Heart Attacks and Women

For many women, a heart attack may feel like a strange discomfort in the back or some other easily ignored sign, instead of crushing chest pain.

When women do go to the hospital, doctors may miss the diagnosis of heart attack because the symptoms are vague. "They're sent home thinking the problem is in their heads, not their hearts," says Nanette K. Wenger, M.D., an Atlanta cardiologist. "Yet in far too many cases, women go on to have heart attacks."

Now evidence confirms that heart disease may differ in women in ways that doctors may not realize. Those findings come from the National Heart, Lung, and Blood Institute's Women's Ischemia Syndrome Evaluation study. (Ischemia means inadequate blood flow.) The study is called WISE for short.

WISE showed that for many women, heart disease does not occur from obvious plaque blockages in arteries, as it does in men.

Instead, for about 3 million women, plaque spreads evenly along the artery wall or in the smaller arteries—areas hidden from an angiogram, the standard imaging test that measures blood flow in the big arteries.

Subtle symptoms

In women with this problem, which is called coronary microvascular syndrome, blood flow to the heart falls dangerously low. But they don't often feel the "elephant-on-the-chest" pain that takes place when large arteries shut down. Instead, they may have subtle symptoms. They may feel pressure or squeezing or shortness of breath. Symptoms may even pop up elsewhere in the body, such as the jaw. (This symptom of jaw pain can also appear in men having a heart attack.)

Most women with microvascular disease will continue to have symptoms, says WISE study project officer George Sopko, M.D. They'll become sicker and keep visiting the hospital. "Worse, they're at greater risk for heart attack or dying within four or five years," he says.

Some experts suggest that hormonal changes associated with aging or inflammation may explain why women's smaller blood vessels don't work right.

The WISE study also shows the need for tests other than the angiogram. WISE used a questionnaire that showed when women had trouble performing daily activities. That questionnaire could help doctors identify which women may be at risk for a heart attack and need a stress test, the best method for measuring blood flow, says Dr. Sopko.

The message is clear, he adds. "Women with symptoms need to take action now, and every woman needs to address her risk factors, the earlier the better," he says.

The stage for heart disease is set before menopause by factors such as high blood pressure, high cholesterol, extra weight (especially around the waist), and smoking—all factors that play a part in plaque buildup.

Check your blood pressure

Before menopause, for instance, a systolic reading (the upper number) of more than 120 on your blood pressure reading seems to show you face an added risk, WISE found. "Any time a woman visits a doctor, including her OB/GYN, she should have her blood pressure checked. If it's high, it should be treated aggressively," says Dr. Wenger.

High blood pressure is one of a cluster of symptoms called metabolic syndrome that also includes high cholesterol; high triglycerides, which are another type of blood fat; insulin resistance; and obesity.

Any woman found to have microvascular disease, metabolic syndrome, and other heart disease risk factors needs treatment.

This often means medication, but with mildly elevated numbers, lifestyle changes such as regular exercise and losing weight may help. The aim is to get your LDL ("bad") cholesterol below 130 mg/dL, your HDL ("good") cholesterol above 40 mg/dL (but above 60 mg/dL is preferable), your triglycerides below 150 mg/dL, and your waist size under 35 inches.

For women with high cholesterol, high blood pressure, or diabetes, however, medication is a must to help prevent heart disease. Exercise and diet are still important, but are secondary.

Don't ignore ANY symptoms

Dr. Sopko recommends you go to the emergency room or see your doctor anytime, anywhere if you have any of these symptoms:

• Any chest pain, pressure, tightening, or squeezing

• Unexplained pain in your jaw, shoulder, back, or arms

• Shortness of breath, particularly at rest

Women are more likely to have "non-classic" heart attack symptoms than men. Still, doctors note, unexplained jaw, shoulder, back, or arm pain can also signal a man's heart attack even when the classic crushing chest pain is absent.