What are the signs and symptoms of a heart attack in a woman, particularly in postmenopausal women or those with risk factors for cardiovascular disease?

Signs and Symptoms of Heart Attack in Women

Women experiencing a heart attack most commonly present with chest pain (87-92% of cases), but they are significantly more likely than men to also experience accompanying symptoms including shortness of breath, unusual fatigue, nausea, and pain in the jaw, neck, back, or arms—symptoms that are frequently misclassified as noncardiac, leading to dangerous delays in diagnosis and treatment. 1, 2

Primary Symptom: Chest Pain Remains Most Common

• Chest pain is the predominant symptom in women with heart attack, occurring with equal frequency as in men (87-92% of women report chest discomfort). 1, 2
• The pain is typically described as retrosternal pressure, tightness, heaviness, squeezing, crushing, cramping, burning, or aching sensation that builds gradually over several minutes. 2, 3
• This chest discomfort may radiate to the neck, jaw, shoulders, back, or one or both arms. 3

Accompanying Symptoms More Common in Women

Women are significantly more likely than men to present with multiple accompanying symptoms alongside or instead of chest pain:

• Shortness of breath occurs in 53-59% of women with heart attack. 2
• Unusual fatigue or weakness is reported by 59-70% of women, often appearing as a prodromal symptom in the days preceding the heart attack. 2, 4
• Nausea and/or vomiting are significantly more common in women than men. 1, 5
• Pain in the jaw, neck, arms, or between shoulder blades occurs in 61.9% of women versus 54.8% of men (particularly in those ≤55 years). 1, 3
• Back pain is reported more frequently by women. 1, 4, 5
• Indigestion or epigastric discomfort may be the presenting symptom. 1, 3
• Diaphoresis (sweating) is a common associated symptom. 3
• Palpitations occur more frequently in women. 1

Critical Clinical Pitfall: Risk of Underdiagnosis

The most dangerous pitfall is that traditional risk assessment tools and physician clinical judgment consistently underestimate cardiac risk in women by up to 50% and misclassify their symptoms as noncardiac chest pain. 1, 6

• Women presenting with chest pain are at significant risk for underdiagnosis, and potential cardiac causes must always be considered—this is a Class 1 recommendation from the American College of Cardiology/American Heart Association. 1
• Women are less likely to receive timely and appropriate care despite having equal or higher symptom burden than men. 1, 2
• The term "atypical" symptoms is misleading, as these patterns are typical for women—the classification is based on male symptom patterns. 6

High-Risk Populations Requiring Heightened Awareness

Postmenopausal and Older Women

• Women with heart attacks are typically 8-10 years older than their male counterparts when they present. 3
• Women ≥65 years constitute the majority of female patients presenting to emergency departments with chest pain. 1
• Elderly women may present with generalized weakness, syncope, acute delirium, unexplained falls, or changes in mental status rather than classic chest pain. 3, 6

Women with Diabetes

• Diabetes is a stronger risk factor for heart attack in women than in men. 2, 3
• Women with diabetes have a higher prevalence of angina symptoms but paradoxically lower rates of obstructive coronary artery disease on angiography. 1, 6
• Diabetic women may present with atypical symptoms due to autonomic dysfunction. 2, 3

Women with Traditional Risk Factors

• Women with heart attacks have higher rates of hypertension (66.6%), hyperlipidemia (68.9%), family history of premature coronary artery disease, and sedentary lifestyle compared to men. 1
• History of hypertensive disorders of pregnancy (gestational hypertension, pre-eclampsia) increases lifetime cardiovascular disease risk but is seldom considered in risk assessment. 1

Pathophysiologic Differences Explaining Symptom Patterns

Women have fundamentally different mechanisms underlying their heart attacks:

• Women have a higher proportion of heart attacks caused by mechanisms other than classical plaque rupture, including plaque erosion, coronary microvascular dysfunction, coronary vasospasm, spontaneous coronary artery dissection, and Takotsubo (stress-related) cardiomyopathy. 1, 2, 3
• Despite having less obstructive coronary artery disease on angiography, women have worse cardiovascular outcomes even after adjustment for risk factors. 1
• Women are more likely to present late to the hospital and be in heart failure on admission. 1
• Mortality is higher in women even after adjusting for baseline characteristics, medications, time to presentation, and revascularization strategies. 1

Immediate Action Required

When a woman presents with chest discomfort plus any accompanying symptoms (especially shortness of breath, nausea, jaw/neck pain, unusual fatigue, or diaphoresis):

1. Obtain a 12-lead ECG within 10 minutes to assess for ST-elevation myocardial infarction. 2, 6
2. Measure cardiac troponin immediately if acute coronary syndrome is suspected. 2, 6
3. Place the patient in an environment with continuous ECG monitoring and defibrillation capability. 2
4. Obtain a focused history emphasizing accompanying symptoms that are more common in women with acute coronary syndrome. 1

Common Diagnostic Errors to Avoid

• Never rely on nitroglycerin response as a diagnostic criterion—esophageal spasm and gastroesophageal reflux disease also respond to nitroglycerin. 1, 3, 6
• Do not assume symptoms are noncardiac based on "atypical" presentation—what is labeled "atypical" reflects male symptom patterns, not female patterns. 6
• Do not dismiss epigastric pain, jaw pain, or isolated fatigue without excluding cardiac causes first, especially in women over 50, diabetics, and those with cardiovascular risk factors. 3, 6
• Women are less likely to have been prescribed primary prevention therapies (statins, ACE inhibitors) despite similar or higher risk than men. 1