Heart Attack Symptoms in Women
Women experiencing heart attacks frequently present with atypical symptoms beyond chest pain, including nausea, back pain, jaw pain, dyspnea, epigastric discomfort, fatigue, and diaphoresis—symptoms that are often misdiagnosed or dismissed, leading to delayed treatment and worse outcomes. 1
Symptom Presentation
Classic and Atypical Symptoms
Chest pain remains the most common symptom in women with acute coronary syndrome, occurring with similar frequency as in men, but women describe it differently—often as pressure, tightness, heaviness, or burning rather than crushing pain 1, 2
Women more frequently experience atypical symptoms including:
Approximately one-third of women with acute coronary syndrome present without chest pain or discomfort, compared to 27% of men—a critical difference that contributes to missed diagnoses 4
Important Clinical Distinctions
Women's symptoms are more often precipitated by mental or emotional stress rather than physical exertion, distinguishing their presentation from the classic exertional pattern 1
Jaw pain occurs in 10% of women versus 4% of men with acute coronary syndrome, and in younger patients (≤55 years), 61.9% of women report pain in the jaw, neck, arms, or between shoulder blades 2
Relief with nitroglycerin should not be used as a diagnostic criterion, as it does not reliably distinguish cardiac from non-cardiac causes 2
Underlying Mechanisms and Risk Factors
Pathophysiology Unique to Women
Women have a higher proportion of acute coronary syndrome caused by non-classical mechanisms including plaque erosion, coronary microvascular dysfunction, coronary vasospasm, spontaneous coronary artery dissection, and Takotsubo (stress-related) cardiomyopathy rather than typical plaque rupture 1
Despite having less obstructive coronary artery disease on angiography, women have worse cardiovascular outcomes even after adjustment for risk factors and imaging findings 1
Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs more frequently in women, affecting 5-25% of all MI presentations in women 1
Risk Factor Profile
Women with acute coronary syndrome are on average 8-10 years older than men and have higher rates of traditional cardiovascular risk factors including hypertension, chronic kidney disease, diabetes, and obesity 1, 2
Diabetes is a stronger risk factor for heart attack in women than in men, and diabetic women may present with atypical symptoms due to autonomic dysfunction 2
Hypertensive disorders of pregnancy (gestational hypertension and pre-eclampsia) increase lifetime cardiovascular disease risk but are seldom considered in cardiovascular risk assessment 1
Management Approach
Immediate Diagnostic Workup
Obtain an ECG within 10 minutes of presentation for any woman with chest pain or atypical symptoms suggestive of acute coronary syndrome, looking for ST-segment elevation, ST-segment depression, T-wave changes, or new Q waves 1, 5
Measure high-sensitivity cardiac troponin in combination with symptoms of ischemia, ECG changes, or imaging evidence of regional wall motion abnormalities to diagnose myocardial infarction 1
Women less often have elevated troponin levels despite having acute coronary syndrome, but when elevated, the prognostic value is similar to men 1
Pharmacological Management
Women should receive the same pharmacological therapy as men including aspirin, P2Y12 inhibitors (clopidogrel), anticoagulants, beta-blockers, ACE inhibitors, and statins, with careful attention to weight-based and renal function-based dosing 1
Use low-dose aspirin (75-162 mg) to reduce bleeding risk, especially when combined with clopidogrel, as women have increased bleeding risk with antiplatelet and anticoagulant therapy 1
Adjust doses of renally cleared medications based on estimated creatinine clearance rather than serum creatinine alone, as women are more likely to have renal impairment 1
Invasive Strategy
For women with high-risk features (elevated troponin, ST-segment changes, hemodynamic instability), an invasive strategy with coronary angiography is recommended similar to men 1
Women should not be denied rapid access to coronary catheterization despite higher rates of non-obstructive disease, as this remains the standard investigation in high-risk acute coronary syndrome 1
For women with low-risk features, a conservative strategy is recommended with noninvasive testing similar to men 1
Cardiovascular magnetic resonance imaging is particularly helpful in women with MINOCA, as it can differentiate cardiomyopathies, myocarditis, coronary microvascular dysfunction, Takotsubo cardiomyopathy, and myocardial infarction 1
Critical Pitfalls to Avoid
Never dismiss atypical symptoms (epigastric pain, jaw pain, fatigue, nausea) as non-cardiac without excluding acute coronary syndrome first, especially in women over 50, diabetics, and those with cardiovascular risk factors 2, 5
Do not assume all epigastric pain is gastrointestinal without obtaining an ECG and considering cardiac causes, particularly in high-risk populations 2
Traditional risk assessment tools often underestimate risk in women and misclassify them as having non-ischemic pain, leading to underutilization of therapies 2
Women are less likely to receive guideline-indicated medical and invasive care compared to men at similar risk, contributing to worse outcomes 1
Younger women (<50 years) face particularly poor long-term outcomes, with all-cause mortality significantly higher than younger men at 11.2 years follow-up despite similar in-hospital mortality 1
Nearly 40% of women have persistent or worsening symptoms at 1-year post-discharge, highlighting the need for aggressive secondary prevention and close follow-up 1