I work in a hospital – and didn’t know I was having a heart attack. Here’s what more women should know

A few months ago at work, when I rose from my seat and walked a few steps, something felt off. There was a strange pressure in my chest and rib cage, but I ignored it, took my water bottle from the kitchen and returned to my desk.

The next day it happened again. There was no pain and my breathing was fine. But whenever I stood up and took a few steps, the odd squeezing would return. I work at a hospital as a neurosurgery coordinator, and the wall was lined with posters about stroke and heart distress signs. I barely glanced at the pictures, having memorized them years ago.

I stood in the hallway waiting for the sensation to pass. One of my co-workers, a nurse, saw me and asked if something was wrong. I told her I felt achy in my upper body, and that my neck and chest felt odd. She suggested I go to the ER.

“You never know,” she said. I thought it was probably just a pulled muscle, but I followed her advice. I owe her my life.

Deaths from heart disease are the number one killer of women, according to the American Heart Association. It causes a third of deaths a year – more than all forms of cancers combined.

At the ER, I mentioned the pressure in my chest area so the triage staff ran tests to check for heart trouble. However, they saw nothing abnormal on my electrocardiogram (which measures electric heart rhythm) or troponin levels (a protein blood test used to diagnose heart attacks).

The emergency staff sent me home with cholesterol and blood pressure medication. The following morning, I called a cardiologist because I was still having the odd sensation. After checking my arteries with a catheter, the doctor admitted me to the hospital. They had found blockages in two of my arteries; one was in the largest coronary artery, the kind of blockage that leads to so-called “widowmaker” heart attacks.

According to the physicians, it was severe enough to discuss heart bypass surgery. Fortunately, a stent was sufficient. The ER staff thought I might have had a heart attack and would have been on my way to another without medical intervention. When I heard the news, I was stunned. I worked in healthcare and was familiar with the signs of cardiac issues. How could I not know my heart was in serious trouble?

It turns out that this issue is fairly common. Symptoms show up differently in women – something I am now grateful to know.

What heart attack symptoms should women look out for?

A heart attack is a specific event, in which the blood flow to the heart muscle is suddenly blocked. (Conversely, heart disease refers to any condition that affects the heart – a common example is coronary artery disease, a buildup of plaque in the arteries. Symptoms for heart attack and heart disease are not the same, but there is some overlap.)

Symptoms of heart attacks are different for men and women, according to the American Heart Association.

The most common signs for men are pain in the chest, left arm, jaw, neck or back; nausea, vomiting, indigestion; and shortness of breath.

For women, the list of possible symptoms is longer: chest pain or pressure in lower chest, upper abdomen, jaw, neck and upper back; nausea or vomiting; fainting and shortness of breath; indigestion or extreme fatigue. Chest pain or pressure is not always present.

In addition, issues such as high blood pressure during pregnancy, menopause, hormone replacement therapy and use of birth control should be considered in evaluating overall risk.

However, this list is not exhaustive. Women should be prepared to look into other areas that may not stand out as symptomatic. For instance, the heart and stomach share nerves, and many women do not know that indigestion, nausea and GI distress can also be heart disease symptoms, said Dr Sirisha Vadali, a cardiologist at HonorHealth in Scottsdale, Arizona, specializing in women’s heart disease: “Lesser-known external factors are vital to getting an accurate diagnosis.”

Vadali also said it’s important to notice even small physical changes that may not seem related to the heart. I told Vadali about my unexpected diagnosis. “I hate to say it, but I’m not surprised,” she said. “I’ve spoken to many women who feel something is wrong, and don’t present the way men do. It’s difficult to explain to medical personnel that nothing really hurts, but your body is telling you there is real trouble-somewhere.”

According to the British Heart Foundation, symptoms may come on acutely, like they did for me. Vadali cautions women to take note of any sense that their body is responding differently and consult a medical provider if concerned.

“I had one young woman who couldn’t walk up a flight of stairs today, but she did two last week just fine,” she said of a patient who ended up needing prompt cardiac assistance.

What tests are helpful for diagnosing heart disease?

Vadali mentioned many women dismiss their own symptoms as anxiety, or just assume they are unfit.

“There’s an under-appreciation of cardiovascular risks in women,” said Dr Americo Simonini, a cardiovascular specialist with Cedars-Sinai medical center in Los Angeles. Other than the usual sugar, cholesterol and blood pressure checks, what else should we be checking for?

“We aggressively measure other things in men that we should be measuring in women,” said Simonini. He mentioned certain types of tests for proteins in the blood and inflammation can present a clearer picture in preventing a future incident, including:

• Elevated high-sensitivity C-reactive protein, or hs-CRP, score: the level of these proteins increases with inflammation, and a high level can indicate blood vessels in the heart are narrowing (cardiovascular disease).

• Lipoprotein(a) elevation: a genetic test for inherited LDL (“bad”) cholesterol; high levels significantly increase risk of heart attack via plaque buildup in arteries.

• Apolipoprotein B elevation: measures the amount of Apo B, which carries substances in your blood that make the plaque.

• Coronary artery calcium score (high CAC): a high score likely means a large amount of plaque is present in arteries and the risk of a future heart attack is high.

“There is a misconception that women are protected until menopause. That’s simply not true,” Simonini said. Women can develop heart disease at any age, but your risk increases after your periods stop. Before menopause, your body makes more estrogen, which helps protect against heart disease. That’s also why women generally develop coronary artery disease later than men.

Women of all ages are surprised to learn they have heart disease, said Dr Sonal Chandra of Focus Cardiology, a private practice in Chicago, Illinois.

“Women are far less likely to receive imaging or other interventions. This happens even when they are showing comparable indicators and classic symptoms of heart distress,” she said. “No one should feel they have to walk away without some answers.”

If patients feel their complaints are not being addressed, they can and should ask for additional diagnostic testing. The more information you have on how symptoms are evolving, the better.

Physicians need to pay attention to women who notice any abnormal physical changes, rather than assume it’s temporary or simply fatigue and stress, Simonini said. Doctors should ask questions and find out why a patient is having those symptoms at that time.

He acknowledged that doctors need more education about women and their disease risks. All of the experts I spoke to encourage women to advocate for themselves by doing the following:

1. Ask your primary care doctor what kinds of cardiac testing is available to you. If bloodwork is suggested first, do it. If you have a family history of heart attacks and want to check your arteries now, discuss proteins and inflammation markers. You may need to consult a specialist for these steps.

2. Provide as much information as possible, even if you don’t think it’s related to your current problem. It could make a difference in someone deciding on a scan or sending you to the ER. The more details you provide, the better someone can assist. For instance, if you have a stomach ache that hasn’t gone away in three days, disclose it.

3. Keep asking about next steps. You are entitled to an answer and it’s the doctor’s job to help you find it. If your inquiries are not being taken seriously, book an appointment elsewhere. Do not give up or wait it out. Persistence can help you identify serious risks.

Not every pain or ache means you have a serious health issue, nor that it is cardiac related. It’s important to remember that, outside of a sharp shooting pain above your heart, it truly could be something minor. There is also no single test that can predict your future health. Numerous variables and overlapping conditions are part of a much larger map. Experts simply encourage you to take notice of your own risk factors and monitor how you feel.

Why is so little known about heart disease effects in women?

Historically, large-scale research specific to female biology and genetics has not been available. In the 2010s, one heart health researcher noted that the participants in typical cardiovascular disease clinical trials were 85% male and that female participants were predominantly postmenopausal.

For example, an influential large-scale clinical study that began in 2011, known as the Million Veteran Program (MVP), involved mostly white, male participants from a similar age group. Participants were monitored for kidney function, blood pressure and diabetes over a span of 20 years. “They had all this data but only from a specific group,” Simonini noted. This massive pool of data informed how treatments and drugs for cardiac disease were developed – and that knowledge became the standard. The MVP has since added new data sets to include a more diverse population.

If research trials were more accommodating, greater female participation would likely follow, said Chandra.

“Women are often primary care givers and work full-time, and it can be a hardship for them to participate during business hours,” she said.

However, the experts I spoke to agree that over the past 10 years, education about gender differences in cardiac health has been slowly improving.

In 2016, the University of Pennsylvania established a dedicated women’s cardiovascular health curriculum for its cardiology fellowship program. Columbia University offers program electives for medical students, residents and graduate students on cardiovascular risks unique to women. This year at Harvard Medical School, continuing medical education credits (CME) are being offered for “diagnosing, managing, and treating medical conditions unique to and prevalent in women”.

What should I do to monitor for heart disease?

Experts stressed the importance of regular testing and checkups from your primary care provider. This can provide both of you with baseline information to compare future measurements against. Check in with them more than once a year if changes such as medications or procedures are necessary, experts say. Provide as much detail about family, environment and diet as possible. This can help your doctor design a prevention plan for the next five years or beyond. This may involve nutrition, genetic testing, imaging, medication or other lifestyle changes.

“Keep asking more and more questions; we are in a profession where we can’t afford to be wrong,” Simonini said.

• Julie Charnet is a healthcare worker and writer in Philadelphia