There's a gender gap in heart disease, in terms of both symptoms and responses. 

We addressed aspects of the gap in Women's Heart Risks, and Women's Heart Problems Found Distinct.

Every year, more than 15,000 American women under aged 55 or younger die from heart disease, making it a leading cause of death among them.

Middle-aged and younger women also have rates of heart-related death higher than those of their male peers … a disadvantage that new research may help explain.

Women miss or ignore warning signs, and delay treatment
The results of a new study extend the gender gap in heart disease to the sexes' differing reactions to early signs of a heart attack. 

Even though heart disease is the number one killer of women, they often ascribe the symptoms to less threatening conditions like acid reflux, the flu, or normal aging. 

To probe this problem, researchers led by scientists from Yale University interviewed 30 women, aged 30 to 55, who'd previously been hospitalized with a heart attack (Lichtman JH et al. 2015).

Through in-depth interviews, they explored how the women responded during the crucial period between their first symptoms and when they sought urgent medical care.

And the results support the perception that women often miss or ignore early heart-attack symptoms and delay emergency care.

The interviews produced five other findings:
  1. Patients inaccurately assessed their personal risk of heart disease.
  2. The women's initial symptoms varied widely in both nature and duration.
  3. Work and family factors sometimes influenced the decision to seek emergency help.
  4. Women did not routinely access primary care, including preventive care for heart disease.
  5. Not all patients received a prompt or complete workup for their symptoms, or a formal diagnosis.
“Young women with multiple risk factors and a strong family history of cardiac disease should not assume they are too young to have a heart attack,” said lead researcher Judith Lichtman, PhD, MPH of the Yale School of Public Health.

In addition, she said, “Participants in our study said they were concerned about initiating a false alarm in case their symptoms were due to something other than a heart attack.”

Study co-author Leslie Curry of the Yale Global Health Leadership Institute said more needs to be done to teach women about the early symptoms of a heart attack and to change the way that women and health care providers respond.

In addition to promoting knowledge about heart disease and encouraging more prompt care-seeking behaviors, another important goal for this population of women is improving preventive heart care, Lichtman added.

The study was funded by the Fannie E. Rippel Foundation and grants from the National Heart, Lung, and Blood Institute.

Heart attack symptoms in women: Chest pain not always present
Young and middle-aged women do not always experience a common, stereotypical heart attack symptom. 

This was confirmed by a recent Canadian study among 1,015 people (305 women and 710 men) aged 45 to 53 who'd been hospitalized for acute coronary syndrome (Khan NA et al. 2013). 

(The term “acute coronary syndrome” means a sudden blockage of blood supply to the heart, caused by a heart attack, unstable angina, or other cardiac crisis.) 

Overall, the women in the study were less likely to experience chest pain – uncomfortable pressure, squeezing, fullness or pain in the center of the chest – than men.

And although it was the most common heart attack symptom in both sexes, one in five female patients didn't feel any chest pain.

The researchers also found no links between a woman having chest pain and the severity of her heart attack.

According to study co-author Dr. Louise Pilote, MD, MPH, PhD, “Our study demonstrates that young women who come into the emergency without chest pain, but other telltale symptoms such as weakness, shortness of breath and/or rapid heartbeats, are in crisis.”

The American Heart Association identifies some common heart attack symptoms in women:
  • Chest pain
  • Shortness of breath, with or without chest discomfort
  • Pressure or pain in the lower chest or upper abdomen 
  • Nausea,, dizziness, lightheadedness, or breaking out in a cold sweat
  • Pain or discomfort in one or both arms, the back, neck, jaw, or stomach
The AHA advises the following if you experience any of these symptoms:
  • Do not wait. Dial 911, follow the operator's instructions, and get to a hospital right away.
  • Do not drive yourself or have someone drive you to the hospital unless you have no other choice.
  • Stay as calm as possible and take deep, slow breaths while you wait for the emergency responders.
Women underrepresented in heart disease research
Because of a research gap, we don't really know what we should about key aspects of the gender gap in heart disease: 
  • Symptom differences
  • Diagnostic approaches and treatments
  • Women's different responses to heart disease
A special supplement to the March 2015 issue of an American Heart Association journal – Circulation: Cardiovascular Quality and Outcomes – is dedicated to heart disease research in women, and includes the new Yale-led report.

As journal co-editor Harlan Krumholz, M.D., S.M., said, “Dedicating a women's themed section in this research journal offers the latest in quality studies on women and reminds us about the importance of this area of investigation.”

“In the future, if we really want to answer all the questions we have about gender differences, then we need studies that are large enough, focused enough and with the intent from the start to illuminate the issues around sex differences.”

These are some of the studies and perspectives in the journal's special supplement:
  • A Veterans Administration study in 3,181 women given cardiac catheterizations found they were younger, more likely to be obese, depressed and suffer from post-traumatic stress disorder, compared with men. Women were also less likely than men to have blockages in their arteries.
  • Among people with atrial fibrillation (AFib), women are at higher risk for stroke then men. Women are as likely as men to have heart failure, but are more likely to die.
  • While they're equally likely to benefit from advanced therapies, including heart transplant and left ventricular assist device (LVAD), women are less likely to be referred for these therapies and if referred, receive them at a later stage.
  • Researchers from Brigham and Women's Hospital said that by analyzing biometric data, clinical trials data and health services data together, we can begin to sort out why men and women differ.
  • At every career stage, women leave academic medicine and research at a higher rate than men. Proposed solutions include helping them balance career and family, and creating better networking and mentoring opportunities.
We'll keep you posted on heart research in women, and hope that the pace picks up!

  • American Heart Association (AHA). Women's heart disease should be a research priority. February 24, 2015. Accessed at news/womens-heart-disease-should-be-a-research-priority 
  • American Heart Association (AHA). Special Supplement: Women and Heart Disease. Circ Cardiovasc Qual Outcomes. January 2015, Volume 8, Issue 1. Accessed at 
  • Bucholz EM, Strait KM, Dreyer RP, Geda M, Spatz ES, Bueno H, Lichtman JH, D'Onofrio G, Spertus JA, Krumholz HM. Effect of low perceived social support on health outcomes in young patients with acute myocardial infarction: results from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study. J Am Heart Assoc. 2014 Sep 30;3(5):e001252. doi: 10.1161/JAHA.114.001252. 
  • Dreyer RP, Smolderen KG, Strait KM, Beltrame JF, Lichtman JH, Lorenze NP, D'Onofrio G, Bueno H, Krumholz HM, Spertus JA. Gender differences in pre-event health status of young patients with acute myocardial infarction: A VIRGO study analysis. Eur Heart J Acute Cardiovasc Care. 2015 Feb 13. pii: 2048872615568967. [Epub ahead of print] 
  • Dueñas M, Ramirez C, Arana R, Failde I. Gender differences and determinants of health related quality of life in coronary patients: a follow-up study. BMC Cardiovasc Disord. 2011 May 27;11:24. doi: 10.1186/1471-2261-11-24. 
  • Khan NA, Daskalopoulou SS, Karp I, Eisenberg MJ, Pelletier R, Tsadok MA, Dasgupta K, Norris CM, Pilote L; GENESIS PRAXY Team. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med. 2013 Nov 11;173(20):1863-71. doi: 10.1001/jamainternmed.2013.10149. 
  • Leifheit-Limson EC, Reid KJ, Kasl SV, Lin H, Jones PG, Buchanan DM, Parashar S, Peterson PN, Spertus JA, Lichtman JH. The role of social support in health status and depressive symptoms after acute myocardial infarction: evidence for a stronger relationship among women. Circ Cardiovasc Qual Outcomes. 2010 Mar;3(2):143-50. doi: 10.1161/CIRCOUTCOMES.109.899815. Epub 2010 Feb 16. 
  • Lichtman JH et al. Symptom Recognition and Healthcare Experiences of Young Women With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes. S.114.001612. Published online before print February 24, 2015. doi: 10.1161/CIRCOUTCOMES.114.001612 Accessed at CIRCOUTCOMES.114.001612.abstract 
  • Mosca L et al. Twelve-Year Follow-Up of American Women's Awareness of Cardiovascular Disease Risk and Barriers to Heart Health. Circ Cardiovasc Qual Outcomes. 2010;3:120-127 published online before print February 10 2010, doi:10.1161/CIRCOUTCOMES.109.915538 
  • Yale University (YU). Younger women delay seeking help for heart attacks, study finds. February 24, 2015. Accessed at younger-women-delay-seeking-help-heart-attacks-study-finds