Published May 17, 2022
Heart disease is the number one killer of women. However, there can be many causes for chest pain other than heart attacks and symptoms can vary depending on the patient.
One common cause of pressure or tightness in the chest is angina, which develops when an inadequate amount of oxygenated blood reaches the heart muscle, typically due to a blocked coronary artery. Angina is a warning sign of underlying heart disease and can lead to a heart attack.
Cardiologist Lisa Freed, MD, director of the Women’s Heart and Vascular Program at Yale New Haven Hospital Heart and Vascular Center, and assistant clinical professor of Cardiology at Yale School of Medicine, says that not all chest pain is angina. It can also be caused by reflux, esophageal spasm, lung issues such as asthma or COPD, musculoskeletal pain, and stress.
Unfortunately, it can be hard to tell the difference between chest pain associated with one of those conditions and chest pain associated with a heart attack. If at any point a woman experiences a sudden onset of symptoms, they should call 9-1-1, because "time is muscle."
“It’s better to go get checked out and have them tell you that you’re fine than to sit at home with a potential heart attack,” said Dr. Freed.
Immediate intervention can help preserve heart muscle.
The classic symptoms associated with heart attacks in women and men include:
Chest pain can sometimes come and go for weeks or even months. Extreme fatigue or pain after exercise can be signs that a woman should see her doctor.
Cardiologist Erica Spatz, MD, director of the Preventive Cardiovascular Health Program at Yale New Haven Hospital Heart and Vascular Center, and associate professor of Cardiology at Yale School of Medicine, said that the first step in determining the cause of chest pain in the hospital setting are an EKG, which looks for signs of decreased oxygen supply to the heart muscle, and a blood test that can show damage due to a lack of oxygen. Sometimes more extensive testing is needed.
“Many women have chest pain and even have tests that show that the problem is due to impaired blood flow to the heart muscle, but they don’t have the traditional paradigm of blockages that are resulting in that chest pain,” Dr. Spatz said. “They may have other causes of decreased blood flow to the heart muscle.”
At the Preventive Cardiovascular Health Program, Dr. Spatz said they take an in-depth look at symptoms, risk factors, family history, order an extensive cholesterol panel and sometimes more invasive testing in the catheterization lab.
“In many of these women, we are finding the wrong tests are being done or not enough tests are being done to really understand the physiology behind what’s causing their chest pain,” Dr. Spatz said.
In addition, Dr. Spatz said clinicians need to use a more expansive model of ischemia to understand chest pain in women. Disease of the small vessels (called microvascular dysfunction), coronary vasospasm, and impaired relaxation of the coronary arteries may be causing the chest pain and even explain heart attacks that are not caused by blockages. These diseases are significantly more common in women and suggest a more sex-specific approach in caring for women with chest pain. Specific diagnostic tests and treatments are needed to truly improve outcomes in women.
Maintaining a healthy diet and weight in addition to a regular exercise routine, along with managing stress and improving well-being, can all help support cardiovascular health. In addition, patients should “know their numbers,” which includes blood pressure and cholesterol levels.
Dr. Spatz said women should also be on the lookout for milestones surrounding their heart health. For example, preeclampsia during pregnancy or pre-term birth is a sign the cardiovascular system could be more vulnerable. During menopause, declines in estrogen levels can result in blood vessels changing.
Lastly, Dr. Freed encourages her patients to advocate for themselves. If something feels off, don’t feel ashamed to seek help, even if initial testing shows nothing is wrong.
“Women tend to delay their care and minimize their symptoms, so I never lose the opportunity to tell them to have their symptoms evaluated,” Dr. Freed said.
