The message is finally sinking in—men are not the only ones who have heart ­attacks.

However: Common medical mistakes are putting millions of middle-aged and older women at risk for a heart attack, the number-one killer of American women, with nearly 300,000 deaths every year.

To find out what women can do to protect themselves, Bottom Line Health spoke with C. Noel Bairey Merz, MD, a renowned women’s heart specialist.


A common scenario illustrates the problem women face. Let’s say a woman sees a doctor and complains about persistent chest pain. The doctor orders an angiogram, a test that detects the plaque in the major arteries of the heart that can decrease or stop blood flow, triggering a heart attack. But the angiogram shows no blockages, so the doctor tells the woman she doesn’t have heart disease. A week later, she has a heart attack.

Many women experience angina, which is marked by frequent and intense chest pain, even when they do not have blockages in the major arteries of the heart—the leading cause of heart attack in men. In women, the pain also can be caused by coronary microvascular dysfunction in the tiny arteries around the heart.

This condition poses a similar threat to a woman’s heart as a blockage in the major arteries. But standard heart tests—such as an angiogram or an electrocardiogram (which detects abnormal heart rhythms and poor blood flow)—don’t detect coronary microvascular dysfunction.

Troubling recent finding: Researchers from the Barbra Streisand Women’s Heart Center, Smidt Heart Institute at Cedars-Sinai in Los Angeles asked 340 women who complained of chest pain but had no blockages in major coronary arteries to have a cardiac MRI, a highly detailed imaging scan of the heart. According to the research, the MRI found nearly one in 10 (8%) of the women had already suffered a heart attack—in most cases, previously undetected.

Other sobering research: In a study conducted by researchers at the Yale School of Public Health, 62% of women having a heart attack were found to have three or more non–chest pain symptoms (see below)—and more than half of those women said their health-care provider did not think the ­symptoms were heart-related.


Because women with heart disease are routinely undertreated, it’s crucial to develop a strategy to effectively diagnose the condition—and, if it’s present, to effectively treat it. To do this, partner with your physician. Here’s what you need to know…

STEP #1: Take heart disease seriously. It kills more women than any other disease—more women than all cancers combined. If you’ve got one or more risk factors for heart disease, ask your primary care physician for a cardiovascular workup (see below). Those risk factors include high blood pressure, high LDL cholesterol, smoking, excess body weight, a sedentary lifestyle, a poor diet (one that emphasizes sugary, fatty processed foods) and a family history of heart disease.

STEP #2: Get a second opinion. Perhaps your physician has conducted tests and told you that you don’t have heart disease—but you have symptoms that make you suspect you do, such as shortness of breath or unexplained chest pain or pressure. Get a second opinion from a doctor who will listen to your concerns. It could be an internist or a cardiologist. Second opinions are covered by most health insurance and—given the seriousness of heart disease—it’s a prudent action.

STEP #3: Get the right stress test. If your risk factors put you at high risk for heart disease, your doctor may order a stress test, also called a treadmill test, exercise electrocardiogram, graded exercise test or stress electrocardiogram. This test—in which you exercise at increasingly intense levels while hooked up to electrodes that measure the electrical activity of your heart—determines blood flow to your heart and can detect abnormal heart rhythms.

Other options include a stress echocardiogram or nuclear stress test, both of which also generate images of the heart and can more accurately­ determine blood flow…and the ­dobutamine or adenosine stress test, a drug-based test used in people who are unable to exercise. If you have any questions about the right stress test for you, consult a cardiologist.

STEP #4: Ask about a stress cardiac MRI or cardiac PET scan. These tests have become more widely available only in the last 10 years. They are more sensitive, so they improve the detection of more subtle and female-pattern abnormalities in smaller hearts—which means they help women more than men. Either test would be particularly important in women with persistent chest pain and an abnormal stress test.

STEP #5: If you’re having unexplained heart symptoms, ask your doctor to investigate less common forms of heart disease. One uncommon condition is spontaneous coronary artery dissection, a tear in the artery wall. This condition, which can lead to heart attack, is more often detected in younger women (half the time during or shortly after pregnancy), who have symptoms such as unexplained chest pain.

The other is stress-related cardiomyopathy (also known as “broken heart syndrome”), which can cause chest pain and shortness of breath. It is caused by severe mental stress or shock, such as the death of a spouse, or a near-miss automobile accident. The condition is usually treatable, and most patients recover, although recurrence can happen in 5% to 10% of cases.

STEP #6: Demand standard therapy. Studies show that women with diagnosed heart disease are significantly less likely than men to be treated with standard therapy. If you’ve been diagnosed with heart disease, talk to your physician about lifestyle changes (including smoking cessation, diet and exercise), along with the drugs you may need—such as low-dose (81 mg) aspirin to prevent artery-clogging blood clots, a statin to lower high cholesterol and medication to reduce blood pressure.

STEP #7: Go to the ER. If you’re having any of the symptoms of a heart attack that are common in women (see below), the emergency room is where you belong. And once you’re there, don’t let anyone tell you that you’re not having a heart attack. Instead, insist on getting the troponin test, which detects protein in the blood generated by damaged heart cells…in other words, by a heart attack. This simple test—a sample of blood is all that’s required—generates results in 15 to 20 minutes and provides incontrovertible evidence as to whether you are or aren’t having a heart attack. Important: Call 911 instead of driving yourself, and take a low-dose aspirin if you suspect that you are having a heart attack.


Most women who are having a heart attack don’t experience crushing chest pain, the “classic” heart attack symptom found in most men. Instead, a woman might have…

  • Sharp or burning pain or pressure in the chest.
  • Pain or pressure in the neck, jaw, throat, abdomen or upper back.
  • Shortness of breath.
  • Indigestion and heartburn.
  • Nausea and vomiting.
  • Extreme fatigue.
  • General upper-body discomfort.

Doctors frequently fail to recognize these symptoms as red flags for heart attack. The result—heart disease and heart attacks are often misdiagnosed in women.

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