I was once asked by a U.S. publisher to review a new book written by a heart patient, a memoir about her surprising diagnosis. But about 12 pages in, she mentioned that she had been a chain-smoker for three decades before her “surprising” cardiac diagnosis. I had to re-read that line. How could a person who had been chain smoking for decades possibly be “surprised” by this predictable outcome? Didn’t this clearly intelligent, educated woman know that smoking is a dangerous risk factor for heart disease (and a whole bunch of other nasty health issues)? I thought of this book recently when a new study from Harvard researcher Dr. Catherine Kreatsoulas reported that women are in fact more likely than men to underestimate their own risk of heart disease. . . . . . .
She explained that, because there’s been a common historical misperception that heart disease is a ‘man’s problem’, “we knew little about the factors that influence our personal cardiac risk assessment – and whether that assessment varied by gender.” Her suspicions that women were the ones doing the underestimating were confirmed this month with the publication of the PRISM study: the “Patient Risk Interpretation of Symptoms Model: How Patients Assess Cardiac Risk”.(1)
This new study’s findings are a big concern to me.
I recall the sobering 2019 national survey results from the American Heart Association that blew the top of my head off. Those shocking results suggested that women’s awareness of heart disease and their own cardiac risk factors in general – and cardiac symptoms specifically – hasn’t only not improved since the last AHA survey, but is actually WORSE than it was 10 years earlier! Barely half of all women surveyed, for example, were aware that chest pain is a symptom of heart attack. Yes. You read that right. See also: Women’s Heart Disease: An Awareness Campaign Fail
Women can’t get appropriate cardiac treatment until we report our cardiac symptoms to a physician, and we’re not going to report them if we’re not even aware that chest pain is the most common cardiac symptom (in both men and women), and we’re even less likely to seek help if we’re unaware that our symptoms represent a cardiac risk.
I’ve been writing about Dr. Kreatsoulas and her cardiac research in women for several years:
For example, she has studied the words women use to describe their cardiac symptoms to physicians. She and her colleagues found a difference between how men and women describe chest pain, which (as I’m mentioning here for the second time) is the most commonly reported heart attack symptom in both sexes. But she found that women sometimes used different language to describe their symptoms compared to men.
When I first interviewed her here,(2) I was shocked by her description of witnessing women arguing with Emergency physicians – even in mid-heart attack – and especially by the words women tend to use to describe their cardiac symptoms:
“I cannot count the number of times I observed a physician leaning over a female heart patient in the Emergency Department 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 record in the patient’s notes, ‘No CP’ – meaning no chest pain!“
As Dr. Kreatsoulas reported, it’s relatively common among female heart attack patients to use words like “pressure, heaviness, fullness, tightness, aching, burning” instead of the word “pain” to describe their chest symptoms. She told me later that she wonders how many women’s charts say “No CP” because of the words they said to a physician – not because they don’t have chest pain.
Another research topic that Dr. Kreatsoulas and her colleagues have investigated was what she calls the “symptomatic tipping point“, that transitional period between experiencing the first cardiac symptoms and seeking medical attention. In other words, when women repeatedly ignore their symptoms, what pushes them to finally seek emergency help?(3)
As she explained:
“We identified six stages before patients seek medical attention and the stages were similar between men and women varying only in duration between and within the stages, as women would wait for a more severe confirmatory event to occur before they would qualify their symptoms as “possibly cardiac”.
Those six stages, in chronological order, include:
- a period of uncertainty (patient attributes cardiac symptoms to another health condition)
- denial or dismissal of symptoms
- seeking assistance/second opinion of someone else, e.g. a friend or family member
- recognition of severity of symptoms with feelings of defeat
- seeking medical attention
When I asked Dr. Kreatsoulas about her team’s research findings, she explained:
“We found several surprising things in our study:
• “The six stages of the ‘symptomatic tipping point’ emerged during the qualitative part of our study. We had no prior knowledge of how patients transition between the internalization of symptoms, the expression of symptoms, and the thinking process that occurs before determining that they need medical attention for these symptoms. This is a novel finding.
• “While we know from prior research that women come to hospital later than men with more advanced stages of heart disease, we were surprised to uncover that one of the reasons for this may be that women go through a longer period of denial than men. While both women and men go through that first period of uncertainty when they are running through a host of other possible health conditions they could attribute their symptoms to (i.e. indigestion or a pulled muscle), men would readily consult with a loved one or friend in this uncertainty stage, but women did not. Even by the time patients reached the fourth stage of recognition of severity of symptoms, men had more self-recognition that they required medical attention – but women tended to wait for others to comment on their symptoms, and then they reacted to those comments.
• “In the quantitative study, we were surprised that while men and women were equally likely to seek medical attention for their symptoms if they felt physically limited by their symptoms, if they felt a change in the severity of their symptoms, or if they experienced a long duration of symptoms, women would wait for symptoms to become significantly more severe and frequent than men.
• “We were surprised that even when female heart patients finally came to the hospital, 1/3 still believed the symptoms were not related to their hearts.
• “Even more surprising, when we asked patients less than an hour prior to undergoing their diagnostic angiograms, women were less likely to think that their symptoms could be due to their hearts compared to men (statistically significant).”
My own gut feeling, however, is that those of us who have personally engaged in this “treatment-seeking delay behaviour“ as described in many research studies on female heart attack survivors – e.g. this study published in the American Journal of Critical Care(4) – may not actually find these observations surprising.
But surprising? No!
One only has to watch Elizabeth Banks’ hilariously chilling Go Red For Women™ video called Just A Little Heart Attack to recognize the distressingly common treatment-seeking delay behaviours that she perfectly nails in just three short minutes of trying to minimize her symptoms – in which she asks her worried young son the classic treatment-seeking delay question:
“Honey, do I look like the type of person who has a heart attack?”
This is so perfect! As a longtime distance runner, I too never imagined that I was even remotely that “type of person”. (I’m guessing that very few women think that they look like “that person”!)
I was, in fact, pitifully ignorant about heart disease before surviving my own cardiac event. It was almost two years after my heart attack, in fact, before I learned that women with pregnancy complications (like the preeclampsia I’d been diagnosed with during my first pregnancy) are at 2-3 times greater risk of heart disease – often years later. Pregnancy has in fact been called the “ultimate cardiac stress test”, and is now the focus of a relatively new medical specialty called Cardio-Obstetrics.
At my Heart Smart Women presentations, I’ve often been asked by audience members who are suddenly worried about their own personal risk of one day ending up like me (a surprised heart attack patient!) – often adding something like, “My grandmother died of a heart attack!” or “I have high blood pressure!” My stock answer (after the standard “I’m-Not-A-Doctor” disclaimer) is that there is simply no downside to living as if we knew with 100% certainty that we’re at very high risk for cardiovascular disease. Even without having any cardiac risk factors, we already know that quitting smoking, exercising your body, eating healthier, getting a good night’s sleep, and learning to manage stress are good ways to live life. And cardiologists have been warning us for years that most heart disease is preventable by making those kinds of lifestyle changes.
Heart disease may look very different in different people. Before my heart attack, if I ever thought about heart disease – which was approximately never! – I pictured an old fat guy out on the golf course, suddenly clutching his chest and falling down unconscious. Just as Dr. Kreatsoulas described in this month’s published study, I too thought of heart disease as a “man’s disease”. By the way, that old fat guy does exist, but that’s likely sudden cardiac arrest – (an electrical problem of the heart) and not a heart attack (a plumbing problem) – which is what I had.
Compared to that old fat guy, I walked into the Emergency Department on my own steam (twice! – two weeks apart), unaided, alert and conscious despite my severe symptoms of central chest pain, nausea, sweating and pain radiating down my left arm. This is what women in mid-heart attack can look like!
I think I went through all six stages before reaching that “symptomatic tipping point” that Dr. Kreatoulas describes. The first stage (a period of uncertainty ) in which “the patient attributes cardiac symptoms to another health condition” was certainly assisted by an Emergency physician who sent me home with a misdiagnosis of acid reflux after my first visit to his Emergency Department.
But if a woman with textbook Hollywood Heart Attack symptoms like mine can be immediately assessed incorrectly, what hope can there be for a woman with vague or unusual cardiac symptoms?
How likely will women be to return to that hospital when their cardiac symptoms return?
And most importantly, what effect does being misdiagnosed in mid-heart attack and turned away from the hospital have on women’s well-documented reluctance to seek emergency treatment for their cardiac symptoms?
Perhaps that’s a new focus for future cardiac research from Dr. Kreatsoulas and her colleagues?
1. Kreatsoulas, C. et al. “Patient Risk Interpretation of Symptoms Model (PRISM): How Patients Assess Cardiac Risk”. J GEN INTERN MED (2021).
2. Kreatsoulas, C. et al. “Reconstructing Angina: Cardiac Symptoms in Women and Men.” JAMA Intern Med. 2013; 173(9):829-833.
3. 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, p.S132.
4. Rosenfeld, A et al. “Understanding Treatment-Seeking Delay in Women with Acute Myocardial Infarction: Descriptions of Decision-Making Patterns”. Am J Crit Care July 2005 vol. 14 no. 4 285-293
I wrote more about addressing cardiac risk factors in my book A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or save 30% by ordering this book directly from Johns Hopkins University Press, using their code HTWN
Q: If you’re a heart patient, what do you think was YOUR most significant cardiac risk factor?
-Learn more about which cardiac risk factors may make you more likely to have heart disease