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Atypical for half the population
Symptoms and assumptions
Most people having a heart attack, women and men, have chest pain. Women are more likely to have other symptoms at the same time. It may be a little discomfort rather than pain, mostly breathlessness, or a back that hurts, or a head that feels foggy. Medicine labeled that combination atypical.
The symptoms can be subtler, and the surrounding assumptions make them subtler still. A woman may not think she can get heart disease, because attention in her family goes to breast health and reproductive health. Doctors miss the clues, so women are not rushed to an electrocardiogram or put in the right part of the emergency room. Each of these piles onto the others and women still end up with bad outcomes.
The classic pain
The classic pain starts on the left side of the chest as a heaviness and can radiate to the neck, the jaw, and the left arm, in men and women alike. Nobody's heart attack feels like anyone else's, and pain in the right arm counts as much as pain in the left.
Delay at the ER door
Many women are reluctant to go to the emergency room because they are embarrassed or don't want to overreact. Among cardiologists, the running joke is that the worst thing is to miss a heart attack. A false alarm caused by bad Chinese food or a pulled muscle costs far less than a person sitting home with a real heart attack.
Why might women's symptoms differ from men's?
Angiography studies such as the NHLBI-sponsored WISE study found that women more often have disease spread through the smaller vessels of the heart rather than one large blockage in a main artery. That diffuse pattern can reduce blood flow across a wide area of muscle, which may show up as fatigue and breathlessness instead of crushing chest pain. Women also tend to be older than men at the time of a first heart attack, and older patients of either sex report a wider range of symptoms.
How does heart pain end up in the jaw?
Nerves carrying pain signals from the heart enter the spinal cord at the same levels as nerves from the neck, jaw, shoulder, and arm. The brain cannot always tell which source a signal came from, so it can place the sensation in those areas. This is called referred pain. The same wiring explains why heart trouble can feel like a toothache or a strained shoulder.
Why do minutes matter during a heart attack?
Experiments in animals by Keith Reimer and Robert Jennings in the 1970s showed that heart muscle deprived of blood begins to die within roughly 20 minutes. The damage then spreads outward from the inner wall of the heart over the following hours. Dead heart muscle is replaced by scar tissue, which cannot contract. This is why emergency teams measure the time from arrival to opening a blocked artery in minutes.
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