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GPs go forth

We must learn to recognise the symptoms of a heart attack in women

Dr Kailash Chand 

Dr Kailash Chand

I was in India recently when a female acquaintance in her early fifties suffered a heart attack.

She had two days of pain in her collarbone and neck and shortness of breath, which her doctor diagnosed as overwork and tiredness. So she continued working, hoping the problem would go on its own. But when it spread to her jaw, an ambulance was called.

Paramedics told her it was a panic attack, so she was hospitalised and not seen for hours. It was only then that she was diagnosed as having had a heart attack. She's lucky to be alive.

But paramedics aren't the only ones who have a role in the efficient diagnosis and treatment of heart attacks. Healthcare professionals share a responsibility, so this episode inspired me to wonder just how often we miss the signs and symptoms of heart attacks in women. Yes, we GPs should do better.

In the UK and Europe, cardiovascular disease kills a higher percentage of women than men. Yet it's considered a disease of men. Many women don't realise that coronary heart disease is such a significant killer - often, their biggest fear is breast cancer. Even more worryingly, however, is the apparent lack of awareness of female cardiovascular diseases in the healthcare sphere. This is partly due to women often having more atypical symptoms than men - back pain, burning in the chest, abdominal discomfort, nausea, fatigue - making the diagnosis process more difficult. And like men, they sometimes fail to recognise their signs and symptoms.

Coronary heart disease in women can be prevented

Typically when we think of a person experiencing a heart attack, we envisage an overweight middle-aged man who has diabetes and smokes. Reality paints a different picture - the wider spectrum of the population are affected, and this, of course, includes women.

Despite over 28,000 women dying of heart attacks each year in the UK, as a gender they have a 50% higher chance of initally receiving the wrong diagnosis following a heart attack.

Currently, there are approximately 3.5 million women living with cardiovascular disease in the UK, with many women's heart failure a consequence of their heart attack. The longer such attacks are left undiagnosed and untreated, the more the heart muscle can be irreversibly damaged.

But coronary heart disease in women can be prevented, and I passionately believe that GPs should understand how. Foremost, the impact of risk factors can be reduced by adopting healthy diet and lifestyle habits. If this is more commonly reiterated to at-risk patients in general practice, a more hopeful future may be on the horizon. 

Key facts: 

  • Women generally present with a heart attack approximately 10 years later than men
  • Women present with a greater risk-factor burden
  • Women are less likely than men to have typical angina
  • Women who present to A&E with new-onset chest pain are approached and diagnosed less aggressively than men
  • Women have more chances to present with angina than a heart attack, but when they present with heart attack, it's more fatal
  • Many cases of heart attack in women go unrecognised, particularly at younger ages or in patients with diabetes
  • All women with intermediate or higher risk should be evaluated
  • Treadmill exercise-testing has a higher false-positive rate in women (for the diagnosis of Obstructive Coronary Artery Disease)
  • The prevalence of significant coronary disease found at the time of angiography is lower in women than men presenting with chest pain
  • Most women with chest pain and no evidence of blockages on coronary angiography have cardiac syndrome X or microvascular disease, or, more rarely, takotsubo cardiomyopathy or coronary dissection

Screening for heart disease:

  • Six-minute walk test: If you can walk more than 500 meters or climb two flight of stairs, you don't have significant blockages
  • Never ignore unexplained weakness, tiredness, first-onset chest burning or first onset-breathlessness, particularly after the age of 40
  • There's a strong family history if any male family member had heart disease before the age of 55, or female before the age of 65

Dr Kailash Chand is a retired GP in Tameside


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Readers' comments (2)

  • Ivan Benett

    Indeed. NICE chest pain guidline 1June 2017 update (which I sat on) explicitly says that we should treat women and ethnic minirities in the same way.
    Notably NICE now recommends that all patients with new onset chest pain with atypical or typical anginal features, as well as those with non-cardiac chest pain and an abnormal resting ECG, should first be investigated with CTCA using a 64-slice (or above) CT scanner. Sadly, this recommendation seems to have been poorly taken up. We should be pressing commissioners for this to be made available

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  • Ivan Benett

    In terms of prevention the evidence has been put together in the NICE guideline - Cardiovascular disease: risk assessment and reduction, including lipid modification
    Clinical guideline [CG181] Published date: July 2014 Last updated: September 2016. Recommendations include risk assessment, lifestyle changes, risk factor modification and statins where indicated. As this article points out CVD can be prevented if we give sufficient focus, energy and resources.

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