more than one problem?”  Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, to order more tests that might not have seemed necessary based on initial impressions.

© 2009 Carolyn Thomas  www.myheartsisters.org  

* Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.

Please note:  information on this site is not meant as a substitute for medical advice

See also:


17 Responses to “Heart attack misdiagnosis in women”

  1. Stephan Perea March 14, 2013 at 12:49 am #

    You might get indigestion from eating too much or too fast, eating high-fat foods, or eating when you’re stressed. Smoking, drinking too much alcohol, using some medicines, being tired, and having ongoing stress can also cause indigestion or make it worse. Sometimes the cause is a problem with the digestive tract, like an ulcer or GERD.

    Like

  2. Concerned May 13, 2012 at 1:06 pm #

    Thank you for this website, it has made me aware of the problems that can be faced by women who complain of symptoms that could be related to a heart attack.

    My own experience was on Weds/Thurs AM early hours. I had taken two Nurofen Express capsules (Ibuprofen) at about 1am for cold symptoms and an hour and a half later woke up with a strange feeling of being drugged, pupils dilated with tingling sensation and numbness of the lips (now I recognise it). I checked that I had not overdosed, first two of second strip, so not likely, and decided to ring 999 (*911 in North America).

    I was told that it didn’t sound serious, so NHS Direct would call me, by then I was experiencing some aching in the upper mid back and tingling down the right arm into the fingers which made the concerned lady on the other end of the phone send out an ambulance. The paramedics checked all vital signs which were normal and asked me if I really wanted to go to A&E and I thought perhaps I should. When I got there, because my signs were good I was sent through to Triage (looked upon as not serious enough for Emergency Medicine) where a GP saw me and said that because my heart sounded good and although I had not had any ECG tests sent me home saying that I had muscular symptoms which caused my aching symptoms and to stop using my computer for a couple of days.

    I therefore had to walk the length of the hospital to get some money to order a taxi home at such an early hour. I did as I was told, rested, had some buzzing in my ears which I put down to a slightly raised BP when paramedics had arrived, and have been exhausted ever since following exertion. Reading all of this I am now on the alert! It has been suggested to me to rule out muscular symptoms and to take it easy. Now I am not so sure ….

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    • Carolyn Thomas May 13, 2012 at 3:23 pm #

      Dear Concerned – your symptoms may or may not be heart-related, but right now you just don’t know for sure. You absolutely did the right thing by seeking help when you did – do not hesitate to call for help again if symptoms persist or get worse.

      Like

      • Concerned May 22, 2012 at 3:29 am #

        Thanks for your comments! I work from home quite a bit but I am finding that on exertion I am still very tired and at the moment I am working in my bed which I have done quite a lot lately, and then off to a client this afternoon. It could be muscular as my Adam’s apple seems to be recognisable when I swallow but I am keeping an eye on this tiredness. My husband feels that this is stress and reminds me to switch off and relax as he is obviously concerned.

        I had an email from a client who told me that he had been IN HOSPITAL with a “suspected heart attack” although I have to say I don’t know all the details yet, but as you say it does show the difference in the way women are treated as opposed to men in these situations.

        Like

  3. Margaret April 17, 2012 at 2:50 am #

    I am at this moment sitting with pain in my left arm from shoulder to elbow – if I go to use the arm the pain intensifies. I have been having stabbing pains in my chest but they come and go they don’t last very long. I feel like I have eaten too much. I have been to the doctor’s but I feel they are not listening to me.

    Like

  4. Ch411 April 12, 2012 at 8:14 pm #

    Even the name of the heart attack you and I both survived ‘the widowmaker’ tells us that doctors still believe this to be a MAN’S HEART ATTACK. When will E.R. doctors get the message and stop telling women heart pts that they have -pick one- anxiety depression gall bladder fatigue menopause?

    Like

    • Carolyn Thomas April 15, 2012 at 8:18 am #

      I think the story that begins this post (male patient with “normal” cardiac test results being kept overnight for observation while women are being misdiagnosed and sent home) is the most telling illustration of how pervasive this issue is. Thanks for your comment here.

      Like

  5. Mary Newman December 10, 2010 at 8:28 am #

    Thanks for the information you have provided.

    I am a 54 year old woman who one month ago had an experience that was like an electrical shock through the upper body and both arms that lasted just a few minutes. After that was gone, I was left very weak and anytime I got up to do anything my heart rate would go up and most times my blood pressure would drop. I had indigestion also. This happened on Saturday and I went to see my family doctor on Monday. He ran an ekg and told me there was signs of a heart attack and sent me to the ER.

    They ran the blood work once, then four hours later and I had a ct scan. Was told it was not heart related, to go home and check with family doctor for stomach issues. My family doctor ordered a holter moniter and a stress test.

    Before I had either test I had another episode where I could not get my breath and my left arm went numb. By the time I reached the ER, I was shaking all over. My heart rate goes up all the time if I do anything, but if I lie down it will go to normal. Again, the ER told me there was nothing, probably anxiety.

    Since then, both my tests have come back with normal results, but I am still getting the rapid heart rate when I do almost everything. If I continue to be active, I will have other symptoms. I have requested an appointment with another doctor because I feel so frustrated.

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  6. sreyanka October 25, 2010 at 9:33 pm #

    I am a 40 year old woman who a month ago had a heart attack.. I had the indigestion feeling that was so painful I had to call a friend and she came and said she was calling 911. The paramedics arrived and i was sitting in my chair freezing to death. I couldnt get enough air into my lungs fast enough. I was taken to the ER and it showed that i had had a mild heart attack. I was admitted to the icu and the next day they did a heart cath and found i was 90% blocked. i was told that i had to have a heart bypass and the next day at 5:30 am i was in surgery.

    Like

  7. Wendy September 14, 2010 at 3:26 pm #

    I am so frustrated.

    Let me start by saying I am a non smoker non drinker no known health problems and rarely have to go to the doctor. (by the way I hate going to the doctor because I feel he really doesn’t listen)

    Yesterday while I was at work I got dizzy my hands and forehead and face went numb and Then within 10 minutes I sounded drunk and was slurring my words unable to get the words out. I went to the ER because I thought I might be having a stroke. The ER did an ekg Chest xray Cat scan Echo cardiograham. The Cat scan had a spot on it they didn’t know what it was so they sent me to for an MRI. and they did blood work. Everything came back normal. The neurologist said he couldn’t see anything on the tests but it could be from a complicated migraine. Even without having a head ache. or it could be MS symptoms but they didn’t see that and there is no family history He doesn’t think it was a stroke because nothing showed on the test and both sides of my face were affected not just one. He did say my B12 level was low–219 so he ordered a b-12 shot. but sent me home saying I should take baby aspirin. and get a shot once a month and follow up with him in two weeks.

    Today just after eating lunch my left arm went numb and was tingling and I have been nauseous all day. I called my doctor who told me to come in and he basically said we have pretty much done every test there is to do he asked me what the neurologist said and then basically repeated it to me saying the b12 or the complicated migraine probably caused my problems and if the numbness persisted they could do a nerve test on my arm but to just watch it and keep track to see if there is a pattern.

    I am really concerned because Heart disease runs very strong in my family My dad had a triple bypass and a stroke his sisters and brother dies of heart failure(2) and an annurism. When I told him this was my concern because I have had chest pains in the past he said yes I can see in your chart you have had some stress. I told him not anything unusual–he had it in my file my problems were from stress I told him only the normal stress of a full time working mom. he said I think you can be confident it isn’t your heart but I am not confident. I feel anxious about it because I think he isn’t really listening to my concerns. I have an appointment with a different doctor Monday are there any tests I should ask about or should I just wait and keep track of my symptoms?

    Like

    • Carolyn Thomas September 14, 2010 at 6:07 pm #

      Hello Wendy,
      No wonder you are frustrated. I’m sorry you’re going through this.

      The standard cardiac diagnostic tests are an EKG and cardiac enzyme blood tests, particularly for troponins which are enzymes released into the bloodstream that are usually not measurable unless you’ve had heart muscle damage during a heart attack. After a cardiac event, troponin levels begin to rise in the blood 4-6 hours after the first symptoms, but can take 24-48 hours to peak. You no doubt already had cardiac enzymes tested yesterday but if your symptoms persist, do not wait for Monday’s appointment: go immediately back to the ER for further tests. And yes, do keep track of every symptom.

      Your symptoms may NOT be due to heart problems, but at this point you don’t know for sure. Something is causing them – what is it? I have met women with atypical heart attack symptoms ranging from a persistent cough to numbness in the lower lip. I have met countless women who in mid-heart attack were sent home from the ER with “normal” cardiac test results and reassured as you were that it was NOT a heart issue. But diagnosis is often complicated because there are many conditions with distressing symptoms that may mimic heart disease. That’s likely why your doctor appears not to be listening to your concerns – he may be stumped by all these “normal” test results. So much of medicine is just trying to eliminate what the problem ISN’T.

      You absolutely did the right thing by going to the ER immediately after yesterday’s symptoms, and again today going to see your doctor. Please keep going back if symptoms persist. You know your body – you know when something is “not right”.

      It’s unfortunately common for women to try to wait it out, see if things get better, keep quiet, not make a fuss. Don’t do that!!

      Best of luck to you,
      C.

      Like

  8. dg June 19, 2010 at 10:00 am #

    Thanks for the above. You’ve made me feel a whole lot better, knowing it’s not just me.

    Here in the UK, I’ve just found out that I’ve got a small heart defect, and minor heart attacks have been wrongly diagnosed for 14 years!

    It seems I started to get them when I developed an underactive thyroid, which raised my blood pressure from normally low to, initially, high. They got it down to normal, but this was high for me and the heart attacks started.

    I was told it was indigestion, gastric reflux, a funny turn – and doctor after doctor (including a hospital consultant) failed to recognise standard signs of a heart attack. It was only recently when I managed to get to the hospital during an attack that they realised what it was, gave me an angiogram and found the problem.

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    • Carolyn Thomas June 20, 2010 at 7:58 am #

      Hello dg – when I was at Mayo Clinic five months after my own heart attack, I met dozens of women who told similar stories of being sent home from the Emergency Department with misdiagnoses ranging from acid reflux to anxiety attacks to gall bladder problems. And of course many docs believe that menopause itself is a nice little all-purpose diagnosis for whatever ails you!

      I think that we need to see two major shifts here: #1 – women need to be far more assertive about demanding quality care when we know that something is seriously wrong, and #2 – medical professionals need far more education on the realities of women’s heart disease.
      Cheers,
      C.

      Like

  9. jb May 28, 2009 at 7:49 pm #

    Thanks for this on heart disease mis-diagnosis. I look forward to each new essay, you clearly have natural ability for writing!

    Like

Trackbacks/Pingbacks

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  2. CreativitytotheMAX - September 25, 2012

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  3. Dr. Joe - August 22, 2011

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