Here’s Why Heart Attack Symptoms Can Be So Hard to Spot in Women

For example, do a quick Google image search of the phrase heart attack and you’ll probably see an older man in his 50s or 60s, hand on his chest, clearly in severe pain. That’s a somewhat fair depiction, given that men are at greater risk of heart attack than women, and that the most common symptom of a heart attack is chest pain or discomfort, according to the American Heart Association (AHA). But that generalization can obscure the reality that heart disease is the leading cause of death for both men and women in the United States, according to the Centers for Disease Control and Prevention (CDC)—and that there can be other symptoms of heart attacks besides chest pain, especially in women. Let’s get to the truth about heart attack symptoms in women.

Let’s talk about the causes and symptoms of a heart attack.

Although heart attacks can happen the same way in men and women, they can sometimes look different. A heart attack, or myocardial infarction, usually occurs when a blood clot in one of the coronary arteries cuts off or seriously restricts the flow of blood and oxygen into the heart, the U.S. National Library of Medicine explains. This can happen when fatty plaque builds up inside an artery, narrowing the passageway into the heart. If the plaque in that artery breaks open, a blood clot forms, restricting or stopping the flow of blood into the heart. The heart cells that are deprived of oxygen start to die, which leads to a heart attack.

The most common sign of a heart attack, in both men and women, is pain or discomfort in the middle or left side of the chest, which can range from mild to intense and last several minutes or come and go, the National Heart, Lung, and Blood Institute (NHLBI) explains.

But women are also more likely to have less expected signs of a heart attack, according to the NHLBI. (Sometimes these are called atypical or nontraditional heart attack symptoms.) These include heartburn, indigestion, nausea, vomiting, shortness of breath, extreme fatigue, and pain in the back, arms, neck, throat, or jaw. Lightheadedness and breaking out in a cold sweat are also potential symptoms, the AHA says. Women are even more likely than men to have no obvious symptoms at all, which is called a silent heart attack, according to the Office on Women’s Health. (Doctors can tell that you had a silent heart attack in the last few days to months using an electrocardiogram test.)

“We don’t really know exactly why women [with heart attacks] present differently than men,” Heba Wassif, M.D., M.P.H., a cardiologist at the Cleveland Clinic, tells SELF. According to a 2016 statement from the AHA, this is a complex and understudied issue. (And, as Dr. Wassif points out, the mere fact that these symptoms are sometimes labeled atypical may perpetuate our overlooking of them.)

Scientists believe it has to do, at least in part, with biological differences in how heart disease tends to develop in men and women—like the characteristics of the plaque, the arteries where it tends to form, and the pathophysiological mechanisms or causes underlying the heart attack, according to the AHA statement.

Here’s why it’s easy to miss women’s heart attack symptoms.

“It’s a combination of factors that contribute to this,” Jacqueline Tamis-Holland, M.D., a cardiologist at Mount Sinai Morningside at Mount Sinai, tells SELF. Underpinning nearly all of them is a lack of awareness of heart health as an important issue for women. “People are understanding and recognizing these things more now,” thanks to public awareness campaigns, Dr. Tamis-Holland says. “But I think [there are] some residual [stereotypes].” Although awareness has increased over the past few decades, only 56% of women know that heart disease is the number one cause of death for women overall, according to the CDC.

Because of that, “Women may be less likely to realize they’re having a heart attack,” Dr. Tamis-Holland says. Yes, that’s in part because the heart attack symptoms women often experience can just seem random—less obviously heart-related and more easily attributable to some other health issue. Shortness of breath, jaw pain, and indigestion don’t set off those alarm bells the way chest pain does.

But there’s also evidence suggesting that this lack of awareness may lead women to try to rationalize or minimize their symptoms if they don’t totally align with those of the standard heart attack. In a 2015 study published in Circulation, for which researchers interviewed 30 women aged 30 to 55 who were hospitalized for a heart attack, a recurring theme was that women were hesitant to believe they could be having a heart attack because their symptoms did not reflect descriptions of heart attacks by doctors or depictions of them in TV or movies.

We also see how this plays out in a large 2018 study published in Circulation. Researchers interviewed 2,009 women and 976 men aged 18 to 55 who were hospitalized for a heart attack at 103 different hospitals across the United States. The researchers found evidence that women were much more likely to chalk up their symptoms to emotions and mental health. Nearly 21% of the women attributed their symptoms to stress or anxiety, compared to just 11.8% of men. That could be a factor in why women in the study took longer to seek help. The median time between the onset of symptoms and showing up at the hospital was 3.2 hours for women, compared to 2.4 hours for men.

The lack of public awareness of the wide range of women’s heart attack symptoms—and women’s risk of heart attack in general—can affect not only the way women react to their symptoms, but also how they’re treated by medical providers. “Absolutely, there is some bias in the way the symptoms are being recognized and perceived by doctors,” Dr. Tamis-Holland says.

Although women in the 2018 Circulation study were more likely than men to have sought care for similar symptoms in the previous week before hospitalization (29.5% versus 22.1%, respectively), they were much less likely to be recognized as having a heart issue. Over half (53%) of those women who did seek care said their provider didn’t think their symptoms were related to their heart health, compared to 37% of men.

These delayed diagnoses tend to occur in the primary care setting, where doctors have to consider a very wide spectrum of possible causes, Dr. Wassif explains. Also, primary care physicians (PCPs) may not be trained to prioritize women’s heart health or feel fully prepared to assess those risks. A survey of 200 PCPs and 100 cardiologists conducted by the Women’s Heart Alliance and published in the Journal of the American College of Cardiology in 2017 found that only 39% of PCPs ranked heart disease as their top concern for women. Around 22% of PCPs felt “extremely well-prepared” to assess cardiovascular risk in women, compared with 42% of cardiologists (42% of PCPs felt “well-prepared” to do this, while 40% of cardiologists said the same.) It’s not surprising that cardiologists felt better prepared overall, given their specialty, but since heart disease is the top killer of women, the hope would be that PCPs would feel just as well-versed in this too.

This kind of thing can even happen with emergency care, where you would think issues like heart attacks would be top of mind. Dr. Tamis-Holland had one patient who was experiencing terrible back pain and believed she may be having a heart attack. The patient told Dr. Tamis-Holland that the bystanders she first told to call 911 didn’t understand why she thought she was having a heart attack if her back hurt. “And then even when she got to the E.R., they first evaluated her for emergency conditions that would be causing back pain,” Dr. Tamis-Holland says.

One more thing to add on top of all of this? The fact that women are often simply very busy taking care of other people. Another theme in that 2015 Circulation study was women downplaying their symptoms under the pressure of work and family responsibilities—something Dr. Wassif can attest to. In addition to their jobs, women are often the primary caregivers for people in their lives, like children or older parents. Under the strain of work obligations and dependents relying on them at home, women may underestimate the seriousness of their symptoms or try to explain them away (to themselves or others), Dr. Wassif says. Dr. Tamis-Holland has had patients express that they hoped their symptoms would go away because they just didn’t have time to deal with them.

If you think you could be having a heart attack, seek care immediately.

Recognizing that something is really wrong can be as much about instinct as ticking off a symptoms list, especially when it comes to anything more subtle than severe chest pain, like sudden fatigue, indigestion, or jaw pain. “You know your body,” Dr. Tamis-Holland says. “If it just doesn’t feel right…you need to consider that maybe it is a heart attack and you should call 911.”

It’s very important to call 911 instead of driving to the hospital (or having someone drive you). As the OWH explains, that’s because getting treatment ASAP after a heart attack is vital—it’s more effective within the first hour—and medics in the ambulance can start treating you right away before you even get to the emergency room.

Be ready to tell the operator that you think you are having a heart attack and your exact location, speaking as slowly and clearly as you can, the OWH recommends. Follow any directions, and stay on the phone with them until help arrives. For instance, they may ask about what medications you are on and tell you to take an aspirin or nitroglycerin pill if you have any on hand, the OWH says. Dr. Tamis-Holland says it’s generally okay to take an aspirin immediately, because it is safe for most people and can start to treat your heart attack ASAP while you’re on your way to get the care you need.

Beyond that, even though you shouldn’t have to do this, it might help if you can explain that any “atypical” heart attack symptoms you’re experiencing really are typical for women, so your doctors can act with that in mind.