When I interviewed Dr. Catherine Kreatsoulas* about the research paper she presented last month in Vancouver at the Canadian Cardiovascular Congress(1), her previous heart studies caught my attention, too.
I was surprised by her explanation from earlier research on how some women describe their chest pain during a heart attack (2), as she told me: . .
“What we found fascinating in that study is that women would use a host of descriptive language to describe their heart attack symptoms, whereas men’s symptom vocabulary was generally more succinct.
“I cannot count the number of times I observed a physician leaning over a female heart patient prior to going for an angiogram, while asking: ‘So tell me about your chest pain’, and the woman very quick to respond:
“Well, I don’t really have chest pain. I have a discomfort, it’s more like pressing. I wouldn’t call it chest pain, I would describe it more as a bad ache.”
“And much to my amazement, I would observe the physician/resident record in the patient’s notes, ‘No CP’ – meaning no chest pain!
“We have no way of accurately estimating just how many patient charts have documented ‘No CP’ – when perhaps a more descriptive term for ‘chest pain’ expressed was used by the patient.” .
This observation made sense to me, as I have frequently heard female heart attack survivors describe their own chest symptoms as “pressure, heaviness, fullness, tightness, aching, burning” – rather than with the word “pain”. See also: How Does it Really Feel to Have a Heart Attack? Women Survivors Answer That Question
And if a symptom anywhere in the chest area is worrisome enough to propel a woman to seek emergency medical care, let’s not split hairs if it doesn’t look exactly like this:
Pictures like this in the media are, in my opinion, downright dangerous for women experiencing cardiac symptoms. They continue to perpetuate the misguided notion that THIS is what a heart attack always looks like – which would be a profoundly false notion.
It’s true that CHEST PAIN IS THE MOST COMMON HEART ATTACK SIGN IN BOTH WOMEN AND MEN. Yet some studies suggest that at least 10 per cent of women experience no chest symptoms at all during a heart attack.(3) This generally translates as no pain, no pressure, no heaviness, no fullness, no tightness, no aching, no burning or any other symptoms of any kind in any part of the chest area.
Or it could, as Dr. Kreatsoulous found, simply mean that chest symptoms were not identified/recorded by physicians.
I met a woman during my Mayo Clinic training, for example, whose only symptom during her heart attack had been a persistent cough.
Another whose only symptom was upper lip numbness.
Some whose only symptoms were vomiting and a sore jaw.
And many whose only symptoms were crushing fatigue and upper back pain.
So many weird and wacky heart attack symptom-combos, in fact, that it is simply no longer possible to blithely accept the insistence of some that men and women always experience identical heart attack symptoms that always include chest pain. That is simply not accurate.
And let’s face it, ladies: we know what pain feels like.
I’ve broken bones falling off my bike, survived a near-fatal case of ruptured appendix/peritonitis, was a distance runner for 19 years, and popped out two babies the old-fashioned, drug-free way – which is to say, I know my pain.
And that central chest pain during my heart attack felt nothing like any of those previous examples of “pain” – in the same way that toothache pain is different than the pain of rheumatoid arthritis. See also: The Freakish Nature of Cardiac Pain (part 1 of my 3-part series on pain)
My own heart attack symptoms felt like a cross between a Mack truck parked on my chest and a roaring burn extending right up into my throat (which was not unlike what running fast up the deadly Quadra Street hill with my running group felt like, too). I also had nausea, sweating and intense pain radiating down my left arm. Textbook Hollywood Heart Attack signs.
It was as “painful” as I can possibly imagine any chest symptom to feel, given that until then I had no clue what heart attack chest pain feels like.
I just knew that something was terribly, terribly wrong.
By the way, before that spring morning in 2008, I had never gone to the Emergency Department except to have a cast put on after that cycling accident. In fact, like most women, it took a lot to force myself to go for help – even with those textbook heart attack signs.
And, unlike the heart patients reported in Dr. Kreatsoulas’ 2013 study, I certainly DID use the specific words “chest pain” loud and clear to the Emerg doc – who still sent me home anyway, misdiagnosed with acid reflux – and apologizing for having made such a fuss over “nothing” but a simple case of indigestion.
I was actually back in my home that morning barely five hours after the first onset of symptoms – far less time than current cardiac treatment guidelines recommend, particularly for cardiac enzyme blood tests.
No wonder all my tests that morning seemed “normal”.
Here’s a simple story that sums up for me the alarming differences between how men and women are often treated when presenting to Emergency with cardiac symptoms:
A woman attending one of my “Heart-Smart Women” presentations told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between a doctor and the (male) patient in the bed next to hers beyond the curtain:
“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.
A male patient with symptoms severe enough to seek emergency medical help is thus kept in hospital for careful observation in spite of “normal” cardiac test results.
But I and countless other females in mid-heart attack are being sent home from Emergency following “normal” test results just like his, and with our misdiagnoses ranging from indigestion to anxiety, stress, pulled muscles, gall bladder problems or menopause.
Consider this, dear heart sisters: we are now warned by respected cardiology resources like Mayo Clinic, the Texas Heart Institute and this from Cleveland Clinic:
“Women may report serious symptoms even before having a heart attack, although the signs may not be identified as ‘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”
- light-headedness or dizziness
- unusual crushing fatigue for several days
We already do know that women like me are far more at risk of being misdiagnosed in mid-heart attack and sent home from the Emergency Department compared to our male counterparts. Research on cardiac misdiagnoses reported in the New England Journal of Medicine found that female heart attack patients 55 and younger were seven times more likely to be misdiagnosed and sent home compared to our male counterparts. (4)
And I’ve often said that if only that first Emerg doc had bothered to simply Google my symptoms, only one possible diagnosis would have popped up in his search: myocardial infarction (heart attack).
The consequences of this were enormous, according to the researchers in the NEJM: being misdiagnosed and sent away from the hospital doubled the chances of dying.
* Dr. Catherine Kreatsoulas is a Canadian epidemiologist who is also a Fulbright Scholar and Heart and Stroke Research Fellow at the Harvard School of Public Health.
.(1) Kreatsoulas C et al. 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.
(2) Kreatsoulas et al. Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men. JAMA Intern Med. 2013; 173(9):829-833.
(3) 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.
(4) 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.
NOTE FROM CAROLYN: I wrote more about how heart patients’ plans can suddenly change in my book A Woman’s Guide to Living with Heart Disease. You can ask for it at bookstores (please support your local independent bookseller!) 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 20% off the list price).
Q: Is it the patient’s responsibility to describe heart attack symptoms in a way doctors can understand?
Part 1 of my 3-part series on pain: The Freakish Nature of Pain
Part 2 of my 3-part series on pain: Brain freeze, heart disease and pain self-management
Part 3 of my 3-part series on pain: Chest pain while running uphill