What are the warning signs of a heart attack in women?

Warning Signs of Heart Attack in Women

Women experiencing a heart attack most commonly present with chest pain or discomfort (just like men), but they are significantly more likely than men to also experience accompanying symptoms including shortness of breath, nausea, back pain, jaw or neck pain, fatigue, palpitations, and diaphoresis—and these additional symptoms should never be dismissed as non-cardiac. 1, 2

Primary Symptoms

Chest discomfort remains the predominant symptom in women with acute coronary syndrome, occurring with equal frequency as in men. 1 The discomfort typically presents as:

• Retrosternal pressure, tightness, heaviness, squeezing, or constriction that builds gradually over several minutes 1, 2
• Pain radiating to the neck, jaw, shoulders, back, or one or both arms 1, 2
• Central or substernal crushing sensation, cramping, burning, or aching 2

Additional Symptoms More Common in Women

Women are significantly more likely than men to experience these accompanying symptoms during a heart attack:

• Shortness of breath (50% of women vs 43% of men) 3
• Nausea or vomiting (28% of women vs 24% of men) 3
• Jaw or neck pain (21.5% of women vs 13.8% of men; in younger women ≤55 years, 61.9% report pain in jaw, neck, arms, or between shoulder blades) 2, 3
• Back pain (7.5% of women vs 4.8% of men) 3
• Fatigue or extreme tiredness (29% of women vs 21.5% of men) 3
• Palpitations (5.5% of women vs 2.8% of men) 3
• Diaphoresis (sweating) 1, 2
• Dizziness or lightheadedness 1, 4
• Left arm pain (34% of women vs 30.5% of men) 3
• Sense of dread or anxiety (13.4% of women vs 10.5% of men) 3

Atypical Presentations

Women may present with symptoms that do not include chest pain at all:

• Unexplained indigestion, belching, or epigastric pain 2
• Vague abdominal symptoms 1
• Persistent shortness of breath without chest discomfort 2
• Approximately 35% of heart attacks in women go unnoticed or unreported due to atypical symptoms 4

Prodromal Symptoms

Women are more likely than men to experience warning symptoms in the days or weeks before a heart attack, including:

• Unusual fatigue or weakness 1, 5
• Sleep disturbances 5
• Gradual onset of discomfort rather than sudden dramatic symptoms 1

High-Risk Populations Requiring Special Attention

Women with Diabetes

• Diabetes is a stronger risk factor for heart attack in women than in men 2
• May present with atypical symptoms due to autonomic dysfunction 1, 2

Elderly Women

• May present with generalized weakness, confusion, mental status changes, or syncope rather than classic symptoms 1, 2
• More likely to have silent or unrecognized myocardial infarction 1

Women Over Age 65

• Are 8-10 years older than male counterparts when experiencing heart attacks 2
• Have higher prevalence of hypertension, hyperlipidemia, and family history of premature coronary artery disease 2

Critical Clinical Pitfalls to Avoid

Traditional risk assessment tools and physician clinical judgment consistently underestimate cardiac risk in women and misclassify their symptoms as non-cardiac. 1, 2 Specific errors include:

• Dismissing accompanying symptoms (nausea, fatigue, shortness of breath) as non-cardiac when they occur with or without chest discomfort 1
• Assuming symptoms must follow an exertional pattern—symptoms occurring at rest can represent unstable angina or acute myocardial infarction 1
• Using nitroglycerin response as a diagnostic criterion (it is not specific for cardiac ischemia and responds to other conditions like esophageal spasm) 1, 2
• Attributing symptoms to other chronic conditions (arthritis, influenza, acid reflux) without excluding cardiac causes first 1
• Failing to recognize that women often do not perceive themselves to be at risk for heart attack 1

Why Women Delay Seeking Care

Women exhibit longer delay times than men before seeking medical attention because: 1

• They expect heart attacks to present with severe, crushing chest pain and doubt their symptoms when they experience gradual onset of pressure or tightness 1
• They attribute symptoms to other conditions or believe symptoms will resolve on their own 1
• They fear embarrassment if symptoms turn out to be a "false alarm" 1
• They are reluctant to trouble healthcare providers or emergency services unless "really sick" 1
• They hold stereotypes about who is at risk for heart attack and do not see themselves as candidates 1

Immediate Action Required

Any woman presenting with chest discomfort plus accompanying symptoms (especially shortness of breath, nausea, jaw/neck pain, or diaphoresis) requires immediate 12-lead ECG within 10 minutes and cardiac biomarker assessment. 2, 6 Women are at risk for underdiagnosis and delayed treatment, which directly increases mortality. 1