Photo credit: Getty Images

Photo credit: Getty Images

You’ve seen it over and over: A male character in a movie or on a TV show is having sex, yelling at someone, playing sports or even riding a Peloton, when all of a sudden, he stops cold. He then goes pale, staggers, clutches his chest — left arm or both — then dramatically slides down a wall.

You hardly ever see women having a heart attack in pop culture, however, even though almost as many women die of some form of heart disease as men in the United States, according to the Centers for Disease Control and Prevention. In 2017, heart disease killed one in five American women, and it’s not only older women: the proportion of younger women hospitalized for heart attack has been growing, research shows.

If you did see a woman experiencing heart attack symptoms in real life, it is liable to look something like this: Two friends are out strolling, when one says she’s just feeling like “something isn’t right” and suggests they sit for a minute. According to Judith Lichtman, Ph.D., MPH, the Susan Dwight Bliss Professor and Chair in the Department of Chronic Disease Epidemiology at the Yale School of Public Health, you’d see a woman who is feeling abnormally tired and really not up to her normal speed, who is also potentially noticing any of the following common heart attack symptoms:

  • Chest pressure, tightness, palpitations or sharp pain

  • Nausea, indigestion, stomach pain or some acid reflux

  • Discomfort in arms, neck, jaw or back

  • Fatigue

  • Shortness of breath

  • Dizziness or fainting

  • Cold sweat and paleness

But because she’s feeling other things in addition to some chest pain or discomfort, unless her friend is alarmed enough to call 911, the woman may well attribute any of these symptoms to exhaustion or the flu and go home and take a nap.

And it’s not only the woman herself who may not know she’s having a heart attack: Lichtman’s research suggest that, perhaps because younger women present with more symptoms than men their age, often neither the woman nor her doctors initially think it’s a heart attack — even though chest pain is the main symptom.

What exactly is a heart attack?

“A heart attack is anytime your heart doesn’t receive enough blood to stay healthy,” says Karol Watson, M.D., Professor of Medicine/Cardiology at the David Geffen School of Medicine at UCLA. “The heart is a muscle, and just like any muscle, requires a constant blood supply to stay healthy and strong,” she says. “If an area of the heart is deprived of blood for any length of time, it can weaken and die, and when it does, that’s a heart attack.”

Blood supply to your heart is slowed or stopped if your arteries become blocked with plaque (a mix of cholesterol, fat and other stuff). There can also be blood clotting around the plaque, which makes it hard for the blood to get to your heart. And once an area of the heart dies, says Dr. Watson, it cannot come back (although the rest of the heart may be able to step up and compensate for the damaged area).

What are the first warning signs of a heart attack in a woman?

When a woman is having a heart attack, one of the first things she may notice is that she’s feeling incredibly tired — that is, more tired than the usual work-kids-I’m-in-charge-of-everything kind of tired. “There’s very good information on what premonitory symptoms that women had prior to being diagnosed, and the most common is overwhelming fatigue,” says Dr. Watson.

You might not think you’re having a heart attack when you feel this way, because it could be something else, and frankly, who hasn’t felt totally wiped?

But here’s the thing: “It’s almost always accompanied by something else: Chest pain, chest pressure, shortness of breath, indigestion,” says Dr. Watson. Fatigue, says Dr. Watson, might not be the most prominent symptom, so it’s important to look at the totality of what you’re feeling. “If you have overwhelming fatigue and any of those other things, that’s a sign that something is off,” she says.

The Four “Silent” Symptoms of a Heart Attack

In addition to extreme fatigue, here are the most common symptoms of heart attacks in women, according to the American Heart Association, so you know what to look for. Note that you may not have all of them:

  1. Uncomfortable pressure, squeezing, fullness or pain in the center of your chest. It lasts more than a few minutes or goes away and comes back.

  2. Pain or discomfort in one or both arms, the back, neck, jaw or stomach.

  3. Shortness of breath with or without chest discomfort.

  4. Breaking out in a cold sweat, nausea, vomiting or lightheadedness.

All of these signs are “silent,” in the sense that they are easy to ignore — especially if you don’t want to believe you’re having a heart attack. Another reason people think of them as silent signs of a heart attack is that individually, these symptoms could all be attributed to other conditions. The chest pain, in particular, may not be the dramatic, elephant-on-my-chest stereotypical “male” heart attack pain, says Lichtman.

And the sheer number of these ambiguous symptoms may be one of the reasons many women don’t know they’re having a heart attack, according to Lichtman’s research — there are other things bothering them, so they blow off the “chest pain or pressure” symptom, says Lichtman.

But when some or all of these symptoms are there at the same time, that’s exactly what a heart attack looks like in women. And when you think about it, any kind of pain or discomfort in the chest should be treated as a “loud” symptom. And whether it’s more like tightness or pressure or feels like a sharp pain, all of that counts as chest pain. “Chest pain is still the biggest common symptom of heart attack that both men and women experience, around 80-90% depending on how you collect the information,” Lichtman says.

How long can a woman have symptoms or signs of blockage before a heart attack occurs?

Is it possible to walk around with heart attack symptoms for a period of time? Yes, but for how long is “impossible to state,” says Dr. Watson. “Every woman is different.”

That’s why if there are any worrisome symptoms it’s best to get them checked as soon as possible. “The symptoms that should send you directly to get checked out are chest pain, shortness of breath or fainting,” she says.

As for knowing whether your blood vessels to your heart are becoming blocked, unfortunately, says Dr. Watson, you probably won’t. “It’s really hard to know pre-symptoms,” she says, though you and your healthcare provider can be on the lookout if she knows your family history and is monitoring your cholesterol, blood pressure and other heart disease risk factors. “What you are going to really feel are the symptoms — I wish there were an early warning sign but there isn’t.”

What women need to know that’s different from men

“For a long time there was a sense that women didn’t have the chest pain that men do, and that’s not true,” says Lichtman. The number one thing women need to know is that chest pain or pressure is in fact one of the symptoms (even if it’s not the biggest or most obvious symptom), even if it doesn’t feel like the stereotype of a crushing weight on your chest. “My rule is, if you have any symptoms between your navel and your nose, that comes on with exertion and goes away with rest, you have to think about your heart,” says Dr. Watson.

The other thing women need to know that’s different from men is that they may have multiple symptoms, and not to disregard the fact that chest pain is one of them. Why? “I think it’s a combination of things,” Lichtman says. “In the back of people’s minds, especially with younger women, people would rather have something else be the cause than a heart attack,” she says. “They’d much rather it be, say, indigestion over a heart attack,” so they tend to focus on the less dire possibilities.

Doctors, too, may not think “heart attack” if when they hear chest pain as just one of many symptoms. “It’s different for different providers, but for some, the order in which you hear [the symptoms] is the order of intensity,” she says. So if a woman lists chest pressure as third or fourth on the list, it may take the doctor longer to think of a heart attack.

The third thing women need to understand is that women with heart attacks have higher mortality rates than men for a variety of reasons, research shows. Calling 911 fast if you show symptoms of a heart attack is one thing you can control.

What should you do if you have symptoms of a heart attack?

  • Call 911 — ASAP. One Swiss study found that women wait almost 40 minutes longer to call for help than men do, perhaps because they don’t recognize the symptoms. Older research shows that calling an ambulance is usually quicker than driving yourself to the ER. That’s because if they know you’re coming, the hospital can prep for you, and you get care along the way.

  • Lead with chest pain or pressure when you get to the hospital and the doctor asks about your symptoms. Even if you have other symptoms, “Put that out first rather than burying it,” advises Lichtman.

  • Don’t play down what you’re feeling. “Be the squeaky wheel,” says Dr. Watson. Dr. Lichtman has done research showing that younger women who need care for a heart attack often don’t want to look alarmist. “Don’t feel bad or think that you don’t want to disturb anyone — this is our job to save your life,” Dr. Watson says.

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