Cardiologists know that, when it comes to seeking emergency medical help while experiencing alarming cardiac symptoms, women can be surprisingly reluctant to call 911. As I’ve written about here, here and here, this is a puzzling phenomenon we call treatment-seeking delay behaviour. It turns out that some cardiologists have to worry not only about patients like this, but about their own mothers.
Two such cardiologists are at St. Vincent’s Heart Center in Indianapolis and
“Our mothers have a few things in common. They are intelligent, self-aware, and careful. And both of them have daughters who are cardiologists.
“Unfortunately, they also share the dubious honor of having delayed calling for emergency care after developing cardiovascular symptoms.
“One mom, a healthy 80-year-old retired insurance agent, noticed some numbness in her face and tongue and weakness in her left hand; when these symptoms did not go away, she became concerned that she might be having a stroke and called the nurse help line provided by her health plan. Not surprisingly, the nurse instructed her to hang up and dial 911 – but instead, she called a family member and asked for a ride to the hospital. Thankfully, her symptoms resolved, tests were negative, and she has felt well since then.
“The other mom, a 74-year-old retired physical therapist, experienced severe indigestion after dinner one evening. She was able to fall asleep as it came and went, but was awakened in the middle of the night by discomfort radiating to her jaw and arms – so she woke her husband, and after some discussion, they drove to the local emergency room, where she was found to be having an inferior ST-segment–elevation myocardial infarction (a heart attack).
“Though both were aware of the symptoms of stroke and heart attack, neither woman thought it would happen to her.
“Neither did the family members who transported them to the hospital. And, as both concerned daughters and data-driven clinicians and researchers, we got to thinking: how could we make this better?“
Drs. Walsh and Joynt suggested these important steps in seeking faster care for cardiovascular symptoms:
- Women need to be aware of the signs and symptoms of cardiovascular disease.
- Women must connect the symptoms we’re experiencing to the possibility of a stroke or heart attack—the recognition that this could be one of those two serious conditions.
- Women need to seek immediate medical care.
Some of the other questions they pondered included:
“Are women less knowledgeable about signs and symptoms of cardiovascular disease? Less likely to recognize cardiovascular symptoms in themselves? Are they slower to seek care? And are these women’s problems or everyone’s problems?”
The answers are not encouraging. For example, they cite a 2012 survey of American women that found a surprisingly low 56% reported that they would associate having chest pain with a heart attack, and only 17% would associate chest tightness symptoms with a heart attack. Similarly, fewer than 18% of women surveyed were aware of atypical heart attack symptoms such as nausea or fatigue.(2) Similar gaps have also been demonstrated in a Canadian study.(3)
And knowledge of stroke warning symptoms seems to be limited in both women and men, with 50-75% of adults unaware of important warning symptoms for this condition. (4,5) By the way, in case you’re one of them, remember this F.A.S.T. guide to the most common stroke signs:
Women are more likely than men to present without chest pain during a heart attack.(6) This is particularly important because the absence of chest pain as a presenting symptom has been associated with increased mortality, especially among younger women.(7)
But although women may find themselves in this atypical cardiac symptom category, both sexes need to know that atypical symptoms are in fact common, as Drs. Walsh and Joynt reminded us.
But the big difference: women are less likely than men to realistically see cardiovascular disease as a risk to their own health.
When it comes to treatment-seeking delay behaviour, we know that older age, female sex, low education level, low socioeconomic status, black race, and diabetes are all factors that have been associated with taking longer to seek emergency treatment during a heart attack. But combinations of more than one of these risk factors (for example, being an older black woman living with diabetes) are even more powerful predictors of delay.(8) And shockingly, researchers have found that even having an increased knowledge of stroke symptoms was NOT associated with the intent to call 911 for these symptoms.(4)
Over the past two decades, the rate of awareness of cardiovascular disease as our leading cause of death has actually increased. In fact, it nearly doubled among women, from 30% in 1997 to 56% 20 years later.(9)
That still means, however, that almost half of us are just not getting the message. Many women, sadly, still see heart disease as a man’s problem. I was one of them! See more here.
The Circulation article contains some interesting insights into both women’s knowledge of cardiac symptoms and their likelihood to apply that knowledge to themselves if and when symptoms occur.
For example, the article cites WomenHeart: The National Coalition for Women with Heart Disease, and the organization’s most-read page on their website. It’s called: “Am I Having a Heart Attack?” In a one-month period ending mid-January 2016, for example, this page was viewed 14,072 times, representing one-third of total website views for the entire site, and easily making it the most widely viewed page on the site.
I’ve observed the same results here on my Heart Sisters blog. One of my most popular articles (often with over twice the readership of whatever is in second place) has been the one called “How Does It Really Feel To Have a Heart Attack? Women Survivors Answer That Question“, which so far has been viewed over half a million times since I wrote it in 2009.
As Drs. Walsh and Joynt say:
“We can only hope that this use reflects women seeking information at times when they are not actually having symptoms, but suspect this is not always the case.”
Women clearly want to know the answer to that “Am I having a heart attack?” question, but my own hunch is far less optimistic than theirs: I suspect instead that the vast majority of readers are experiencing frightening symptoms when they visit either of our websites to get that specific answer to that question. It’s what I call the 2 a.m. all-alone-and-scared Dr. Google search. . .
For me, the most striking part of the Circulation essay was this call to action by these two daughters whose mothers had experienced cardiovascular symptoms:
“How else might we encourage both women and men to seek care quickly when symptoms strike? One possibility is that our messaging needs to focus not only on knowledge but also on support, letting patients know that false alarms are okay, and we are not going to laugh if they come to the ER worried about a heart attack or stroke.
“Continuing to normalize that heart disease may also be important: culture and identity play a role in our perceptions of disease risk as does familiarity with the disease in others. Socioeconomic gaps in knowledge and delay are also significant, and campaigns focused on underserved populations might have particular promise in improving outcomes.
“Finally, we need to enlist men to help women, women to help men, caregivers to help care recipients, and most salient to us, children to help parents, to both recognize and act on potentially life-threatening symptoms when they occur.”
1. Circulation Cardiovasc Quality Outcomes. (2 Suppl 1):S97-9. .
2. Lori Mosca et al., Fifteen-Year Trends in Awareness of Heart Disease in Women: Results of a 2012 American Heart Association National Survey. Circulation. 2013;127:1254–1263.
3. L.A. McDonnell et al., Perceived vs. actual knowledge and risk of heart disease in women: findings from a Canadian survey on heart health awareness, attitudes, and lifestyle. Canadian Journal of Cardiology, 2014;30:827–834.
4. C. Fussman C et al., Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey. Stroke. 2010;41:1501–1507.
5. H. Mochari-Greenberger, National women’s knowledge of stroke warning signs, overall and by race/ethnic group. Stroke. 2014;45:1180–1182.
6. John Canto et al., Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. Journal of the American Medical Association (JAMA). 2012;307:813–822.
7. N.A. Khan, Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Internal Medicine. 2013;173:1863–1871.
8. H. Ting et al., Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction. Archives of Internal Medicine. 2008;168:959–968.
9. E.C. Leifheit-Limson et al., Sex differences in cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: The VIRGO Study. Journal of the American College of Cardiology, 2015;66:1949–1957.
Q: Has your own mother delayed seeking treatment despite distressing symptoms?
- The symptomatic tipping in women’s heart attacks
- What is causing my chest pain?
- The freakish nature of cardiac pain
- How women can tell if they’re heading for a heart attack
- Be your own hero during a heart attack
- Finally! An official scientific statement on heart attacks in women
- 6 reasons women delay seeking help – yes, even in mid-heart attack
- Most common heart attack signs in men and women
- Do NOT drive yourself to the ER in mid-heart attack