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Women can have heart attacks without chest pain. That leads to dangerous delays.

(Michael S. Williamson/The Washington Post)

“But, it’s not my heart. It’s not my heart,” my patient repeated to me. “It’s my stomach. Nothing is wrong with my heart.”

A few minutes earlier, I had rushed to the emergency room in response to an alert from my pager. This pager was reserved for one specific occasion: Someone was concerned that a patient in the hospital was having a massive heart attack.

When I reached the ER, I spotted an older woman looking uncomfortable. Earlier that evening, she had developed pain just above her belly button. After a few hours, when her symptoms did not abate, her family brought her into the hospital to be evaluated. She was sweaty, nauseous and breathing heavily.

She never had chest pain. But even without that symptom, I was fairly certain she was having a heart attack. Many people do not recognize the signs of a heart attack, especially in women. Lack of awareness can cause people to wait to come to the ER and potentially suffer damage to the heart.

She thought she had a 24-hour bug. What she really had almost killed her.

Chest pain remains the most common symptom of a heart attack in men and women. But women having a heart attack are more likely to have unusual symptoms — such as nausea, dizziness, pain around the belly button, feeling of heart racing, neck or arm pain — when compared with men. They are also more likely than men to have a heart attack without chest pain. Furthermore, the incidence of heart disease and hospitalizations for heart attacks is rising in young women.

My patient had high blood pressure as well as diabetes, both risk factors for heart disease. In addition, as part of her initial evaluation in the ER, she had received an electrocardiogram (or EKG), a picture of her heart that told me her heart muscle was injured from lack of blood flow.

After asking her a few questions about how she was feeling and listening to her heart and lungs, I told her my concerns. We needed to perform a coronary angiogram, a procedure to check for any blockages in the blood vessels feeding the heart. If there were blockages, we would try to open the blood vessels with a stent.

In cardiology, we know that time is muscle: The more time passes, the more the heart muscle is without oxygen during a heart attack. We needed to act fast.

She could not understand how she could have a heart attack without feeling pain in her chest. I called her daughter from the ER and explained the situation.

The patient herself was being her own advocate, trying to avoid what she felt would be an unnecessary procedure. To her, we were focused on the wrong thing. She wanted us to address her stomach pain. I showed her the EKG. We discussed that she had ongoing injury to the heart and this was manifesting as the pain she experienced in her stomach.

Shortly thereafter, we performed an angiogram and found that one of the arteries feeding her heart was 100 percent blocked. After a stent was placed to keep the artery open, her stomach pain went away.

A few weeks later, I saw another woman in the ER. She had been feeling dizzy and nauseous at home, and her family had convinced her to come to the hospital. When I spoke to her in more detail, she described having left-sided arm pain on and off the previous day. She thought it was probably because of an issue with her muscles. She, too, did not think it could be related to her heart because she never felt any chest discomfort. By the time our paths crossed, she already had suffered permanent damage to her heart muscle.

Heart disease is often thought of as a man’s disease. Typically, the only people who get heart attacks in TV shows and movies are overweight white men clutching their fists over their chests. Therefore, many feel the signs of a heart attack are impossible to miss, but they can be subtle. Many women worry about breast cancer, for instance, but more women are more likely to die of cardiovascular causes than all forms of cancer combined.

“Only 60 percent of women know that heart disease is the number one killer of women,” said Sonia Tolani, a cardiologist at Columbia University Irving Medical Center. “For women of ethnic minorities, this figure drops to one third.”

Tolani as well as her colleague, Natalie Bello, also a cardiologist at Columbia, created a mobile application, Love My Heart for Women, to help educate women about cardiovascular disease and their risk.

“Many of our friends were turning 40 years old and were preoccupied with getting their mammograms but no one was talking about their risk of heart disease,” Tolani said. “It was clear to us that there was not a lot of education about heart health among our peers.”

Since the first American Heart Month in 1964, every February, we have various societal initiatives to raise awareness about heart disease. In 2004, the American Heart Association created the Go Red For Women initiative to raise awareness about heart disease in women, as well as raise research money to help reduce heart disease and stroke in women.

As we partake in these events and wear red, we must also remember the women in the ER who were not clutching their chests but had heart attacks all the same. Heart disease may not feel or look the same from person to person but it can affect everyone, heart month or not.

Ersilia M. DeFilippis is a cardiology fellow at NewYork-Presbyterian/Columbia University Irving Medical Center in New York.

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