What are the signs, symptoms, and treatment of myocardial infarction (MI) in females?

Female Signs and Symptoms of Myocardial Infarction

Chest pain remains the predominant symptom in women with MI, occurring with equal frequency as in men (87-92%), but women are significantly more likely to present with accompanying symptoms including nausea, shortness of breath, fatigue, jaw/neck pain, and diaphoresis. 1, 2, 3

Primary Symptom Presentation

• Chest pain/discomfort is reported by 87-92% of women with MI, described as retrosternal pressure, tightness, heaviness, squeezing, crushing, cramping, burning, or aching sensation that builds gradually over several minutes 1, 2, 4
• The chest pain radiates to the neck, jaw, shoulders, back, or one or both arms in the majority of cases 2, 3
• Women with MI are more likely to present with "typical" symptoms than men (77% vs 59%) when using standardized diagnostic criteria 1, 4

Accompanying Symptoms More Common in Women

Women are significantly more likely than men to experience these additional symptoms alongside or instead of chest pain:

• Shortness of breath occurs in 53-59% of women with MI 1, 5
• Unusual fatigue is reported by 59-70% of women, often as a prodromal symptom in the days preceding MI 1, 5
• Nausea and vomiting are more common in women than men 1
• Epigastric discomfort and unexplained indigestion or belching occur more frequently in women 1, 2
• Diaphoresis (sweating) is significantly more common in women 2, 3
• Pain in jaw, neck, arms, or between shoulder blades occurs in 61.9% of women versus 54.8% of men aged ≤55 years 1, 2, 3
• Upper back/shoulder blade pain is reported by 42-47% of women 1, 5
• Palpitations are more common in women 1, 2

Prodromal Symptoms

• 68-90% of women experience prodromal symptoms in the days or weeks before MI, most commonly unusual fatigue (70%), shortness of breath (53%), and upper back/shoulder blade pain (47%) 5
• Women's ischemic symptoms are more often precipitated by mental or emotional stress and less frequently by physical exertion compared to men 1

High-Risk Populations Requiring Heightened Awareness

Women with Diabetes

• Diabetes is a stronger risk factor for MI in women than in men 2, 3
• Women with diabetes may present with atypical symptoms due to autonomic dysfunction 1, 2, 3

Elderly Women (>75 years)

• May present with generalized weakness, confusion, mental status changes, syncope, acute delirium, or unexplained falls rather than classic chest pain 1, 2, 3
• In patients >75 years with chest pain, ACS should be considered when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present 1

Younger Women (≤55 years)

• Are equally likely as men to present with chest pain (87% vs 89.5%) but more likely to report associated symptoms (61.9% vs 54.8%) 1

Critical Clinical Pitfalls to Avoid

• Traditional risk assessment tools and physician clinical judgment consistently underestimate cardiac risk in women and misclassify their symptoms as nonischemic chest pain 1, 2, 3
• Women are less likely to receive timely and appropriate care despite similar or higher symptom burden 1, 2
• Never dismiss accompanying symptoms (nausea, fatigue, shortness of breath, jaw/neck pain) as non-cardiac when they occur with or without chest discomfort 2, 3
• Up to 30% of women with STEMI present with atypical symptoms, leading to delayed presentation and treatment 1
• Women present later to medical care than men, often because prodromal symptoms are not recognized as cardiac in origin 1, 5

Pathophysiologic Differences Explaining Symptom Patterns

• Women have a higher proportion of MI caused by mechanisms other than classical plaque rupture, including plaque erosion, coronary microvascular dysfunction, coronary vasospasm, spontaneous coronary artery dissection, and stress-related (Takotsubo) cardiomyopathy 2
• Women more often have nonobstructive CAD (1-49% stenosis) at angiography despite symptomatic ischemia, with elevated hazard for coronary events particularly in women <75 years 1
• Myocardial ischemia is associated with higher IHD mortality among symptomatic women than among men 1

Immediate Diagnostic Approach

• 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, 3
• Place patient in environment with continuous ECG monitoring and defibrillation capability 1
• Use high-sensitivity cardiac troponin with sex-specific thresholds (>16 ng/L for women vs >34 ng/L for men) to avoid missing MI in women 4
• Assess cardiovascular risk factors including age, hypertension, hyperlipidemia, diabetes, family history of premature CAD, and sedentary lifestyle—all more prevalent in women presenting with suspected ACS 1

Treatment Considerations

• Women derive equal benefit from aspirin, clopidogrel, anticoagulants, beta blockers, ACE inhibitors, statins, and GP IIb/IIIa antagonists (when troponin elevated) as men 1
• Women are at increased risk of bleeding complications, requiring careful attention to dosing of antiplatelet and anticoagulant agents based on estimated creatinine clearance rather than serum creatinine alone 1
• Use low-dose aspirin (75-162 mg) to reduce excess bleeding risk, especially in combination with clopidogrel 1
• Women and men receive equal benefit from reperfusion strategies and should be managed identically 1