Heart attacks: “Men explode, but women erode”

by Carolyn Thomas  ♥ @HeartSisters

heart-460546_1280Los Angeles cardiologist Dr. Noel Bairey Merz believes that the biggest issue facing women heart patients is that as a society we have been programmed to think of heart disease as a man’s problem. During a presentation in Australia last year, she told her audience:

“The fatty build-up of plaque in a coronary artery causing a heart attack will usually rupture or ‘explode’ in men.

“But in women, it will often be a much smaller, more subtle event, caused by ‘erosion’, not explosion. 

“Often their symptoms may throw doctors off track to the wrong diagnosis, and in many cases, women won’t even know they have had a heart attack until it’s too late.”   .

 In an earlier TED talk, Dr. Bairey Merz described the differences between what she calls male-pattern and female pattern heart attacks:

Hollywood heart attack. Ughhhh. Horrible chest pain. A big clot explodes in the middle of a coronary artery. Doctors can see this hugely abnormal EKG.  And they all go up to the cath lab and boom, boom, boom – get rid of the clot. That’s a male-pattern heart attack.

“Some women have those heart attacks, too, but a whole bunch of women have another kind of heart attack where plaque erodes, doesn’t completely fill the coronary artery with a big clot, symptoms are subtle, EKG findings are different – that’s a female-pattern heart attack.

“So what do you think happens to these gals? They’re often not recognized, sent home, or told:I’m not sure what it was. Might have been gas!’

So then we said: ‘We’re going to hypothesize that the fatty plaque in women is actually different, and it’s deposited differently, compared to men.”

Part of that hypothesis, she explained, starts with the common knowledge of how women and men become obese in general.

Where do men get fat? Right here in their bellies, she pointed out.

But where do women get fat? All over! Cellulite here, cellulite there.” Dr. Bairey Merz and her colleagues at Cedars-Sinai Heart Institute observed that  the big “lumpy bumpy fatty plaque” blockage in a man having a heart attack resembles what she calls “a beer belly in his coronary artery”, unlike the plaque in women’s arteries, which she described like this:

“Plaque in a woman’s coronary artery can look very smooth, just laid down nice and tidy! 

“After 50 years of honing and crafting coronary angiograms, doctors can easily recognize male-pattern disease. But it can be hard to see that female-pattern disease by angiography. Now what are the implications of that?

“Nobody can tell that they even have a heart problem.”

Regular Heart Sisters readers will know immediately that Dr. Bairey Merz is describing what I’ve been writing about here for five years: women presenting to Emergency and then being misdiagnosed and sent home in mid-heart attack – just as I was – because their cardiac test results were “normal”.

Dr. Bairey Merz was also quoted in a Harvard Women’s Health Watch article called Standard Tests Don’t Detect Microvascular Disease about her work on the Women’s Ischemia Syndrome Evaluation (WISE) study. This landmark investigation into ischemic heart disease (meaning reduced blood supply to the heart muscle) was described as “laying the groundwork for better ways to evaluate and treat women with heart disease.”  For example:

“Heart disease, like cancer, is not one, but several disorders. Discoveries from the WISE study suggest that many women have a form of heart disease called coronary microvascular dysfunction (MVD) or small vessel disease that is not detected by standard diagnostic procedures, and thus goes unrecognized and untreated.”

What triggers MVD is not known, but Dr. Bairey Merz suggests that high blood pressure during pregnancy, for example, might predispose some women to the condition.

(Coincidentally, I was diagnosed with pre-eclampsia during my first pregnancy – typified by spiking high blood pressure. And we now know that women with pre-eclampsia are up to five times more likely to develop heart disease compared to women who do not have pregnancy complications).  After surviving a “widowmaker heart attack” in 2008 caused by a 95% blockage in my left anterior descending coronary artery, I was subsequently diagnosed with coronary microvascular disease, too.  See also: My Love-Hate Relationship With My Little Black Box

Typically, the narrowings in these smaller blood vessels – too small to stent or bypass – are caused by the same soft, vulnerable plaque that clogs bigger vessels where most heart attacks begin, explains Dr. Bairey Merz.  This narrowing reduces the space for blood flow and makes the arteries less able to expand in response to exercise or emotional stress.

Dr. Bairey Merz believes that the best diagnostic test for detecting MVD may be something called coronary reactivity testing. This angiogram-like test lasts 60-90 minutes and allows doctors to see how very small vessels supplying the heart respond to different “challenges” from medications.

And she recently added this additional diagnostic tool to an article called Myocardial Infarction Re-Defined in the American College of Cardiology’s In Touch site:

“A majority of patients with microvascular coronary dysfunction also have atherosclerosis evidenced by intra-coronary vascular ultrasound (IVUS).”

See more about Dr. Bairey Merz:


Q: Have you heard of this “explode-erode” gender difference in heart attacks?


8 thoughts on “Heart attacks: “Men explode, but women erode”

  1. Dear readers of this amazing website:

    Today, November 11, 2014, the Canadian national newspaper, The Globe and Mail, has recognized Carolyn, and this blog in particular, by the best (by my standards) journalist of health care in the country, André Picard.

    Carolyn is to be congratulated for the outstanding work she has done for women and heart disease and this recognition by Mr. Picard is a great acknowledgement!

    Please do read it! Those of us suffering from heart disease are so fortunate to have this jewel among us.

    Thank you Carolyn!

    Liked by 1 person

  2. I always love your posts, and learn from them! Here’s another for me to print out and carry with me when i see my Duke Cardiologist in a couple weeks or so.

    I’ve been told so many things about my heart– I hardly know what applies anymore! I do know I’ve been told many times in my 15 year journey with disabling heart disease, that my arteries were too small to stent! Wouldn’t you know, I’d say, the only thing small about me, would have to be my coronary arteries! I had two heart attacks that I did not know I had. And I have been told I have ischemic heart disease.

    I expect to erode now, for two years I expected to explode any minute! I live with an unstentable, inoperable, 99% blockage in my LAD — widowmaker– but have for 15 years! Credit for still being alive goes to plavix, imdur, ranexa, and metoprolol I believe!

    Liked by 2 people

    1. Hi Helen – you bring up an important point: that sense of dread that many heart patients live with – “For two years I expected to explode any minute!” (and that kind of stress is not good for heart health!) The human body is an amazingly resilient machine, isn’t it?


  3. Makes intuitive sense, once you think about it. And so that means that the angiogram is far from “the gold standard” (as my first cardiologist insisted) but, In fact, cannot detect the damage many/most women experience at ALL.

    Honestly, it’s a scientific outrage the way nearly all cardiac (not to say medical) research still is exclusively on men (or nearly). Generations of scientists and doctors have been systematically miseducated about What We Do Know. Even the well-intentioned ones.

    So hooray for Dr. Bairey Merz and her research! For not only identifying the problem, but actually coming up with an all-round better test. For all like-minded scientists. And to Carolyn, for sharing what you learn where we all can see it.

    Liked by 1 person

    1. Thank you, Kathleen. The angiogram is still widely referred to (by cath lab docs and nurses) as the “gold standard” of cardiac diagnostic tools. Similarly, the type of heart attack I had is still called “the widowmaker” – NOT the “widower”maker… Just this week, I participated in a WomenHeart online webinar about women and implantable cardiac devices, where I learned that when coronary stents were first introduced, they were too large to be implanted in the coronary arteries of almost all female heart patients. Duh….


  4. Another great informative post!

    (I started laughing early on when I read ‘We’re going to hypothesize that the fatty plaque in women is actually different, and it’s deposited differently, compared to men.”

    Who knew that my fat deposits itself differently than men’s fat inside – not just where it’s visible!)

    Liked by 1 person

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