I was a woman on a mission while covering the proceedings of the 64th Annual Canadian Cardiovascular Congress in Vancouver. Specifically, my mission was to track down researchers working in the area of women’s heart disease. They were, sadly, few and far between, my heart sisters, as I had to explain here earlier.
“Out of over 700 scientific papers presented at this conference, I could count on one hand the number that focused on women’s heart health.”
Luckily, I did track down Dr. Karin Humphries from the Centre for Health Evaluation and Outcome Sciences at St. Paul’s Hospital in Vancouver, and her University of British Columbia doctoral student Mona Izadnegahdar. Their paper found, not surprisingly, that women under age 55 fare worse than their male counterparts after a heart attack.(1)
While chatting with me about their findings, Dr. Humphries and Mona happened to mention the “popular misconception that women and men present with different heart attack symptoms”.
In fact, the duo openly laughed off what they call “The Oprah Effect”, which apparently started a few years ago when a guest on Oprah Winfrey’s television show told millions of viewers that female heart attack symptoms may indeed be different than those experienced by men.
But Oprah was wrong, insisted my two interviewees, and they say that her wrong-headedness has served only to “confuse” women about actual heart attack warning signs. Here’s how they explained it:
“The Oprah Effect has done a huge disservice. Women have the same symptoms as men, and chest pain is still the predominant symptom.
“The difference is that women can also have other symptoms which we attribute to the fact that women may have better body awareness and are better communicators, while men are more truncated in their descriptions of where they feel pain.”
Now, despite this duo’s claims, here is the truth: chest pain is indeed the most commonly reported heart attack symptom for both men and women. Most of us experiencing a heart attack do report some degree of chest symptoms – described in many women not as “pain”, but frequently as heaviness, discomfort, fullness, squeezing or pressure.
But many studies have also reported an absence of any chest symptoms in women’s heart attacks ranging from 10%(2) to over 40%(3). What this means is that for up to 40% of us in mid-heart attack, there is absolutely no pain or any other symptom in the chest area at all.
Full disclosure: During my own heart attack three years ago, I had lots of time (after being misdiagnosed with indigestion and sent home from the E.R. despite presenting with central chest pain, nausea, sweating and pain radiating down my left arm) to experience plenty of increasingly debilitating textbook chest pain symptoms before finally returning to hospital, this time to a newly revised – and correct – diagnosis of myocardial infarction.
Since then, I have spoken to thousands of women about our biggest health threat as part of my community education commitment with Mayo Clinic after graduating from their WomenHeart Science & Leadership Symposium For Women With Heart Disease.
And what I can now tell you without a moment’s hesitation is that I have yet to meet any woman, anywhere, at any time who is not already very well aware that chest pain = heart attack.
There seems indeed to be little if any “confusion” among women that chest pain is their predominant heart attack symptom. Far from it, in fact.
What I have found instead is abject surprise when my audiences learn that so many of us can actually be experiencing heart attack when our only symptoms are vomiting and upper back discomfort.
Or crushing fatigue and a ‘pins and needles’ sensation in the jaw.
Or elbow pain and clammy sweats.
All of these scenarios represent real-life symptoms from just three real-life female survivors. (See also: “How Does It Really Feel To Have a Heart Attack? Women Survivors Tell Their Stories”)
That’s why I despair when I hear of these potentially misleading pronouncements from experts, who are then widely quoted in the media.
It’s hard enough to convince women with ‘Hollywood Heart Attack’ chest pain symptoms to seek immediate medical help.* But it’s even harder to get women with vague, atypical symptoms to seek that same help during a cardiac event. (For more on women’s documented treatment-seeking delay behaviour in mid-heart attack, read about this Oregon research).
Dr. H and Mona’s concern about this “confusion” that women apparently feel because of “The Oprah Effect” was enhanced by a study known as AMI55, and their subsequent conference presentation based on it called “Are Young Women’s Acute Myocardial Infarction Symptoms Really Different Than Men’s?” (3)
Their answer to this question was a resounding “NO!” But this answer appears to be based on an enrollment of just 40 women in the study.
Interestingly, the study also suggested that:
“Women were more likely to feel neck/throat pain, as well as left arm/shoulder pain. The number of symptoms experienced were also greater in women compared to their male counterparts.”
One is tempted to ask, then: Why is this study’s headline and presentation title not sounding a loud and public warning to women to be alert for unusual neck/throat or arm/shoulder pain as potential heart attack warning signals in women?
Other researchers might also query their conclusions. Mayo Clinic cardiologists, for example, remind us:
“Women are more likely than men to have heart attack symptoms unrelated to chest pain. These symptoms may be more subtle than the obvious crushing chest pain often associated with heart attacks. This may be because women tend to have blockages not only in their main arteries, but also in the smaller arteries that supply blood to the heart — a condition called small vessel heart disease or microvascular disease.
“Many women tend to show up in emergency rooms after much heart damage has already occurred because their symptoms are not those typically associated with a heart attack.”
And according to cardiologists at the Texas Heart Institute:
“Women tend to feel a burning sensation in their upper abdomen and may experience lightheadedness, an upset stomach, and sweating. Because they may not feel the typical pain in the left half of their chest, many women may ignore symptoms that indicate they are having a heart attack.”
The University of Ottawa Heart Institute agrees, adding:
“For some women, chest pain may not be the first sign of heart trouble. These women report less common symptoms, such as unusual tiredness, trouble sleeping, indigestion, and anxiety up to a month before the heart attack. Women with diabetes often have more atypical symptoms.”
National Institutes of Health research called “Women’s Early Warning Symptoms of Acute Myocardial Infarction” reported these prodromal signals observed in over 500 female heart attack survivors studied:
“The symptoms most commonly reported were unusual fatigue (70.6%), sleep disturbance (47.8%), and shortness of breath (42.1%).”
The Cleveland Clinic (widely considered the top heart institute in North America) concludes:
“Women often have different symptoms of a heart attack than men and may report serious symptoms before having a heart attack, although the signs are not ‘typical’ heart attack symptoms. These include:
- neck, throat, shoulder, upper back, or abdominal discomfort
- shortness of breath
- nausea or vomiting
- anxiety or “a sense of impending doom”
- lightheadedness or dizziness
- unusual fatigue for several days
And the U.S. Department of Health and Human Services Office on Women’s Health reminds us that women can experience “pain or discomfort in one or both arms” during a heart attack, and not just the left arm pain that’s commonly described in men. According to their 2011 women’s heart attack awareness campaign called Don’t Miss a Beat: Call 911:
“Women are twice as likely as men to experience unexplained nausea, vomiting, or indigestion during their heart attack. These feelings are often written off as having a less serious cause.
“Sudden and unusual tiredness or lack of energy is one of the most common symptoms of heart attack in women, and one of the easiest to ignore. It can come on suddenly or be present for days. More than half of women having a heart attack experience muscle tiredness or weakness that is not related to exercise. Pain in the back, neck, or jaw is also a more common heart attack symptom for women than it is for men.“
“The Oprah Effect” seems also to have been earlier embraced by another Vancouver researcher named Martha MacKay, who in 2009 was a Canadian Institutes of Health Research clinical research fellow and doctoral student at the University of British Columbia School of Nursing.
I wrote about her study back then too, in which she looked at male and female heart patients undergoing elective (meaning: not emergency) balloon angioplasty, an invasive cardiac procedure in which a small balloon is inflated inside a blocked coronary artery to help open up that artery. When patients in this study were asked to describe symptoms felt during the moment when that balloon inflated (thus ostensibly mimicking a heart attack), both male and female subjects reported the same thing: chest pain.
Her presentation at the Canadian Cardiovascular Congress inspired media headlines blaring: “The Heart Attack Myth!” as she concluded:
“Both the media and some patient educational materials frequently suggest that women experience symptoms of a heart attack very differently from men.
“These findings suggest that this is simply not the case.”
Subsequent sensational headlines created a firestorm of concern among heart attack survivors and those of us who are trying to educate women about cardiac symptoms – ALL heart attack symptoms.
One women’s health advocate, in fact, expressed to me her dismay at those headlines in this fashion:
“This ‘research’ has set back women’s awareness of heart attack symptoms by a full decade!”
Increasingly alarmed by the media pickup that the unfortunate “Heart Attack Myth” headlines seemed to be garnering day by day, I contacted cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic in Rochester, Minnesota.
Here’s how Dr. Hayes responded to my questions about Martha’s study conclusions:
“This study demonstrates that men and women experience similar symptoms when they have ischemia due to an acutely occluded coronary artery (which is what happens during a heart attack in many but not all people).
“What it does not translate to is that there are no sex differences in heart attack symptoms. Not every heart attack occurs as a result of sudden, complete blockage such as this.”
Perhaps a more accurate headline to describe this particular 2009 study, therefore, should have been instead:
“Men and Women Experience Similar Momentary Chest Pain Symptoms During Elective Angioplasty Procedures”
January 31, 2016: The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be undertreated“, and including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”
Q: Are women being confused by “The Oprah Effect”?
- ‘Women’s Heart Attack Myth’: Revisiting the controversial Canadian study
- Mayo Clinic: “What are the symptoms of a heart attack for women?”
- Am I having a heart attack?
- Time equals muscle during women’s heart attack
- Women fatally unaware of heart attack symptoms
- Is it heartburn or heart attack?
- What is causing my chest pain?
- Is it a heart attack – or a panic attack?
- All about Eve: the differences in pathophysiology of heart disease between men and women
- Battle of the Sexes: disparities in treatment and diagnosis of cardiovascular disease in men and women
(1) M. Izadnegahdar, J. Singer, M. Gao, J. Kopec, KH Humphries. “Sex Differences in One Month Health Status of Young Adults Post Acute Myocardial Infarction: Preliminary results from AMI55 study”, Canadian Journal of Cardiology, Volume 27, Issue 5, Supplement, p. S152, September 2011.
(2) Canto JG, Rogers WJ, Goldberg RJ, et al. Association of Age and Sex With Myocardial Infarction Symptom Presentation and In-Hospital Mortality. JAMA. 2012;307(8):813-822.
(3) 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.
(4) M. Izadnegahdar, J. Singer, M. Gao, C.R. Thompson, J. Kopec, K.H. Humphries. “Are Young Women’s Acute Myocardial Infarction (AMI) Symptoms Really Different Than Men’s? Preliminary Results From AMI55 Study”. Canadian Journal of Cardiology, Volume 27, Issue 5, Supplement, Pages S151-S152, September 2011.