Typical vs. “atypical” heart attack signs in women

by Carolyn Thomas  @HeartSisters

Before I was misdiagnosed with acid reflux and sent home from the Emergency Department, the heart attack symptoms I was experiencing had seemed pretty dramatic during that eventful early morning walk. They were, in fact, what all physicians (and Dr. Google) would consider to be typical heart attack signs. 

My most debilitating symptom at the time was the central chest pain that doctors know as angina pectoris (a Latin name that translates gruesomely as “strangulation of the chest”). In my case, it felt like a cross between a Mack truck parked on my chest and a burning searing pain going up into my throat. I also felt like I was going to vomit, I was sweating profusely, and I had pain radiating down my left arm. (None of those textbook symptoms, by the way, helped to convince the Emergency physician that I was, in fact, having a heart attack. Read more about misdiagnosis of women’s heart disease in this Heart and Stroke Foundation report here). 

Those textbook “Hollywood Heart Attack” heart attack symptoms in both men and women can typically include:

  • chest pain or discomfort
  • nausea
  • crushing fatigue
  • shortness of breath
  • sweating
  • dizziness

Particularly in women, cardiac symptoms that are called “atypical” may also be reported. But, as paramedic/women’s heart health researcher/documentary filmmaker Cristina d’Allessandro asks in the film “A Typical Heart”: 

“Why do we call women’s symptoms ‘atypical’ when women make up more than half the population?”

Cardiologist Dr. Martha Gulati is president of the American Society for Preventive Cardiology and chair of the writing committee for the new Chest Pain Guideline, published jointly in 2021 by The American Heart Association and the American College of Cardiology. She and her team declared:

“Atypical” is a misleading descriptor of chest pain, and its use by health care professionals is discouraged – and may be misinterpreted as ‘benign’. 

(FULL DISCLOSURE:  Dr. Gulati also wrote the beautiful foreword to my book, A Woman’s Guide to Living With Heart Disease  (Johns Hopkins University Press).

Here are some not-quite-textbook cardiac symptoms that you should know:

  • an abrupt change in how your body feels*
  • chest pain, which may be central or be felt armpit to armpit (and may not even be described by the word “pain”) but in at least 10 percent of women(1) – and that may be as high as 40 percent(2) depending on the clinical study – no chest symptoms at all are present during a heart attack
  • unusual pain, discomfort, pressure, heaviness, burning, tightness, or fullness in the left or right arm, upper back, shoulder, neck, throat, jaw, or abdomen
  • weakness, fainting, light-headedness, or extreme/unusual fatigue
  • shortness of breath and/or difficulty breathing
  • restlessness, insomnia, or anxiety
  • a bluish color or numbness in lips, hands, or feet
  • nausea or vomiting
  • clammy sweats (or sweating that’s out of proportion to your environment or your level of exertion)
  • persistent dry, barking cough
  • a sense of impending doom

During a heart attack, our heart muscle cells begin to run out of oxygen because something is preventing the oxygenated blood flowing through our coronary arteries from feeding that muscle.

A heart attack may also cause a sensation of pain or discomfort to travel from the heart to the spinal cord, where many nerves merge onto the same nerve pathway. Your arm may be perfectly fine, for example, but your brain thinks that part of your pain is in the arm (or in the jaw, shoulder, elbow, neck, or upper back) screaming out for help.

That’s what referred pain is. It happens when pain is located away from or adjacent to the specific organ involved – such as in a person’s jaw or shoulder, but not necessarily anywhere near the chest.

Not all of these signs occur during every cardiac event. Some female survivors report that their symptoms came on suddenly and simply felt unusual – not alarming.

Sometimes the most extreme symptoms don’t necessarily imply the worst heart muscle damage. Symptoms can also go away and then return over time.

Stable symptoms typically become worse with exertion but go away with rest. If symptoms come on when you’re at rest, they’re considered to be unstable – and that could mean a serious emergency for which you need immediate medical care.

Screen Shot 2016-03-25 at 5.06.28 PM

LISTEN to your body.  DON’T IGNORE symptoms.  GET HELP fast.

What to do if you’re having these symptoms:

  • Immediately call 911 and say: “I think I’m having a heart attack!” Do not apologize for bothering them. Do not minimize your symptoms. Do not self-diagnose by saying something like: “It’s probably nothing, just a pulled muscle, indigestion, stress…”  etc.
  • Chew one full-strength uncoated aspirin tablet (with water if you like) while you’re waiting for the ambulance.  .NOTE: Some people should NOT take aspirin if they’re on certain drugs, or are allergic to aspirin, or have a non-allergic sensitivity to aspirin. Check with your doctor, and if you’re one of these people, skip this step.
  • Unless absolutely unavoidable, do not drive yourself to the hospital – and do not ask a friend or family member to drive you there.


(1)  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 2026.

(2) J. Canto et al, “Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality,” JAMA. 2012 Feb 22;307(8):813-22.

* An abrupt change in how you feel is probably the most important message your heart can send you. If symptoms “just don’t feel right”, if they feel unusual for you, if you have never experienced anything like them before, do not hesitate to seek help.


Read more about heart attack symptoms in my new book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press, 2017). This post is a brief excerpt from Chapter 1 of this book, which is already in its second printing! Thank you, readers!

NOTE FROM CAROLYN:   If you are experiencing these or other alarming symptoms described here, see your doctor. Please DO NOT leave a comment here asking me what you should do. I am not a physician and cannot tell you. This blog is not a substitute for professional medical advice.


Q: Heart patients: would you describe your own first heart attack symptoms as typical or atypical?


See also:

-Watch this 22-minute documentary called A Typical Heart, a remarkable Canadian film about the deadly disparity between male and female heart disease, through the lens of healthcare professionals, researchers, patients, and their families (Disclaimer: I was one of the eight Canadian heart patients interviewed).

Women’s early warning signs of a heart attack

Slow-onset heart attack: the trickster that fools us

Hysterical female? Just anxious? Or heart attack?

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

Am I having a heart attack?

Time equals muscle during women’s heart attack

Women fatally unaware of heart attack symptoms

Is it heartburn or heart attack?

What is causing my chest pain?

Heart attack misdiagnosis in women

Why does your arm hurt during a heart attack?

23 thoughts on “Typical vs. “atypical” heart attack signs in women

  1. I’m 35 year old male and I have been going to the er for the last 3 months with chest pain that radiates to both sides of my chest my arms up my neck the back of my neck and I also have high blood pressure.and they do all the test chest x-ray blood work ekg and I get sent home every time saying nothing is wrong. But I know my body should I be worried


  2. Help! I had chest and jaw pain. Went to ER in small town. He said EKG showed MI. When heart enzyme test showed 9 (took 6 hours to show up), sent me by ambulance to city hospital, where they found blockage and put in a stent. 5 months later, it happened again, only I had sweats and dizziness. Went to ER. Stayed 2 hours. They called it reflux because enzyme test was normal. Followed up with Cardiologist. Said neither episode was a heart attack because my heart was not damaged. They were just “events”.

    So, I take it that you cannot have a heart attack unless you have heart damage. True or false?

    Liked by 1 person

    1. Hello Lynn – such a good question! Don’t you love dueling doctors and their differing diagnoses? I’m not a physician so cannot comment specifically on your heart attack, but I can tell you about the guidelines for diagnosing a heart attack, published in the cardiology journal, Circulation, as described by Harvard cardiologist, Dr. James Januzzi, Jr. (a member of the Joint Task Force for the Universal Definition of Myocardial Infarction). He also includes a list of the six categories of heart attack:

      To be diagnosed with a myocardial infarction (heart attack), a person shows a troponin (cardiac enzyme) level in the blood that’s substantially higher than normal, plus one or more of the following:

      – symptoms of heart attack

      – worrisome changes on an ECG (EKG) or imaging test

      – identification of a clot in a coronary artery (e.g. during an angiogram procedure in the cath lab)

      The cardiac enzyme blood test is generally considered an important test for heart muscle damage due to a heart attack as it tends to be specific for heart attack (troponin is NOT typically detectable in the blood). But troponin can sometimes be elevated in non-heart attack cases (if you’re an Iron Man triathlete, for example). It does sound like *something* was found in your cardiac enzyme tests five months before your second “event”. Please read: No Such Thing as a ‘Small’ Heart Attack

      Personally, I don’t care what they call it as long as doctors don’t make people like you feel dismissed!

      Please make an appointment with your family doctor and ask for a review of your medical records and a clear explanation/translation of exactly what the charts say (including whether your “clear” cardiac enzyme test used was the high sensitivity troponin test or not).


  3. Hi Carolyn, I have Hypertrophic Cardiomyopathy which has chest pain as a symptom sometimes daily due to thick muscle/microvascular issues….. and this pain can even radiate into my left shoulder jaw and arm…..So I have had to learn….what is my baseline HCM chest pain and what might be different about any particular episode?

    In my case the differentiation was
    1) Chest pain that occurred during exertion instead of at rest
    2) Pain that occurred in between my shoulder blades which I had never experienced before.

    After my cardiologist interviewed me extensively about the changes in my chest pain, He scheduled a cardiac cath, where they found a 90% lesion in my Circumflex artery and stented it …..avoiding a heart attack! We must know our own bodies and hopefully sign up with healthcare providers that respect our differences.

    Liked by 1 person

    1. Hello Jill – what a dramatic story! Thanks so much for telling us how you managed to tell the difference between “normal” HCM symptoms and these new and different symptoms. Any chest pain that comes on with exertion and is relieved by rest is a very serious cardiac warning sign. I tell my blog readers and my Heart-Smart Women presentation audiences to take action for ANY troubling new symptoms that just do not feel “normal”.


  4. I have read that the Birth Control Pill damages blood vessel walls and wonder what percentage of us women with heart symptoms/ problems, have taken it and think it may well have contributed to their microvascular disease. I was left on one of the early, high dose birth control pills for almost 18 years, and have experienced most of the symptoms mentioned here. Doctors dismiss my concerns – probably as they prescribed them. The Pill now has a much lower dose so may not be so damaging now.


    1. Hello Sandra – I’m not a physician so cannot comment specifically on your situation, but my understanding is that, since the pill was first prescribed in the 1960s, there have been some ongoing concerns about cardiovascular risk. Over 80% of us have used birth control pills at some point in our lives. Here’s a good research paper (co-written by cardiologist Dr. Noel Bairey Merz of UCLA who has written extensively about MVD). She points out that newer generation birth control pills (far lower dose than early pills) show no increased cardiac risk for current users, but “a persistent increased risk of venous thrombo-embolism (VTE)”.


  5. Be sure to unlock your door, turn off the stove/iron (whatever), leave the diamond studs in the drawer and have your ID ready to go with you when they arrive minutes later.

    Liked by 1 person

    1. Good advice, Anne. Many of us wouldn’t have the presence of mind to remember all those things unless we wrote a list! Especially unlocking the door! A friend of mine called 911 during her heart attack while she was sitting in her living room watching TV one evening. (Luckily, her phone was right next to her). But she was unable to get up from the chair, and had visions of the first responders having to smash down her front door to get in – until she remembered that the basement door had one of those keypad locks (she had just installed it for when she’s gardening in the back yard so she wouldn’t need to keep her key with her). She told the 911 operator the keypad code – paramedics were there in a flash and let themselves in nicely via the basement entrance.


  6. There’s another symptom, ancillary to the “unusual fatigue”, that’s seldom mentioned, and that is the incidents of sudden **daytime** sleepiness. This is very different from being tired from doing something/anything or too much. It can occur when one is well-rested, unstressed, and generally minding one’s own business — but suddenly, there’s a strong urge to at least nap for a bit. Although it may seem 110% unremarkable, it is very definitely a reportable symptom.

    Liked by 1 person

    1. You’re right, Sandra – this kind of fatigue is far more severe than any kind of ‘normal’ sleepiness. More like having the worst flu imaginable, or being hit by a bus (not that I have been hit by a bus to personally compare it, but it’s that full-body debilitating exhaustion that makes it almost impossible to move). I think it’s why we’re so puzzled by this kind of exhaustion (we weren’t doing anything strenuous that might have caused it!) plus as women, most of us get used to feeling really tired on occasion. But any kind of extreme fatigue that feels that “unusual” is indeed a reportable symptom.


      1. Carolyn, one of the many things I treasure about you and your blog is that you validate what only the unintelligent and very uninformed would call “silly little symptoms”.

        Liked by 1 person

        1. Oh, Sandra – I am all over these “silly little symptoms”! I have heard of some of the weirdest heart attack symptoms from so many heart patients that I am no longer surprised by how weird some of them are (e.g. a woman whose only heart attack symptom was that her lips went numb, or another whose only symptom was a persistent cough, or … or … or …) Mind you, at the end of my Heart-Smart Women talks, I now beg my audiences not to all stand up and go directly en masse to the nearest ER after 90 minutes of hearing me talk about silly little cardiac symptoms!!! This is why I like the descriptor “if this feels not normal FOR YOU!” – a potentially helpful way to determine if a symptom needs checking out or not.

          Liked by 1 person

  7. My 86 yr old mother had sudden, excruciating elbow pain that would wake her up from a sound sleep and occasionally hurt suddenly during the day. Saw her regular doc and she/female doctor said “it’s just arthritis”, even though mom never had any arthritic problems before.

    Then I got her in to her cardiologist. Same answer. They did an EKG and said it was great, her BP was good, no worries. The NEXT DAY, she had a heart attack. 99% blocked. Her arteries were extremely calcified and was told trying to get through them was like “getting through the Rock of Gibralter”.

    NOBODY would listen when my mother KNEW her body and knew something was wrong. I tell everyone about the elbow pain! If it helps one person, I’ll feel better!

    Liked by 2 people

    1. This is a good example of the referred pain described in this book excerpt. Many people experience general arm pain or discomfort as a cardiac symptom, but it can sometimes be focused mostly on one part of the arm (e.g. the wrist or the elbow). Thanks for sharing your mother’s experience, Lisa.


    2. I had elbow pain for a long time before I had stents placed. About three months later, I noticed it was gone. And hasn’t come back.

      Liked by 1 person

    3. The weird pain I have is in the bicep or just beneath it.
      I was so afraid to take my nitro. I read the report, I will be no longer afraid. God Bless you all

      Liked by 1 person

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