The symptomatic tipping point during heart attack

by Carolyn Thomas  @HeartSisters

I’ve been fascinated by studies on why women wait so long to get medical help despite heart attack symptoms ever since the spring of 2008 when I spent way too long before seeking help for my own increasingly debilitating signs.  I sometimes replay that two-week experience in my little peabrain, and I ask myself the same question being asked by a team of Harvard researchers in a new study:

“Why do women wait longer than men before seeking help even when they’re in the middle of a frickety-frackin’ heart attack?”

Dr. Catherine Kreatsoulas is an epidemiologist from Canada and the lead author of this study presented at the Canadian Cardiovascular Congress in Vancouver.(1)  She’s also a Fulbright Scholar and Heart and Stroke Research Fellow at the Harvard School of Public Health. 

What Dr. Kreatsoulas and her research team have reported in this study is that when heart symptoms strike, women are more likely to delay seeking emergency care, even when doing so may put their health at risk.
She warns women what can happen if we do this:

   “The main danger is that when someone comes to the hospital with a more severe or advanced stage of heart disease, there are simply fewer treatment options available.”

This is precisely why cardiologists like to say:

Time is muscle!

The longer we wait after the onset of early heart attack symptoms, the greater our risk of suffering permanent heart muscle damage as that muscle becomes deprived of oxygenated blood flow because of one or more blocked coronary arteries. This is important to women because we delay seeking treatment longer and have worse outcomes from myocardial infarction (heart attack) than do men.

The Harvard researchers developed the term “symptomatic tipping point”. This captures the transitional period that we go through between the time we first experience early heart attack symptoms and when we finally get medical attention to address those symptoms. They identified six transitional stages common to both men and women during a heart attack, although they found that men respond to their symptoms faster than women do.

The six stages, in chronological order, include:

  • a period of uncertainty (patient attributes their symptoms to another health condition)
  • denial or dismissal of symptoms
  • seeking assistance/second opinion of someone such as a friend or family member
  • recognition of severity of symptoms with feelings of defeat
  • seeking medical attention
  • acceptance

When I asked Dr. Kreatsoulas about her team’s research findings, she explained:

”    We found several surprising things in our study:

•      “The six stages of the ‘symptomatic tipping point’ emerged during the qualitative part of our study. We had no prior knowledge of how patients transition between the internalization of symptoms, the expression of symptoms, and the thinking process that occurs before determining that they need medical attention for these symptoms. This is a novel finding.

•       “While we know from prior research that women come to hospital later than men with more advanced stages of heart disease, we were surprised to uncover that one of the reasons for this may be that women go through a longer period of denial than men.

“While both women and men go through that first period of uncertainty when they are running through a host of other possible health conditions they could attribute their symptoms to (i.e. indigestion, a pulled muscle), men would readily consult with a loved one or friend in this uncertainty stage, but women did not.  Even by the time patients reached the fourth stage of recognition of severity of symptoms, men had more self-recognition that they required medical attention – whereas women waited for others to comment on their symptoms, and then they reacted to others’ comments regarding those symptoms.

•       “In the quantitative study, we were surprised that while men and women were equally likely to seek medical attention for their symptoms if they felt physically limited by their symptoms, if they felt a change in the severity of their symptoms, or if they experienced a long duration of symptoms, women would wait for symptoms to become more severe and frequent than men.

•       “We were surprised that when patients finally came to hospital, only 2/3 thought the symptoms were related to their hearts.

•       “Even more surprising, when we asked patients less than an hour prior to undergoing their diagnostic angiograms, women were less likely to think that their symptoms could be due to their hearts compared to men (statistically significant).”

My own gut feeling, however, is that those of us who have engaged in this treatment-seeking delay behaviour as described in research on female heart attack survivors published in the American Journal of Critical Care (3) may not actually find these observations surprising. 

Embarrassing? Yes.

But surprising? No!

One only has to watch Elizabeth Banks’ hilariously chilling Go Red For Women™ video called Just A Little Heart Attack to recognize the distressingly common treatment-seeking delay behaviours that she perfectly nails in just three short minutes, in which she asks her worried young son (while suffering textbook heart attack symptoms that even a little kid can identify as being heart-related) the classic treatment-seeking delaying question:

“Honey, do I look like the type of person who has a heart attack?”

This is so perfect! None of us, after all, thinks we look like “those people”.  I was pitifully ignorant about heart disease before surviving my own cardiac event. And as a longtime distance runner, I never imagined that I was even remotely the “type of person who has a heart attack”.  

Rather, I pictured an old fat guy out on the golf course, suddenly clutching his chest and falling down unconscious.  That’s what I figured a heart attack was.

I didn’t know that the golf course scenario I was imagining was actually sudden cardiac arrest, which is, of course, NOT a heart attack. So when a man with the letters M.D. after his name confidently misdiagnosed me in mid-heart attack in the Emergency Department, adding that I was “in the right demographic for acid reflux” before sending me home, I believed him.

And really, how could I be having a heart attack when I was able to walk, talk, remain conscious, drive, go to work, fly to Ottawa for my mother’s 80th birthday – all while suffering increasingly debilitating symptoms of what I now believed was simply indigestion?  No way was I going back to Emergency to make a fuss over a case of indigestion when those identical symptoms of central chest pain, nausea, sweating and pain down my left arm kept returning! Even though I am fully aware that “pain down my left arm” is NOT a symptom of indigestion, I was in full-blown denial by then – helped in no small measure by that über-confident doc in Emerg.

Screen Shot 2016-03-25 at 5.06.28 PM

Here’s another denial example: I was recently sent an advance copy of a new book for the purpose of providing a review for the book. It was written by a heart patient who wrote that she smoked two packs a day for over 30 years before her cardiac event – yet by her own description was the most surprised woman in her hospital when finally diagnosed. Surprised!? Clearly, many of us appear to be delusional when it comes to assessing our own cardiac risk factors (like smoking) which dramatically increase the likelihood of experiencing a cardiac event, as well as evaluating severe symptoms while we are having it.

In fact, so far I’ve never encountered a single heart patient who has ever said to me: “Yep, I knew it! I’ve been expecting this heart attack for years!” 

So if you haven’t watched the Elizabeth Banks video, stop reading right now and watch it!  I now show this little film at the beginning of every Heart-Smart Women presentation that I do.  My audiences invariably laugh right out loud and simultaneously cringe in nodding recognition through every scene.  It is pure brilliance.

According to Dr. Kreatsoulas, women tend to stay in the second denial stage (demonstrated beautifully by Elizabeth’s character) longer than men do, although it’s hard to pinpoint how much longer. And while men would consult with a friend or loved one more readily about their symptoms, she found instead that…

“…women would wait for others to tell them they looked horrible.  Women displayed more of an optimistic bias, feeling that the symptoms would pass and get better on their own.

“This finding was substantiated in the second part of the study where women were one and half times more likely than men to wait for symptoms to become more severe and more frequent before seeking medical attention.”

 “Other priorities could be taking over, such as women’s focus on caregiving roles or even risk aversion. That may be due partly to a perception that coronary artery disease is a “man’s disease,” even though it’s a leading cause of mortality for women.

“If women aren’t thinking about heart attack, then it’s easier to disregard the symptoms.”

I love the concept here of “optimistic bias”. It sounds so much better, doesn’t it, than “What the hell were you thinking?!” which my own family and friends threw at me once I was finally correctly diagnosed and hospitalized with a heart attack. It also goes well with the “Fine, just fine” classic response we sometimes offer when things are quite clearly not fine at all.  See also: Denial and Its Deadly Role in Surviving a Heart Attack

Similarly, Dr. Kreatsoulas also cited research suggesting that when women are ill, they are often more concerned with how long they may be out of commission and not necessarily as concerned about the best treatment options.  She added that both men and women often attribute symptoms to other non-cardiac possibilities such as heartburn or a pulled muscle.

“   But when women feel even a small improvement in symptoms, they seem to dismiss them for a longer period of time.”

This is important. Given that many women report that their cardiac symptoms often come and then go away, this dismissal also makes sense at the time. And consider Dr. Jean McSweeney from the University of Arkansas for Medical Sciences whose research on hundreds of female heart attack survivors found that 95 percent of the women she interviewed actually suspected something was very wrong in the months leading up to their attack.

Yet when symptoms come and go, we can experience an understandable and profound sense of “Whew! Glad that’s over with!” during that break in symptoms. 

For more about women’s heart attack symptoms, read: The Myth of the “Hollywood Heart Attack” for Women based on the U.S. Department of Health & Human Services National Women’s Health Information campaign.

And as Dr. Kreatsoulas sums up her own team’s conclusions:

“What we really need to get a handle on is to try to understand why women come to hospital later than men, and with more advanced stages of disease.  Future research efforts need to be dedicated to this area so that education and preventative strategies can be appropriately targeted to women.”

Meanwhile, while we’re awaiting those future research efforts, here’s what I now tell women in my heart presentation audiences:


“You KNOW when something is just not right.

“If you feel any symptoms – obvious or vague – that might be a heart attack, call 911! Imagine that these symptoms are happening to your daughter or your sister or your Mum – and then take the same immediate action to seek help that you would for the women you care about.”


NOTE FROM CAROLYN:   I wrote more about treatment-seeking delay in Chapter 2 of my new book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for it at your local 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).


(1) Kreatsoulas C, Crea-Arsenio M,  Giacomini M, Shannon HS, Velianou JL, Anand SS. The Symptomatic Tipping Point: Factors That Prompt Men and Women To Seek Medical Care. Presented at the Canadian Cardiovascular Congress, October 2014. Canadian Journal of Cardiology Volume 30, Issue 10, Supplement, Page S132, October 2014.
(2)  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.
(3)  Rosenfeld A et al. Understanding Treatment-Seeking Delay in Women with Acute Myocardial Infarction: Descriptions of Decision-Making Patterns.  Am J Crit Care July 2005 vol. 14 no. 4 285-293


Q:  What was the “symptomatic tipping point” for you that finally convinced you to get medical help during a health crisis?

See also:

Downplaying symptoms: just pretend it’s NOT a heart attack

How gender bias threatens women’s health

‘Knowing & Going’ – act fast when heart attack symptoms hit

“You’ve done the right thing by coming here today”

How having a wife shortens time to heart attack care

Too embarrassed to call 911 during a heart attack?

Yale Heart Study asks why we wait so long before seeking help in mid-heart attack

Researchers openly mock the ‘myth’ of women’s unique heart attack symptoms

Denial and its deadly role in surviving a heart attack

Are you a priority in your own life?

The sad reality of women’s heart disease hits home

14 thoughts on “The symptomatic tipping point during heart attack

  1. I found the video disturbing – I KNOW all those symptoms for heart attacks in women. I didn’t have anything except the kick in the chest by a mule, and thought that came from 13 weeks of violent coughing from two different viruses.

    If I’d had the other symptoms, I would have been there much sooner.

    So if you’re waiting to be that woman in the video, to have more symptoms, you are taking a huge risk.

    Of course I only had the 95% blockage – not the heart attack.


    1. That Elizabeth Banks video is not about listing all possible heart attack symptoms in women but about women’s treatment seeking delay behaviours (which is also what this blog post is about, and which occur in women with either typical or atypical symptoms).

      Liked by 1 person

  2. You write so clearly, Carolyn. My first symptom was “indigestion” which went on for a couple of hours. If I had not been at my endocrinologist’s office, I would have continued my busy day.

    I think women might be guilty of this because they think, “No way is my day being interfered with; people need me.”

    Twice in more recent times, I waited to call 911 until I could not make it to the bathroom without chest pain!

    It happens even when we know better!!

    Liked by 1 person

    1. Thanks Pauline for these thoughts. I think you may be right about your “people need me” excuse. That’s why I like the acid test question: How would you respond if these symptoms were happening to your daughter/Mum/sister/friend?” Invariably, we’d be screaming blue murder to get immediate medical help for others…


  3. Carolyn,
    I often have heard that women’s pain threshold is generally higher than men’s. Are there studies that verify or debunk this ?

    If it is true, might it account for women being ” . . . one and half times more likely than men to wait for symptoms to become more severe and more frequent before seeking medical attention” ?


    1. What a good question, Judy-Judith! A number of studies have suggested, contrary to our opinion about the Man Cold, that men actually had higher pain thresholds/tolerances and lower pain ratings than women – BUT that was when research subjects in a lab had to submerge a hand in icy water, not when doing real life painful things like popping out babies or breaking bones or having heart attacks…. I suspect it’s more of an individual propensity – I’ve known women who dealt with severe pain stoically without so much as a wimper, and wimpy men who freaked out over every little twinge – and vice versa. Or is it less about pain thresholds and more about willingness to stop what we’re doing during pain to say: “I need help!”

      Liked by 1 person

      1. I hope women/medical establishment et al. will begin to change as women and heart attack information – research, symptoms, survival, treatment etc – gets increasingly disseminated to the public and doctors. Your part in all this, I am sure, is making a significant difference from which generations to come will benefit.

        Liked by 1 person

  4. This blog post is an excellent analysis of why women wait, however, there is an area I disagree with. The comment:

    “men would readily consult with a loved one or friend in this uncertainty stage, but women did not. “

    strikes me as a glossing over of reality. As in the situation when men are lost and don’t ask for directions, they often do NOT “READILY” consult with a loved one or friend. That loved one or friend often DOES, push, cajole and coerce the male of the species to seek help. Fearing that the man is likely suffering “the big one” and that the wife might “lose him”, women are often first to push the male to seek help, just as they are often quicker to ask for directions. (wink wink).

    In fact, men often say, no, no, I’m not sick or some flavor of that response..but often, the woman or wife insists.

    Numerous studies cite the fact that in quality of life, men’s lives are higher than women’s. Women are the caretakers. In those same studies, women’s quality of life suffers the most within marriage and family, probably due to the expected and ongoing role of care taking.

    The question with getting women to help is: who is the caretaker for women? – and women are far more likely to put themselves last in all respects in sacrifice for others.

    Bottom line, there is nobody there to help women out of the denial stage.

    When you are in denial, it’s a safer place to be. Others must love you enough, or you must love yourself enough to realize that denial does not serve you. The Elizabeth Banks video uses humor to the nth degree to point this out. I love her!

    We’ve solved the directional issue with GPS and WAZE and such. Now, how will we perform a denial-ectomy, so that women and their loved ones realize what a heart attack really looks like? Elizabeth on the floor goes part of the way. Elizabeth walking around “feeling not quite right” would also help with the identification.


    1. What a thoughtful perspective, Mary – thanks so much for this. There are a number of examples of “glossing over” generalities in this particular study which is not unusual in qualitative research.

      I asked Catherine specifically about this very statement (because of many other studies suggesting men’s outcomes are better than ours during heart attack) specifically, might this reality have something to do with the fact that men have wives!?! For example, when men say “Gee I’m having this weird pain in my chest”, wives jump all over this disclosure and insist, as you correctly say: “I’m calling 911!”

      But there are indeed many men who are also reluctant to “make a fuss” by drawing attention to their symptoms (for example, here’s an interesting dialogue between Dr. Angelo Alonzo of the Yale Heart Study and Australia’s Len Gould (a heart attack survivor himself) about male heart patients being too embarrassed to make a fuss – just as many women feel! The important distinction: men who have wives seek emergency care far faster than single men (or women, married or otherwise).

      But until women can get past our reluctance to put ourselves first during ANY symptoms that look, feel, sound or smell cardiac (or until we start signing up for that that denial-ectomy!!) we’ll continue to see more and more studies that repeat what we already know.


      1. You mention this elsewhere on the website but I honestly think most women get brushed off when they list their symptoms – for everything!
        Get told you’re just overweight, lose some and you’ll feel more energetic. Oh you’re getting older, it happens to the best of us. Women do a lot, you’re just stressed. Or it’s probably just anxiety.

        Get told that enough and you just “deal with” discomforts and symptoms of anything that pops up. Until they become un-ignorable.

        Liked by 1 person

        1. So true, Kara! I think it boils down to being worn down by dismissive responses. I have some readers who have told me they won’t go to the ER anymore for ongoing cardiac symptoms “because I already know what they’re going to tell me there.”


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