Women's symptoms of heart disease are still going undiagnosed

Martha Bowman of Inverness, Fla., was 51 when she developed unusual, intense pain in her jaw, left arm, back and chest. Though she was overweight, had high blood pressure and high cholesterol levels, all major risk factors for heart disease, her doctors blamed her symptoms on carpal tunnel syndrome and a bad case of indigestion.

A year later, Bowman suffered a massive heart attack and underwent major surgery. Had her heart problem been diagnosed earlier, she's convinced, doctors could have helped manage her symptoms and possibly staved off the attack.

“I am positive that if I was a man, they would have ordered more tests,” said Bowman, who was a financial secretary for much of her life but is now disabled by her heart condition. She recounted that a male friend of hers went into the same doctor's office, said he was thinking of taking up jogging and was given a treadmill stress test, whereas no one suggested such a test for her.

Bowman’s case is not unusual. Despite much evidence to the contrary, many doctors still are not paying attention to the risks of heart disease in women. They stick to the conventional wisdom that it's largely a man's disease, even though it is the leading cause of death for women.

A study published in The New England Journal of Medicine in August compared outcomes for men and women after major cardiac events. It showed that women were less likely to receive aggressive surgical treatments and that their death rate was higher.

Another study, which appeared in the journal Circulation in February, showed that when doctors were given case studies of men and women with identical symptoms and risk factors, the women were deemed to be at lower risk and the therapies recommended were less aggressive.

"We’re still seeing papers come out every month showing that women don’t do as well," said Dr. Nanette Wenger, head of the cardiology clinic at Grady Memorial Hospital in Atlanta and co-author of the New England Journal study. "Younger women do worse than younger men. Women have increased bleeding risk, and that hasn’t been explained. There are many things that have to be examined. People are now saying, 'Yes, women do worse, and we need to understand why.'"

One factor leading to the perception that heart disease is less common in women is that its onset comes about 10 years after menopause, at around age 65, which is about 10 years later than when it commonly occurs in men. Still, 5 to 10 percent of all heart-related deaths occur in women under 65, and though it's relatively rare, even women in their mid- to late-30s can suffer a heart attack.

Additionally, the risk factors that lead to heart disease later in life are often evident decades earlier. Diabetes, a sedentary lifestyle, smoking, being overweight and high blood pressure and cholesterol could all be managed from an early age if women took their risks for developing the disease seriously.

Another reason that heart disease has been downplayed in women is that early medical studies almost exclusively involved men. “When I was treating patients who had cardiac arrest and went to the literature to see what was available to know how to treat them, most of it was done on middle-aged men,” said Wenger, who did some of the first clinical research looking at heart disease specifically in women.

To help remedy the situation, Congress passed a law in 1993 mandating that government-funded health studies include women in the studies and in the analysis. Before this law, researchers largely avoided enrolling women of childbearing age out of fear of causing birth defects or because they didn’t want the potential changes brought on by pregnancy to confound results.

Now that women are included in the studies, researchers are also finding that symptoms of heart problems in women often differ from those in men. “Many women are learning that the symptoms are not the textbook 101 man clutching his chest scenario," said Dr. Nieca Goldberg, the author of “Why Women Are Not Small Men.” “The pain could be lower down, they could easily mistake it for indigestion,” she said. Goldberg heads the women’s heart center at Lenox Hill Hospital in Manhattan.

Additionally, 43 percent of women never have any chest pain before or during a heart attack, but instead have pain in their arms, neck, jaw or back, said Dr. Jean McSweeney, a professor in the Department of Nursing at the University of Arkansas and a co-author of a study in 2001 that looked at early warning symptoms in women. Nausea, fatigue and shortness of breath are also common, she said.

Diagnosis can be complicated by the fact that many women experience these symptoms to a greater or lesser degree in their daily lives. However, if related to a heart condition, the symptoms will arise suddenly and their impact will be severe.

“With normal fatigue you can go to bed and wake up refreshed,” McSweeney said. “This is about women who are still tired even when they wake up. It interferes with their ability to do normal activity. They mention that they have to sit down and rest when they make the bed or when they’re trying to prepare a meal.”

Diagnosis may be especially difficult if women downplay their symptoms or misdiagnose themselves. “If the woman doesn’t think she’s vulnerable, she’s going to walk in clutching her chest and say, 'I have indigestion,' whereas a man might say he was having a heart attack. Sometimes the health professionals are led down the wrong path,” Wenger said.

Denial seems to play at least some part in this. “What would you rather believe, that you have heart disease or indigestion?” asked Bowman, who was told to take an antacid for her chest pains, which were sometimes so bad that she would have to lie down on the floor.

Bowman also points out that after a heart attack women don't seem to get as much help as men. At a support group she attended after her experience, she said, "The women who were cardiac patients came alone, and the men came with their wives.”

As a result of her experience, Bowman believes that women who think they have symptoms need to be more persistent in seeing that they are given the right tests. “Women have to be more proactive,” Bowman said. “If you have these symptoms, yell, scream, demand the care that you need.”

After suffering a heart attack, some women find it difficult to talk about their condition, fearing how others will react. “It’s almost like a secret society,” said 39-year-old Chrissie Pearce, who suffered a heart attack earlier this year. “Women are suffering, kind of in silence. It’s almost like being ashamed.”

But not Bowman, who bought posters of women showing their surgery scars for her doctor to put up in his office. She recently started wearing V-neck sweaters again, even though it makes her own scar visible. “This is who I am, and I’m not going to hide it anymore,” she said.

E-mail: sls2118@columbia.edu