Heart attack in women: why the warning signs go unnoticed

A heart attack strikes women too: in France, 36,480 women were hospitalized for acute coronary syndrome in 2014, or 32.2% of all cases. Yet in women, the alarm tends to be raised later. Chest pain remains the most common sign, but it more often comes with shortness of breath, nausea or back pain. Patients and clinicians alike readily put these signals down to stress. This uncertainty delays the emergency call and weighs on survival.

What is a heart attack (myocardial infarction)?

During a myocardial infarction, part of the heart muscle dies from lack of blood because a coronary artery has suddenly become blocked. In the most common form, a fatty plaque (atheroma) cracks open in the artery wall and a clot forms on top of it. The heart cells that are destroyed do not regenerate. The only remedy is to reopen the artery as quickly as possible after symptoms begin, most often with coronary angioplasty, as the US National Heart, Lung, and Blood Institute explains.

France records an average of 80,000 heart attacks a year and about 12,000 deaths, according to Inserm, the French national institute for health and medical research. Nearly 10% of victims die within the first hour, and mortality reaches 15% at one year. French public health surveillance counted more than 110,000 hospital stays for acute coronary syndrome in 2014, including more than 60,000 for a myocardial infarction.

Before menopause, a woman is about four times less likely than a man to have a myocardial infarction, Inserm notes. After menopause, the risks become similar. Young women, however, are affected more often than they used to be. Between 2004 and 2014, hospitalizations for ST-segment elevation myocardial infarction rose by 21.7% among French women under 65 (Gabet et al., 2017). This is the most severe form on the electrocardiogram. The fastest rise was among women aged 45 to 54, at +3.6% a year. The authors point to the spread of smoking and obesity among women.

Why a heart attack in women can look different

Differences in symptoms stem first from age and coexisting conditions. Women develop coronary heart disease several years later than men, the American Heart Association points out (El Khoudary et al., 2020). In the US NRMI 2 registry (434,877 patients), one third of infarctions presented without chest pain (Canto et al., 2000). These patients were on average 7 years older (74.2 vs 66.9 years) and more often had diabetes (32.6% vs 25.4%). This group was also 49% women, compared with 38% among patients who had chest pain.

The underlying mechanism also differs more often in women. Several situations that are rare in men mainly affect women:

• Spontaneous coronary artery dissection: the artery wall tears apart without any fatty plaque and blocks blood flow. The American Heart Association describes it as an important cause of myocardial infarction in young women, often without classic risk factors (Hayes et al., 2018). It is associated with pregnancy and with physical or emotional stress.
• Myocardial infarction with no obstructive coronary arteries, known as MINOCA: coronary angiography shows no blocked artery. A meta-analysis of 28 publications found it in 6% of infarctions, in younger patients, 40% of whom are women (Pasupathy et al., 2015).
• Takotsubo syndrome, which mimics a cardiac emergency after an emotional or physical shock. Among 1,750 patients in an international registry, 89.8% were women, with a mean age of 66.8 years (Templin et al., 2015).

These forms make diagnosis harder. An inconclusive electrocardiogram or normal-looking arteries can lead clinicians to wrongly rule out a cardiac cause. Takotsubo syndrome is not an infarction in the strict sense, but it causes as many serious in-hospital complications as an acute coronary syndrome.

Heart attack in women: what studies show about symptoms

Chest pain remains the leading sign of a heart attack in women, but it is more often missing and surrounded by more accompanying symptoms. The US NRMI registry analyzed 1,143,513 patients hospitalized between 1994 and 2006. Of these, 42.0% of women arrived without chest pain, compared with 30.7% of men (Canto et al., 2012). The gap was widest before age 45 and became minimal after 75.

In-hospital mortality reached 14.6% in women and 10.3% in men in this registry. Before age 55, a woman without chest pain died more often than a man in the same situation. An earlier analysis of the same registry had already shown in-hospital mortality more than twice as high in women under 50 (Vaccarino et al., 1999).

The VIRGO study challenges the idea of “atypical” female symptoms. It surveyed 2,009 women and 976 men aged 18 to 55 who were hospitalized for a myocardial infarction. Chest pain, pressure or discomfort was present in 87.0% of women and 89.5% of men (Lichtman et al., 2018). Women, however, more often reported at least three associated symptoms: 61.9% vs 54.8%. These included, for example, palpitations or pain in the jaw, neck, arms or between the shoulder blades.

A meta-analysis of 27 studies confirms this twofold finding (van Oosterhout et al., 2020). During an acute coronary syndrome, women more often have pain between the shoulder blades (odds ratio 2.15), nausea or vomiting (1.64) and shortness of breath (1.34). Chest pain nevertheless dominates in both sexes: 74% of women report it, compared with 79% of men. The authors recommend dropping the “typical” and “atypical” labels. The World Health Organization makes the same point: shortness of breath, nausea, vomiting and back or jaw pain affect women more often than men.

A Scottish study shows that the blood test matters as much as the symptoms. The researchers measured troponin using a separate threshold for each sex. Under these conditions, 92% of women and 91% of men with a suspected coronary event presented with chest pain (Ferry et al., 2019). Among women whose infarction was confirmed, so-called classic symptoms were even more frequent than in men (77% vs 59%). Above all, 27 of the 90 infarctions in women (30%) would have been missed by the older single-threshold assay. They were only picked up with high-sensitivity troponin and a lower, female-specific threshold.

Finally, some signs can precede the event by several weeks. In a survey of 515 women, 95% reported warning symptoms (McSweeney et al., 2003). The most common were unusual fatigue (70.7%), sleep disturbances (47.8%) and shortness of breath (42.1%). Only 29.7% had felt chest discomfort during this period. These memories were collected 4 to 6 months after hospitalization, and the authors stress that nobody knows whether they can predict an infarction.

Why heart attack signs go unnoticed in women

Heart attack signs go unnoticed in women because several delays add up, from the perception of symptoms all the way to treatment. The first delay comes from the patients themselves. In the VIRGO study, 20.9% of women attributed their symptoms to stress or anxiety, compared with 11.8% of men. In the United States, only 44% of women knew in 2019 that heart disease is their leading cause of death, down from 65% in 2009 (Cushman et al., 2021).

The second delay occurs before arrival at the hospital. A registry of 41 hospitals in Central and Eastern Europe followed 6,022 severe infarctions (Bugiardini et al., 2017). The median time from first symptoms to hospital reached 270 minutes in women, compared with 240 in men. Thirty-day mortality was 1.58 times higher in women (odds ratio). This gap disappeared when patients arrived within the hour.

The third delay concerns diagnosis. One study covered 10,689 patients in 10 US emergency departments (Pope et al., 2000). Women under 55 with acute cardiac ischemia were more likely to be sent home (odds ratio 6.7). Shortness of breath as the main complaint or a normal electrocardiogram also raised this risk. In VIRGO, 29.5% of women had already sought care for similar symptoms before their hospitalization. For 53% of them, the clinician had not thought of the heart, compared with 37% of men.

The last delay affects treatment. In Sweden, the relative excess mortality of women one year after an ST-segment elevation myocardial infarction reached 1.89 (Alabas et al., 2017). It fell to 1.43 once access to guideline-recommended treatments was taken into account. Part of the gap therefore reflects less complete care. The Lancet commission on women and cardiovascular disease sums it up: in women, these diseases remain under-studied, under-recognized, under-diagnosed and under-treated (Vogel et al., 2021).

The Australian figures come from 6,330 infarctions transported by ambulance (Stehli et al., 2021). Added together, delays within the health system amounted to 10 extra minutes for women. Their 30-day mortality was 1.38 times higher (odds ratio). The gaps look modest, but they involve a muscle that loses cells with every minute the artery stays blocked.

Heart attack: the signs to recognize and when to call for help

The right reflex does not depend on the type of symptoms: whether the situation is “clear or ambiguous,” Inserm urges people in France to dial 15 immediately. Elsewhere, call 911 in the US, 999 in the UK or 112 in Europe. Emergency teams (the SAMU in France) can record an electrocardiogram on site and send the patient straight to a cardiac catheterization lab. In a woman, the following signs should raise the alarm, alone or together:

• Pain, pressure, tightness or burning in the chest, even if it is mild.
• Pain that spreads to the jaw, neck, an arm, the back or between the shoulder blades.
• Unusual shortness of breath, at rest or with minimal effort.
• Nausea, vomiting or pain in the pit of the stomach, with no obvious digestive cause.
• Cold sweats, faintness, dizziness or sudden weakness.
• Intense, unusual fatigue, especially if it comes with any of the signs above.

The table below sums up what to do in each situation. The same principles apply to stroke, whose signs can be spotted with the FAST test and an immediate emergency call.

In the emergency department or on the phone, describing exactly what you feel helps the clinician. It helps to mention when the symptoms started, any smoking, diabetes, high blood pressure or past pregnancy complication. A patient can also ask whether an electrocardiogram and a troponin test have been done. The menopause transition worsens blood lipids and vascular health, according to the American Heart Association. This is a good time to take stock with your doctor (see our levers for aging well after menopause). For some women at intermediate risk, the coronary artery calcium score helps refine this risk.

Lowering your heart attack risk: the factors that weigh more in women

Preventing a heart attack relies on the same levers in women as in men, but several factors carry more weight for women. The INTERHEART study, conducted in 52 countries, attributed 94% of infarction risk in women to nine modifiable factors, compared with 90% in men (Yusuf et al., 2004). They include smoking, blood lipids, high blood pressure, diabetes, abdominal obesity and psychosocial stress. These vascular and inflammatory mechanisms are explained in our pillar on altered intercellular communication.

• Quit smoking: tobacco raises coronary risk 25% more strongly in women than in men (Huxley and Woodward, 2011). This meta-analysis pooled 86 prospective cohorts and 3.9 million people. In former smokers, this sex-related excess risk no longer appears.
• Keep an eye on blood sugar: diabetes multiplies coronary risk by 2.82 in women, compared with 2.16 in men (Peters et al., 2014). The relative excess for women therefore reaches 44%.
• Report an early menopause: in the UK Biobank, natural menopause before age 40 was associated with a 36% higher cardiovascular risk (Honigberg et al., 2019). This excess reached 87% after surgical menopause, among 144,260 women followed. This is an association, not a proven cause.
• Mention your pregnancies: preeclampsia, gestational diabetes, preterm delivery or a low-birth-weight baby raise later cardiovascular risk, according to the American Heart Association (Parikh et al., 2021).
• Move every day and eat fruit and vegetables daily: in INTERHEART, these two habits were associated with a lower risk of infarction (odds ratios 0.86 and 0.70).
• Have your blood pressure and LDL cholesterol checked regularly, two factors that rise after menopause.

These factors do more than guide prevention. Once your doctor knows them, they also change how a vague symptom is read on the day it appears. Shortness of breath with nausea does not carry the same weight in a 52-year-old woman who smokes and has diabetes as in a patient with no risk factors. Saying so clearly to the emergency call handler or in the emergency department speeds up the right diagnosis.

Frequently asked questions about heart attack in women

What are the signs of a heart attack in women?

Chest pain or discomfort remains the most common sign in women: 87% of patients aged 18 to 55 describe it in the VIRGO study. More often than in men, it comes with shortness of breath, nausea, pain between the shoulder blades, in the jaw or arm, sweating or intense fatigue. A single one of these signs, if unusual and persistent, is reason enough to call emergency services (911, 999 or 112).

Why is a heart attack more often missed in women?

Several delays add up. Women more often attribute their symptoms to stress (20.9% vs 11.8% of men in the VIRGO study) and reach the hospital later. In emergency departments, women under 55 were more likely to be sent home despite acute cardiac ischemia. Forms without a blocked artery, which are more common in women, also complicate the diagnosis.

Can a heart attack happen without chest pain?

Yes. In a US registry of 434,877 patients, one infarction in three presented without chest pain on arrival at the hospital. These patients were older, more often women or people with diabetes, and arrived later. Their in-hospital mortality reached 23.3%, compared with 9.3% for patients with pain. Sudden shortness of breath, faintness or unexplained sweating should prompt an emergency call.

Can fatigue signal a heart attack in women?

Sometimes. In a survey of 515 women hospitalized for a cardiac event, 70.7% recalled unusual fatigue in the preceding weeks, and 47.8% recalled sleep disturbances. These memories are retrospective, and fatigue has many other causes. New and persistent fatigue, especially with breathlessness on exertion or with risk factors, warrants a prompt medical visit.

Do women die from a heart attack more often than men?

At the same age, young women fare worse. In the US NRMI registry, in-hospital mortality among women under 50 was more than twice that of men the same age. The gap disappeared after age 74. In Sweden, the excess mortality among women drops markedly once access to recommended treatments is taken into account.

What should you do while waiting for help if you think you are having a heart attack?

Call 911, 999 or 112 (15 in France) without waiting for the pain to pass, then sit or lie down and stay calm. Do not drive yourself to the emergency department: the emergency team can record an electrocardiogram on site and send you straight to a specialized unit. Do not take any medication, aspirin included, without the go-ahead of the emergency doctor or dispatcher. Leaving the front door unbolted and getting your prescriptions ready helps the responders.