Synopsis: Young women are at relatively low risk of heart attacks, but when they have one, a much greater proportion die than among men of the same age. Surveys show young women are often unaware of their risk and are much less likely to go to the emergency room when a heart attack occurs. Experts discuss reasons and possible remedies.

Host: Reed Pence. Guests: Dr. Judith Lichtman, Associate Professor and Chair of Epidemiology, Yale School of Public Health; Dr. Holly Andersen, attending cardiologist and Director of Education and Outreach, Perelman Heart Institute, New York Presbyterian Hospital.

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Heart Attacks in Young Women

REED PENCE: When you think of a heart attack, you probably picture a scene as if it’s in a movie: an older man clutches his chest in pain– a stereotype so pervasive that doctors call that the “Hollywood heart attack.” But it’s an image that may be doing a disservice to young women, a demographic rarely associated with heart attacks.

JUDITH LICHTMAN: Women who are in this age group, 18-55, may represent only about 5% of all heart disease in women. However, studies have shown that a younger woman who has a heart attack is twice as likely to die as a similarly aged man.

PENCE: That’s Dr. Judith Lichtman, Associate Professor and Chair of Epidemiology at the Yale School of Public Health. Recently, she and her team extensively interviewed thirty female heart attack survivors. They concluded that the reason women are more at risk of death is because they’re extremely reluctant to seek help when they have a cardiac event.

LICHTMAN: We would hear the women talk about how they were thinking, because the chest pain wasn’t the “Hollywood heart attack,” that they had heard about before, that they could see in older gentlemen clutching their chest and falling to their knees; they felt that if they had indigestion or heartburn that probably was something else. So, we often heard how many of the women would self-medicate. They would take antacids. They would downplay their symptoms. They did not connect that they were having a heart attack.

PENCE: Lichtman says what really surprises her is that women don’t consider themselves at risk for a heart attack, even if they display many of the risk factors.

LICHTMAN: The women would self-report, “Well, you know, I thought it was my diabetes being out of control.” or “My blood pressure was high. And when I think about it, my mother or my aunt had a heart attack at a young age.” So, it was interesting that a lot of the women did self-report to us in an open conversation how they knew they had some of the risk factors for heart disease. They commonly had a first-degree relative that had had heart disease at a young age and yet, it was as if they were not connecting the dots. They didn’t say, “You know, I have these risk factors. I have a strong family history. Perhaps I am at risk for heart disease.”

PENCE: Even for some of the patients who suspected they were, in fact, having a heart attack, Lichtman says they were often hesitant to go to the hospital. One potential reason? They don’t want to be a bother.

LICHTMAN: Several of the women talked about that, that they were concerned about making too big of a deal or complaining. And what was really fascinating is one of the participants, in fact, was a nurse who worked in the emergency department, and her concern was that she didn’t want to trouble anybody in case she was wrong. And we have a very nice narrative that we describe where somebody said that they were relieved when they found out they had a heart attack. But, the way the person described it, with such an emphasis that they were relieved that it wasn’t their error about the symptoms. To me, that’s a very interesting statement. I feel it should have been the opposite. They should have felt relief that they got in quickly, not that they were in fact finding out that they had had a heart attack.

PENCE: Lichtman says this problem is becoming a crisis. Dr. Holly Andersen agrees. She’s an Attending Cardiologist and Director of Education and Outreach at the Perelman Heart Institute at New York Presbyterian Hospital.

ANDERSEN: We know that more women have died from heart disease every year in this country than men since 1984. And although the death rate due to heart disease is actually decreasing in women now; overall, death rates due to heart disease in our youngest women, age 29 to 45, appear to be increasing. And this is very concerning.

PENCE: So how do we change that? Young women are generally a low-risk group, it’s true, but they need to learn that doesn’t mean they have no-risk. Lichtman says young women must be educated about their reality and learn to react appropriately.

LICHTMAN: Many of the women that we talk to; what they talked about was that they symptoms didn’t go away. So, if they took something over the counter, they waited for awhile; the symptoms just got to an acute point where they could no longer ignore them. In the case of younger women, we do see a pattern where many of them have chest pain. They may have other symptoms on top of that. They commonly had a number of risk factors, whether it be diabetes, hypertension, high cholesterol, low activity. Those kinds of things compounded with the chest pain and, potentially, a strong family history, should be a group coming forward when they don’t feel well and they have some of these symptoms.

PENCE: The question then is how to get young women to consider heart attacks a health risk for them. And that’s hard to do when health care professionals often don’t even see the risk themselves.

LICHTMAN: Some of the women; they did call their care provider. They did say, “I don’t feel well. I have chest pain.” And in more than one example, they were told to have an appointment in a few days. It’s important for us to realize it’s not just the individual who may not perceive themself at risk. Even when they have manifest symptoms, many of them typical of a heart attack; when they went and engaged with a health care system, the health care system didn’t consistently, rapidly detect that they could be having a heart attack. Another woman who went into the emergency department said she waited a very long time and when she finally got one nurse and described it, then they reduced the delay. But, it was clear to us that it wasn’t just describing the symptoms; that because this is a more rare population, there’s room for improvement also in getting healthcare providers to rapidly triage and identify women who could be having a heart attack.

ANDERSEN: We did a study of primary care doctors and heart disease didn’t register as a top-tier health concern among a majority of primary care doctors.

PENCE: Andersen says it would also be helpful if the medical community made it a priority to include women in heart disease studies.

ANDERSEN: Women have only made up 26% of the participants in all cardiovascular research trials. And that’s a problem. One of the good things that’s happening is the FDA is now doing something called drug trials snapshot. And they’re letting we, the consumers, know who the people were in this trial that the FDA has approved. How many were women? How old were they? What ethnicities were they? So, the consumers can judge whether or not that drug has been proven to be safe in them. And I think that’s the only thing that’s going to put pressure on the drug companies and the device makers to enroll more women and minorities into their trials, because it’s more expensive for them. But, if we who are underrepresented in the trials refuse to take their drugs because they haven’t been shown to be effective in us, then they’ll pay attention.

PENCE: There’s another benefit in including more women in studies as well. Andersen says it’s not just a wake-up call that women can have heart disease. It would also improve the validity of the studies.

ANDERSEN: We are chromosomally, genetically different. And when you put those cells in chromosomes together, we’re physiologically different. In stem cells, for instance, female stem cells and male stem cells are very different, and I think it will be better science if we’re studying both and reporting both.

PENCE: Fortunately, Andersen says it seems as if the medical community is listening and putting more of an emphasis on researching heart disease in women. But it’s still up to women to be proactive about their heart health when a crisis occurs.

ANDERSEN: We’ve done a poll, and so does the American Heart Association, asking women, “If you believed that you were having a heart attack, what would you do?” 36% of women who believed they were having a heart attack would not call 9-1-1, and didn’t tell us why. So, women don’t tend to act, even if they’re afraid they’re having a heart attack. They’re more likely, and I’ve seen this in my practice, to curl up in the fetal position, hoping that it will go away. They really don’t have time to have a heart attack right now, so they don’t act. And for those of us that treat heart attacks; we have a saying that “time is muscle” and if you can get to us, I think we can save you. But, all too often, they can die in the middle of the night and we don’t have a chance to save them.

PENCE: In addition to being quicker to act when something feels off, Andersen wants women to assess their risk more seriously.

ANDERSEN: If heart disease, meaning coronary artery disease, runs in your family, you have a higher risk. If you’ve had diabetes during your pregnancy, or your blood pressure went up, or you have something called “preeclampsia,” you have a significantly higher risk. If you have an autoimmune disorder, primarily in women, like lupus or rheumatoid arthritis, your risk is increased. If you smoke, if you have high blood pressure, if you have high cholesterol, if you are inactive or sedentary, if you are overweight, particularly, have a big waistline; that all significantly increases your risk. And guess what, stress is a really big part of why we’re seeing increased death rates in our younger patients. We’re more stressed, we’re more on, we’re more wired in than we’ve ever been before.

PENCE: Finally, Andersen says it is vitally important that women learn what their symptoms of a heart attack are likely to be.

ANDERSEN: Women are less likely to have chest pain with their heart attacks. 40% of women having heart attacks have no chest pain. And we’re so used to associating heart attacks with chest pain; we’re putting up chest pain clinics across the country. We always see the “Hollywood heart attack” of a man gripping his chest, well; women don’t typically present this way. Their symptoms are more likely to be subtle. They might have chest pressure. They might have just jaw pain or back pain or an overwhelming sense of fatigue. But, most women having heart attacks know there’s something wrong.

PENCE: Lichtman agrees and even has a few ideas for how women could be educated on heart attack symptoms most efficiently.

LICHTMAN: I think we need better examples in the media. It’s one thing for us to assume that scientific literature gets to everybody. I certainly, as a researcher, try to contribute. But, we need to do a much better job of helping young women connect the dots. Meaning, “What’s my personal risk? What should I do about it?” and “Is there a good media example?” We clearly heard from many of the women that we talk with that the “Hollywood heart attack” of an older gentleman who falls to his knees and grabs his chest is not one that they experienced. It’s not one that they identified with. So, I think what’s important for us is to think about ways that we can get the message out to this population. What are good media examples; what are ways that we can engage them in the preventive care that could really make a difference for them.

PENCE: Once young women know the risks and symptoms of a heart attack, Andersen says crisis must breed action and a potentially lifesaving trip to the emergency room. And if their doctors don’t take them seriously and don’t run tests on their heart, it’s important that they be persistent.

ANDERSEN: Heart disease is your number one health care risk. There’s so much you can do to lower your risk. There’s so much you can do to prevent heart disease. But, if you think you’re having symptoms of heart disease, don’t wait, act. And make sure your health care professionals are taking you seriously. Don’t apologize. Demand to be taken care of. I’d much rather be taken care of for indigestion in the emergency room than miss a heart attack.

PENCE: You can find out more about all of our guests and learn more about heart disease in women through links on our website, You can find archives of our shows there as well… and also on iTunes and Stitcher. Our writer this week is Evan Rook. I’m Reed Pence.

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