First of all, I think even using the word “pain” to describe a common heart attack symptom may be misleading for many women.
It’s important to remember that some women experience NO chest symptoms at all during a heart attack.(1) And since my own heart attack, I have met countless heart attack survivors who don’t use the word “pain” to describe their chest symptoms. Cardiac researcher Dr. Catherine Kreatsoulas reminds us that words matter when women describe their chest symptoms, and can actually influence how they will be treated in the Emergency Department – or not.
These are just some of the ways we describe the chest ‘pain’ of heart attack:
These symptoms – called angina pectoris – can appear not only in the chest area but anywhere from neck to navel, such as the jaw, throat, or upper abdomen, and can be associated with discomfort in the shoulders, neck, head, left or right (or both) arms.
Cardiologist Dr. Richard Fogoros reminds us that “these symptoms can last from less than a second to days or weeks, can occur frequently or rarely, and can occur sporadically or predictably. With such a broad definition, you can see why the term ‘chest pain’ is in itself of little help to doctors.”
It’s also important to remember that there are some heart attacks that are accompanied by atypical symptoms – although, to quote paramedic/researcher/film maker Cristina d’Allesandro: “Women make up over 50% of our population, so why do we call our symptoms ‘atypical’ during a heart attack?”
When I was at Mayo Clinic after my own heart attack, I met two women there whose only symptoms in mid-heart attack had been a persistent cough and numbness in the lower lip, respectively. For more on the variety of actual heart attack symptoms in women, read How Does It Really Feel To Have A Heart Attack? Women Survivors Answer That Question
Study results on the absence of chest pain in women during heart attack vary widely, from 8-42%. For example, as Florida cardiologist Dr. John Canto explained to me (December 3, 2016):
“Chest discomfort is the hallmark symptom for both women and women during myocardial infarction (MI, or heart attack). But when absent, it is more commonly seen in women than men. On average, in our 2012 national study (1.1 million MI patients, 465,000 of them female), 38% of women with STEMI did not did not have this hallmark symptom on presentation.(2) This is because (older) age is a major contributing factor to MI presentation without chest discomfort and more women who present with MI are older than men, on average by almost a decade. ”
Cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic told me that she now prefers to “focus less on symptom DIFFERENCES (which multiple studies suggest are few and can’t be relied upon for diagnosis) and more on symptom RECOGNITION by both patients and physicians, which continues to contribute to disparities in outcomes.”
Angina can also occur in the absence of any coronary artery disease. Up to 30% of people with angina with a heart valve problem called aortic stenosis, which can cause decreased blood flow to the coronary arteries from the heart, can have angina. People with severe anemia may have angina because their blood doesn’t carry enough oxygen. People with thickened heart muscles need more oxygen and can have angina when they don’t get enough.
When it comes to chest pain, Dr. Fogoros adds that it’s important to keep in mind that chest pain is merely a symptom, not a diagnosis.
And because it can be a symptom of anything from a catastrophic to a trivial medical problem, when a person experiences chest pain it’s important to try to characterize that pain as rapidly as possible as being either completely benign or possibly significant.
Anecdotally, yoga afficianados can also report experiencing chest pain after doing yoga. The poses used in Bikram yoga, for example, can manipulate muscles, including those in the chest region. Overextending them or straining one of them while getting into and out of poses could cause chest pain after a session. Inflammation in the lungs, an embolism, and high blood pressure may be exacerbated by the practice. Injured ribs will likely produce chest pain, particularly after exercise, including yoga. Heartburn often mimics the chest pain associated with a heart attack, and may be aggravated by the changes in posture and position required during Bikram yoga. And if you suffer from asthma, the heat and humidity of hot yoga may make it difficult to breathe. Trying to get enough air in your lungs could make your chest hurt as well.
Dr. Fogoros offers the following list of the more common causes of chest pain*:
- angina due to coronary artery disease
- angina due to coronary artery spasm (Prinzmetal’s Angina)
- angina due to coronary microvascular disease
- heart attack
- heartburn (acid reflux, indigestion)
- benign chest wall pain
- costochondritis, an inflammation of the cartilage that connects a rib to the breastbone
- anxiety or panic disorder
- asthma, bronchitis, pneumonia, pleuritis
- mitral valve prolapse
- recent chest trauma
- peptic ulcer
- aortic dissection
- Thoracic Outlet Syndrome
Let’s look at the condition on this list called benign chest wall pain as an example. In young, healthy people presenting with chest pain, this diagnosis is particularly common according to Dr. Fogoros. He believes that doctors do not understand this condition very well, and consequently neither do their patients.
“Because this condition is completely harmless, the lack of understanding on the part of patients as to what is causing the pain often leads to months or years of needless worry or anxiety.”
*Need a translator? Visit my patient-friendly, jargon-free glossary of hundreds of complex cardiology terms.
(1) S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart 2009;95:1 20–26.
(2) J. Canto et al, “Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality,” JAMA. 2012 Feb 22;307(8):813-22.