by Carolyn Thomas ♥ @HeartSisters
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.”
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 – but described by many women NOT as “pain”, but frequently as heaviness, discomfort, ache, burning, fullness, squeezing or pressure.
In fact, many studies have also reported an absence of any chest symptoms in women’s heart attacks ranging from 10%(2) to over 40%(3) depending on which study you’re reading. What this means is that for at least 10% of us in mid-heart attack, there is absolutely no pain or any other symptom in the chest area at all.
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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 severe 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.
There seems indeed to be little if any “confusion” among women that chest pain is a heart attack symptom.
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 compared to our male counterparts, 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.”
So my question is: 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 – sometimes weeks or even months before diagnosis:
“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
- sweating
- 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 that particular 2009 study, therefore, should have been instead:
“Men and Women Experience Similar Momentary Chest Pain Symptoms During Elective Angioplasty Procedures”
♥
IMPORTANT UPDATE:
January 31, 2016: The American Heart Association released its first ever scientific statement on women’s heart attacks in its 92-year history, 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.”
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NOTE FROM CAROLYN: I wrote much more about cardiac symptoms in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
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Q: Are women being confused by “The Oprah Effect”?
See also:
‘Women’s Heart Attack Myth’: Revisiting the controversial Canadian study
Mayo Clinic: “What are the symptoms of a heart attack for women?”
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?
A Typical Heart: a 22-minute documentary about “the deadly disparity in diagnosis, treatment and outcomes among male and female heart patients.’
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Heart Sisters 
Articles keep saying pain in the upper back but don’t specify exactly where. Is it found in the middle of the back or more toward one side or the other?
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Hi Susan – I’ve never seen a definitive answer to your question. Women report back symptoms during a heart attack in every imaginable location, and ranging from mild to severe. A number of my blog readers have described symptoms “between shoulder blades” – but that’s not the only place reported. A better question would be: is this symptom, no matter what or where it is, unusual for me? For example, if you’ve experienced upper back pain in the past every time you play tennis, and today you have upper back pain following yesterday’s tennis game, that’s not “unusual”.
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I was 38 in 1983. I woke one morning with heavy beating in my throat that just would not stop. I went to the doctor and also told him how my heart would beat fast at night when I went to bed. He sent me for tests, never called me back, I had to call him. He said “You have a few palpitations, learn to live with it and don’t come back to see me with this problem.”
Later at night I would have to lay over my pillow to breath and would sit up sleeping. I had a feeling of impending doom. Told my husband what I wanted the kids to have. I had terrible back, shoulder, jaw and ear pain. I often broke out in a cold sweat. I was so exhausted. When I took a nap, I felt like I had gone somewhere else, I was so deep into the sleep. Eating beef was hard, I had trouble trying to swallow it. One day when I went out in the cold my jaw pain was so bad I thought I was going to pass out. I walked into another doctor’s office having a heart attack. Still they didn’t believe it but did put me in the hospital. They soon found out it was a heart attack, few days later I had another one. I was in the hospital for a month. In 2010 I had to have two stents put in.
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What an ordeal you went through, Sharon! Sounds like classic chest pain was not among your cardiac symptoms. And at your young age (38), docs were likely refusing to seriously consider a heart-related cause back then.
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This makes me mad. Ugh. It’s as if researchers and other medical folks are making a conscious and concerted effort to dismiss–the absolute known fact– that heart attack symptoms in women can often present differently than from those in men.
There may or may not be chest pain–though often there is. Despite this sometimes sameness, there are still the very real differences! The differences didn’t go away! It must be some deeply ingrained cultural thing.
I have not had a heart attack; my heart disease is of a genetic, non-ischemic origin. I have a strong family history of sudden death at a young age and when I started presenting with complete heart block at the age of 35, I was told that I had no risk of sudden death, despite the fact that both my brother and my Dad died of SCA–as well as my Dad’s father. My brother was 40 and my Dad was 52 and his Dad was 28 (my Dad had AV block, as well, and a pacemaker). I gave detailed family history on a silver platter; I provided autopsy reports. I disagreed about my “no sudden death risk” status, but I was not listened to. Ever. Second and third opinions even were all dittoed, “You are not at risk for sudden death.”
I was vocal and not at all popular. I never believed them. Luckily, when I did have my cardiac event (with a pacemaker which showed V. Tach and V. Fib on interrogation), I came out of it on my own. I was unconscious for several minutes in the passenger seat of our family car while my husband was driving. If I had been a man, they would have placed a defibrillator with pacemaker functions, at the time that I first presented with heart block and the strong family history.
This is such a tremendously excellent website Carolyn. I am sorry I did not find it sooner. Thank you!
Mary
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Thanks for your perspective, Mary. Even with classic symptoms (like mine during my heart attack, which included central chest pain and other textbook MI symptoms), women are more likely to be misdiagnosed and sent home during a cardiac event – so really, women with strange atypical symptoms but “normal” diagnostics are often in for a battle to “prove” they deserve further investigation at all.
I don’t know how many more studies or official scientific statements or treatment guidelines we need before this “Oprah effect” myth dies a peaceful death at last.
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This truly angers me. Sounds like physician ignorance is a significant contributor to both unnecessary deaths and increased heart damage to many women. Shame on them.
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Not just physicians, Mary. Researchers Karin Humphries and Martha Mackay are nurses, not physicians. And a University of Pennsylvania study found that ambulance paramedics were equally dismissive of women’s heart attack symptoms while transporting them to hospital. For example, of the women transported to hospital by ambulance who were subsequently diagnosed with heart attack, not one had even been given aspirin by the paramedics en route, as recommended treatment guidelines dictate.
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Change that to caregivers, etc. ☺
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When having my recent heart attack, I had no chest symptoms whatsoever.
What I did have though was intense pain in my throat, jaw and neck both sides, and my right shoulder tip. Pressure I felt was across the top of my chest directly under my throat. I couldn’t breathe, but as for chest pain, it was totally absent.
I fear going through the experience again though some experts keep reminding me my risk is very high. I know that but I don’t need people telling me my life is very much shortened.
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Hello Lesley – thanks for your story that reminds us yet again what we already know: many women do indeed experience heart attack with “no chest symptoms whatsoever”. Your anxiety over another impending cardiac event is perfectly normal at this stage; reader Lorraine Gladwell wrote this poem about her own fear of the next attack that you might identify with.
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I was happy to read this article about the “Oprah Myth” and heart attack symptoms. I had intense chest pressure and loss of feeling in both arms. Classic symptoms, but I still didn’t believe this could be happening to me. Women do have the same symptoms as men.
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Hi Marleen,
No matter what our cardiac symptoms (textbook or not!) it can be hard to believe it’s really happening, right?
But please re-read the post: the whole point of this article (as confirmed by the opinions of the cardiac care experts quoted above) is that many women DO NOT in fact have the same symptoms as men; we know that up to 40% report NO chest pain at all during a heart attack, and that’s a critically important message that all women need to know about.
Thanks for your comment here.
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I am a retired R.N., now 67 with CAD, hx of an MI ten years ago. I then had about 3 years of unstable angina with additional stents added, now totalling six. I don’t have frequent attacks, only 3 in last six mths. I don’t know if it is G.I or heart because my pain has not been described on symptoms. L. sided chest pain, radiating up midline to right jaw, right ear. This pain is at least an 8 out of 10. my respirations increase and I do feel a sense of strong suspicion of heart. Have some minor R arm pain. the episode lasts from 6 to 20 min. I first take 3 Tbsp maalox, then within 5 min if pain persists I take a nitro. It lessens to a lvl 5-6 but does not go away for another 12-18 min. I am on nitrates daily.
I feel foolish that with my hx, I still don’t know how to handle these episodes of unknown etiology. I wish to add that I have had no food before this began and I was not exerting. i have googled the jaw/ear pain that is so excruciating without finding answers. Can you help? Should I assume heart and take nitro q 3 min til it stops?
signed,
“foolish Lynn”
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Hello Lynn (and by the way, I don’t agree at all that you are being ‘foolish’ – but I can sure understand how you might feel like that!) I am wondering what your cardiologist is recommending? And I’m sure you’ve had a G.I. workup at some point. Could it be time to ask your doc for follow-up tests? I’m guessing you are soldiering through these episodes on your own, without seeking medical help. Have you gone to the E.R. during one of these attacks?
It does sound like your current regime (nitrates) is keeping your symptoms generally under control (three episodes in the past six months). But of course, we’d like to see zero episodes, right?
SOMETHING is causing these symptoms (and 8 out of 10 pain unrelated to exertion is NOT normal, as you know) yet especially for many women, we tend to minimize or even ‘normalize’ these events. Right now, you have no idea if this is heart-related or not. Whatever is causing these episodes needs to be identified. So much of medicine is just trying to figure out what the problem is NOT, eliminating one possibility after another in the absence of confirmed results. Pls don’t be a hero by trying to dismiss these episodes or feel like you just have to endure them.
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In many American Emergency Departments, the first triage hurdle is the high school-educated person behind the desk whose only function seems to be to ascertain one’s insurance status. I went in with a pulse of 220-230 due to what was later identified as Atrial Flutter. I thought it was a heart attack, not knowing anything else to call it.
The young woman asked me if I had chest pain, and I truthfully replied no. What I had was a thundering, racing heart and syncope. With no chest pain, I was banished to the waiting room for 90 minutes. Next time I will go directly to the fire station and let them bring me in with an ambulance. Getting past that first desk is a hurdle for many women in the overcrowded Emergency rooms here.
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Hi Allison,
Your scenario is, alas, the same story for far too many women who have to get past the E.R. gatekeepers in order to reach the lifesavers in Cardiology. “Any atrial arrhythmia (such as atrial flutter) can cause a tachycardia-induced cardiomyopathy. Intervening to control the ventricular response rate or to return the patient to sinus rhythm is important. Thrombus (blockage) in the left atrium has been described in approximately 25% of all patients with atrial flutter.” That’s according to findings of University of Calgary researchers, reported in the American Journal of Medicine in 2005. Guess your E.R. receptionist must have skipped that issue…
To me, that also means the front desk person in EVERY hospital Emergency Department MUST be an experienced health care professional who knows how to do appropriate triage. But according to another study reported in the Canadian Medical Association Journal: “Triage receptionists are often not medically trained, but rely on established criteria and experience.”
Not good enough.
Thx for your comment here.
C.
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I had 4 acute episodes of vomiting that were diagnosed as hiatus hernia yet ischemic signalling & treadmill test ignored. Consequently I was never referred to the cardiology dept & was told Health Authority rationing?
When I had cardiac arrest, they were same symptoms including my arm which felt it was falling off. Still to this day, this has never been addressed.
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Good grief. Once again, had you been a male patient presenting with ischemia and positive test results, there would have been no mention of “Health Authority rationing”.
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A year before my MI there were strange things happening to me and as I reported these events to my doctor he treated me for everything from indigestion to neurological problems and never considered my heart. He was a third generation physician of our family and since neither my mother nor my grandmother had heart problems, he surmised that I did not either.
September, 2003 I was helping a neighbor move a couch. Suddenly my left arm went numb and I sat down. She insisted I was having a heart attack and wanted to call an ambulance. She brought me an aspirin, insisting I take it. I would not let her call an ambulance. I went back to my doctor and reported this incident and again he dismissed heart problems.
November 5, 2003 I had my annual physical which included an EKG. My doctor saw a small blip in the EKG, my cholesterol was 242 and my BP was 162/94 but he pronounced me very fit and gave me a 1500 calorie diet to start following. The next day, 11-6-03, during a nice lunch with my elderly mother in her retirement home, I suffered a massive heart attack and thankfully had a registered nurse at my side in a flash plus paramedics in under five minutes and only by the grace of God and these skilled medical professionals, did I survive.
It might not be that women’s symptoms are so different, it might just be that some doctors don’t look at women as having heart attacks because they specialize in treating men.
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And that too! Had your physician been looking at test results like yours with a male patient, my hunch is that immediate action would have been taken on further diagnostics. Thanks, Grannie….
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Carolyn ~
Thanks for your informative, factual article, and providing extreme back up support from our favorite top doc — Dr. Hayes from Mayo.
I have had six heart attacks all caused by Spontaneous Coronary Artery Spasm, so I definitely appreciate the quote from the cardiologist above: “You can be just as dead from a coronary vasospasm that blocks blood flow to heart muscle as efficiently as a fully occluded artery does!”
BTW, when someone asks me what my heart attack symptoms were, I say “there were similarities and differences for all six, so basically, ”all of the above.'”
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Hello MISurvivorX6 – and speaking of “similarities and differences”, you raise such a good point: symptoms of a second (or third, or sixth!) heart attack may be very different even in the same person; sometimes women dismiss warning signs of a subsequent cardiac event if the symptoms don’t feel the same as the first one did.
Cheers,
C.
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Carolyn,
So my first major episode of coronary spasm (no MI) was massive chest pain, radiating pain on left side of jaw, incredible shortness of breath, clammy sweats, and migraine.
My first MI (and hopefully my last) came on with slightly less severe chest pain and incredible shortness of breath but none of the other symptoms.
Both events scared the bejeezus out of me as I have the subsequent spasms with no MI . Hmmm, I wonder what kind of category these researchers would put me. Chick MI or non-chick MI
JG
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Thanks JG for reminding us that coronary spasm (such as Prinzmetal’s variant angina) can cause the same debilitating and horrific symptoms that a blocked artery can.
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Terrific article Carolyn! Quite terrifying to see that despite all those top rated medical institutions publicly stating there are more extensive symptoms to female heart attacks that DOCTORS treating women in clinical settings are still NOT choosing to follow new treatment ‘guidelines’. It truly is going to take a Congressional Act. Thanks for yet another beautifully referenced piece.
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Hey Jaynie – lovely to hear from you again. You’re so right – it is terrifying, isn’t it?
Cheers,
C.
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“Oh bother”, in the words of Winnie the Pooh.
All my cardiologists practise out of St Paul’s hospital. Haha.
I have not had a heart attack, but I am being treated for endothelial dysfunction (small vessel disease) and this kind of press will only make it more difficult for women like myself to be taken seriously when we present in emerg rooms with chest pain, but also shortness of breath, jaw and neck pain, nausea, etc. especially in the absence of typical markers on tests like ECGs and CT scans or echos.
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Hello Lauren,
You may be interested in a recent flurry of reader comments over at “How Women Can Have Heart Attacks Without Having Any Blocked Arteries” which includes a discussion about small vessel disease and specifically, the diagnostic technology that’s considered the ‘gold standard’ for accurately identifying it: coronary reactivity testing. Not sure if St. Paul’s is using this technology – if they do, you are likely in good hands there.
Cheers,
C.
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Carolyn, thanks, as always, for being out in front regarding women’s heart issues, and disparities in research, diagnosis and care.
In case any researchers are reading here, my own heart attack featured not only chest pain, but left arm pain, neck and jaw pain, nausea and cold sweats.
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Good reminder, Laura, that women tend to have more cardiac symptoms than are reported by our male counterparts.
Cheers,
C.
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Thank you ONCE AGAIN for staying on top of this for all of us women! This is such a wonderful site with so much great information.
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Thanks for your comment, Cheryl!
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My experience with heart disease was my shortness of breath sometimes accompanied by tingling down both arms. I thought it was problems with my lungs.
In less than a week from visiting my primary physician, I was in the hospital waiting for open heart surgery. At the age of 47, I had a CABGx4 (quadruple bypass). The gifted surgeon that did my surgery, Dr. Robert Clough, told my husband after my surgery that I would have had a heart attack within 6 months had I not had the surgery and there would have been nothing that could have been done for me. I would have lost my life.
Keep spreading the word of the symptoms women have. There are seven, know them all. It may save your life or the life of someone you love.
Denise Sullivan
Old Town, Maine
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Thanks for sharing this, Denise – “shortness of breath and tingling down both arms” = example of serious cardiac symptoms women can experience.
Cheers,
C.
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