When I interviewed Dr. Catherine Kreatsoulas* about the research paper she presented last month in Vancouver at the Canadian Cardiovascular Congress(1), she mentioned her previous heart study that caught my attention.
I was surprised by her explanation from that 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
If there is actually such a person working in medicine, it means we have a lot more work to do to help enlighten them before they misdiagnose us and send us home.
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. They continue to perpetuate the notion that THIS is what a heart attack always looks like – which would be a profoundly false notion.
Some studies suggest that about 8-10% 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.
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 tractor trailer parked on my chest and severe burning extending right up into my throat. I also had nausea, sweating and dull 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 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 subjects 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 like crazy for having made such a fuss over “nothing” but a simple case of indigestion.
So here’s my question: if I – even in the midst of classic cardiac symptoms – was sent home despite what Dr. Kreatsoulas and other researchers would clearly consider “typical” cardiac symptoms, can you imagine how swiftly such a physician would send home women presenting with weird and wacky “atypical” symptoms?
I was actually back in my home that first 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 treated when presenting to Emergency with cardiac symptoms:
A woman attending one of my heart health 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 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, or menopause.
Consider this, dear heart sisters: just as respected cardiology resources like Mayo Clinic and the Texas Heart Institute do, no less than the world-famous Cleveland Clinic (widely considered the top heart institute in North America) warns:
“Women often have different symptoms of a heart attack than men and may report serious symptoms even 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”
- light-headedness or dizziness
- unusual 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.
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).
Research on cardiac misdiagnoses reported in the New England Journal of Medicine looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with heart attack symptoms. Investigators found that women 55 and younger were seven times more likely to be misdiagnosed and sent home compared to our male counterparts. (4)
The consequences of this were enormous, according to researchers: 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.
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
- Researchers openly mock the ‘myth’ of women’s unique heart attack symptoms
- The symptomatic tipping point during heart attack
- How gender bias threatens women’s health
- Why we ignore serious symptoms
- How to communicate your heart symptoms to your doctor
- Mayo Clinic: “What are the symptoms of a heart attack for women?”
- Women missing the beat: are doctors ignoring women’s cardiac symptoms?
- ‘Knowing & Going’ – act fast when heart attack symptoms hit
- How does it really feel to have a heart attack? Women survivors tell their stories