After nearly three decades of raising awareness about heart disease in women, cardiologist Dr. Nieca Goldberg still has female patients who said they hesitated to call for help at the onset of a heart attack.
“Often many women I meet tell me they just took an aspirin and checked out the symptoms on the internet,” said Goldberg, the medical director of the Joan H. Tisch Center for Women’s Health at NYU Langone. “And truly, if you think you have a heart attack, you need to call 911 and not waste time going online to check your symptoms.”
It’s not just Goldberg’s patients. A study released this week by the European Society of Cardiology found that women having a heart attack wait approximately 37 minutes longer than men before contacting medical services. Researchers performed the retrospective analysis on 4,360 patients — 20 percent of whom were women — treated at Triemli Hospital in Switzerland from 2000 to 2016. (The study did not find that the delay was associated with higher rates of death.)
One of the reasons women wait longer to call for help is that they don’t know that heart attack symptoms for women are sometimes different from men’s, according to the study’s author and experts interviewed by HuffPost after its release.
“Men often get crushing chest pain. It’s kind of clear. They’ll call for help or go to the ER,” said Dr. Suzanne Steinbaum, an expert in female cardiovascular medicine at New York’s Mount Sinai hospital who works with the American Heart Association’s Go Red for Women initiative. It’s possible for women to experience the classic chest-clutching, arm-numbing signs of heart attack, but sometimes they’re far less obvious. “Women’s symptoms could be more subtle, like shortness of breath or jaw pain, back pain, nausea, vomiting, even flu-like symptoms.”
Signs can also include throat, neck, chest, stomach or shoulder pain that lasts for more than 15 minutes and cold sweat, dizziness and weakness.
“The subtleties of these symptoms sometimes lead women to believe maybe they will feel better soon or it’s going to pass, and they don’t reach out for help,” Steinbaum added.
Goldberg said women might hesitate because they’re worried about looking silly if they show up at the hospital and aren’t having a heart attack. But she and Steinbaum agree that the risk is far too high to ignore the symptoms.
“The head of my fellowship program used to say, ‘Remember, time is muscle,’” Steinbaum said. “The longer you wait, the higher the chance of damaging a bigger part of your heart, and if that happens, the greater chance of really becoming quite sick with heart failure or death.”
“The subtleties of these symptoms sometimes lead women to believe maybe they will feel better soon or it’s going to pass, and they don’t reach out for help."”
Despite the fact that heart disease is the leading cause of death for both men and women in the United States, heart disease has been historically perceived as a man’s disease and has been studied and treated as such.
“It’s not that women don’t have heart attacks,” said Goldberg. It’s that they differ in women, presenting differently and often later in life. “The most common time for [women] to have them is about 10 years after menopause, whereas in men, the prime time to have a heart attack is their 40s and 50s.”
Heart attack rates are rising among people ages 35 to 54 ― and those rates are rising faster among women.
About 80 percent of cardiovascular disease can be prevented. That is why it’s important to raise awareness about heart disease in women, its prevalence and how it differs from heart disease in men — not just among patients but among members of the medical and research community as well, where women’s needs aren’t getting the attention they should.
A Women’s Disease Too
During her residency, Goldberg once heard a doctor say women don’t get heart disease. Then in 1990 a female patient came in with what she suspected were symptoms of a heart attack. While other doctors told the patient she was likely just stressed, Goldberg wasn’t convinced.
After a stress test came back abnormal, she persuaded the patient’s doctors to do further cardiac testing. The patient was found to have a 99 percent blockage in a major heart artery ― on the precipice one of the deadliest types of heart attacks there is.
Goldberg said a lot of advances have been made since then but more has to be done to dispel the myth that heart disease affects mostly men.
Gender disparities in diagnosis and treatment are still considered a significant issue. A study published by the American Heart Association in February found that when women sought medical care for heart attack symptoms, 53 percent of the time, their health care providers did not believe their symptoms were health related. That’s compared with 37 percent of men who were told the same thing.
In August a report from Stony Brook University in New York found that women having a heart attack waited 20 percent longer than men did from the moment they arrived at the hospital to when they began to receive care. That month another study, published in Proceedings of the National Academy of Sciences of the United States of America, showed that women are more likely to survive a heart attack if their cardiologist is a woman.
“I think it’s become important to understand there are studies that have shown that doctors have really not been as proactive about taking care of their women patients compared to their male patients when it comes to heart disease ― whether it’s because they’re not as aware or perhaps because there is an unconscious gender bias to it,” Steinbaum said.
“I would like to believe in the medical world, [bias] doesn’t exist, but the problem is we are all human beings,” she added.
Part of the problem, Goldberg said, is a lack of female cardiologists, who have thus far led the way when it comes to researching and raising awareness of heart disease in women.
“I think a lot of the movement on cardiovascular disease in women has been led by women who are cardiologists,” she said. But “we make up only 12.5 percent of the board-certified cardiologists in our country. And I think our male colleagues have to also get involved.”
Giving women the knowledge and language to communicate their symptoms is an important way to overcome possible bias, Goldberg and Steinbaum stressed.
“Women themselves, they’re not educated about the symptoms. They’re not really good advocates for themselves to even go and say, ‘I’m not sure, but I might be having a heart issue,’” Steinbaum said. “I think personal advocacy becomes a very, very important part of this.”
The Knowledge Gap
Steinbaum said the conversation around heart disease began to shift in 1984, when more women began dying of the disease than men.
Before then, “all heart disease research was done on men,” she added. “Women were just not part of those trials and certainly not part of the major preventive trials. So we’ve gone from not having women in trials to now beginning to study women’s hearts and realizing there is a fundamental difference [between women and men], and we are learning.”
For instance, it is known that conditions such as diabetes, lack of exercise and cigarette smoking increase both men’s and women’s risk for heart attack. But research has revealed that there are others conditions, including gestational diabetes and autoimmune disease, that can increase the risk of heart disease specifically for women, according to Goldberg.
““A lot of the movement on cardiovascular disease in women has been led by women who are cardiologists. ... I think our male colleagues have to also get involved.””
Both cardiologists said to learn more about the unique issues in heart disease among women, more research must be done regarding prevention, risk factors, and treatment. Steinbaum said this includes having women represented in clinical trials for pharmaceuticals and devices that are used in treatment and surgery. “Women’s participation in research studies is only about 20 percent,” Goldberg said.
It’s especially low among black women, who are disproportionately affected by strokes. Almost 50 percent of African-American women ages 20 or older have some form of cardiovascular disease. But Steinbaum said they get less care and are less likely to be involved in clinical trials than white women.
“Unless we have women represented in clinical trials, we won’t have enough information about treatment and diagnosis for women in heart disease,” Goldberg said.
Neither she or Steinbaum knows why so few participate in clinical trials, but they hypothesize that at least part of it is that many women are still the primary caretakers for their families and are too busy juggling work, children and more to participate in trials that are time-consuming.
“We have to make research easier for potential individuals to engage in and give them a better understanding about participation in research and how it will drive important changes in health care in women,” Goldberg said.
In the meantime, spreading the word about the particular ways heart disease can manifest in women is crucial to making sure they recognize the signs and get the help they need — and fast.