It is a sad thing to admit – and no doubt what we’re about to say will be a shock to many – but as cardiologists with decades of experience, our advice to women is this: if you think you’re having a heart attack, take a man with you to the hospital. It may just save your life.
Research shows that women’s symptoms are often not taken seriously by emergency medics, but if there’s a man around to advocate the patient is less likely to be dismissed.
Even in our brilliant NHS, which has some of the most cutting-edge treatment available in the world, evidence shows women are much more likely to die from heart problems than men. We are 50 per cent more likely to be wrongly diagnosed – which can be fatal – and less likely to be treated promptly.
Women are 34 per cent less likely than men to get an angiogram – a type of X-ray used to diagnose a heart attack – within 72 hours of their symptoms starting. We’re also three per cent less likely to receive timely procedures using drugs or stents to restore blood flow. In fact, the British Heart Foundation (BHF) calculates that 8,243 women’s lives were lost in England and Wales between 2002 and 2013 because they didn’t receive the same standard of care as men.
The outcomes for women having heart operations – such as valve replacements and transplants – are also worse, largely because the procedures were developed for, and trialled on, men. Even after being discharged from hospital after successful treatment, women are less likely to be given the drugs recommended to prevent further heart attacks.
Research shows that women’s symptoms are often not taken seriously by emergency medics, but if there’s a man around to advocate the patient is less likely to be dismissed
The outcomes for women having heart operations – such as valve replacements and transplants – are also worse, largely because the procedures were developed for, and trialled on, men
We don’t want you to panic, but if you know all this then you can do something about it.
The first thing to know is that women’s risk of cardiovascular problems dramatically increases in mid-life, around the time she starts going through the hormonal changes of the menopause. The second is that a woman having a heart attack may have symptoms which are not considered typical.
A regular feature of health campaigns highlighting heart attack symptoms is the image of a man – it is usually a man – clutching his chest in agony while the pain radiates outwards and down the arms. While there is overlap between the way both sexes experience a heart attack, symptoms can be different in women.
About 80 per cent of women may experience tightness or heaviness in the middle of the chest, but they are more likely than men to have pain in their back, between the shoulder blades, along with nausea and breathlessness. Sometimes, overwhelming fatigue is one of the only symptoms.
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The reasons behind the differences are complex. More women may develop heart attacks due to temporary blockages, when fatty plaques in the heart’s arteries erode. There are likely other biological differences we don’t know about.
These differences are why doctors may not suspect a heart attack in a woman when she arrives at A&E, and this delays treatment.
Women often misread the signs too. As clinicians, we’ve seen significant numbers who think they’re having panic attacks, indigestion or suffering a chest infection. They don’t want to bother anyone and the last thing on their mind is that they’re having a heart attack.
And so they soldier on. But by the time they come to hospital the damage can be serious, and such delays and misdiagnoses increase the risk of death by 70 per cent.
Everyone needs to be aware that every year double the number of women die of heart disease than they do of breast cancer. That is why it’s important to have someone to advocate for you – ideally a man, but ultimately having anyone who can say you’re not acting normally will help.
As the US physician Dr Alyson McGregor describes in her book Sex Matters, women often have trouble convincing doctors how serious their pain is. The more a woman tries, the more their behaviour is perceived as hysterical and will be downgraded as ‘typical female behaviour’.
Dr McGregor agrees that if you have someone else there to say ‘she’s not usually like this’, that might just be crucial.
Medical sexism is real – however male doctors might deny it. Survival rates are up to three times higher for women treated by a female doctor. Just having more women as part of a clinical team improves how well male doctors treat women.
Heart attacks are almost as likely in women after the menopause as they are in men. The reason is poorly understood, but is thought to be linked to hormonal changes.
The female sex hormone oestrogen protects against the formation of plaques – inflammation and build-up of fatty deposits in the arteries which can lead to heart attacks. Oestrogen peaks in our early 30s – and when it wanes that protection does too. Women often gain weight around this time, partly because the body tries to compensate for the oestrogen reduction with fat cells, which produce a weaker form of the hormone.
A healthy, balanced diet, limiting alcohol and exercising at least 150 minutes a week – which can be brisk walking but should also include strength exercises – are a good way to start. It’s also never too late to stop smoking
The way women store fat changes, too. It accumulates around our internal organs, which can cause cholesterol levels to rise and increase the risk of type 2 diabetes (see panel, right). Both high cholesterol and type 2 diabetes increase the risk of heart disease. Blood pressure also increases around this time, which is a huge risk for the development of coronary artery disease – the hardening of the arteries.
Studies have shown there are other female-specific factors which may also increase your mid-life risk of a heart attack, including fertility and pregnancy disorders such as pre-term delivery, gestational diabetes and polycystic ovarian syndrome.
We recommend that if you’re attending hospital with any of the symptoms we’ve mentioned, make sure the team has considered if it might be a heart attack. If you’re being taken by ambulance, ask if you can be taken to a specialist heart attack centre instead of a local A&E.
The guidelines are clear on the protocol doctors should follow.
Patients should have an electrocardiogram (ECG) to measure the heart’s electrical activity and a blood test to check for troponin, a protein released by the heart if it’s damaged. Some patients may also get an angiogram, which involves injecting a dye into the arteries and taking X-ray pictures of the heart to check for blockages.
If there is a complete blockage, known as a STEMI, you may need coronary angioplasty, which restores blood flow to the heart by inserting a balloon via a catheter into the blocked artery and inflating it. A stent – a mesh tube that acts as a scaffold to keep the artery open – may also be implanted in a similar procedure. For heart attacks which involve a partial blockage – called NSTEMIs – only medications will be given.
Women are 34 per cent less likely than men to get an angiogram – a type of X-ray used to diagnose a heart attack – within 72 hours of their symptoms starting
Yet women are less likely to get an angiogram or an angioplasty. A study found men have 20 per cent more of these procedures than women and were nearly twice as likely to survive while in hospital.
Women are also less likely to get the recommended medication following a heart attack and are more likely to die in the year following the attack than men. The guidelines recommend taking five drugs after a heart attack: antiplatelets, which prevent abnormal blood clotting, ACE inhibitors to lower blood pressure, beta blockers to control heart rate and lower blood pressure, statins to reduce cholesterol, and aspirin, a blood thinner. Check you’ve been given all of them, and if not, make sure the doctor explains why.
It is also worth knowing there are cardiovascular conditions which disproportionately affect women but are less likely to be picked up in tests – so-called silent heart attacks which can result in them being told nothing is wrong and sent home.
If an angiogram appears clear but the symptoms suggest a cardiovascular problem, doctors shouldn’t just stop investigating but use other techniques – such as a cardiac MRI, echocardiogram or intravascular imaging – until the issue is discovered.
If you’re in this situation, and an angiogram is clear but you’re still concerned, ask whether other tests can be carried out. Keep this article, in case you need to refer to it.
Much still needs to be investigated. There is a distinct possibility that women’s heart troubles may need to be treated differently because of their unique biology. And that needs further research.
Part of the problem is that most heart research has been carried out on men or male animals.
In Dr McGregor’s book, she describes a visit to a well-known US university which was proud of the 200 dummies it had for students to practise on that simulated various diseases. All were male – the one depicting pregnancy had a blonde wig and a womb next to it on the table.
So what can women do to help themselves avoid a heart attack in the first place?
A healthy, balanced diet, limiting alcohol and exercising at least 150 minutes a week – which can be brisk walking but should also include strength exercises – are a good way to start. It’s also never too late to stop smoking.
And all adults aged 40 to 74 should have an NHS Health Check every five years – if you haven’t had one, call your GP surgery and ask for it.
This will assess your blood pressure, cholesterol, BMI and blood sugar levels, and can give you an idea of whether you’re at increased risk of a heart attack in the next ten years.
High blood pressure is one of the most under-diagnosed heart conditions and the number one risk factor for a heart attack – and it’s entirely preventable. If blood pressure stays consistently high, medication can bring it down. But a healthy diet and regular activity are vital.
But most importantly, act on any concerns you have.
And never ignore breathlessness or pain in your chest, upper back or left arm.
Don’t wait until it’s too late.