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Getting to the bottom of why men and women report different cardiac symptoms is trickier than might be expected. In fact, some researchers think the differences can be emphasized too much. If a woman doesn't think she can have heart disease, notes Dr. George Sopko of the NHLBI, she's not going to interpret her symptoms as heart disease--even if her symptoms are the same as a man's.
Truth is, the classic heart attack made famous onstage and onscreen, where you clutch your chest and fall to the ground, doesn't tell the whole story. "Half the time women don't do that," says Cedars-Sinai's Bairey Merz. "But 40% of the time, men don't have a typical heart attack either." Men, however, have been conditioned for decades to suspect that they might be suffering a heart attack even when they feel perfectly healthy. So while women are more likely to experience the prelude to an attack as shortness of breath, extreme fatigue or a feeling that they have a bad case of indigestion, they often can't believe that their symptoms are cardiac in origin. Equally important, their doctors often don't believe it either. Doctors tend to put off ordering necessary tests for women having a heart attack or fail to treat them aggressively enough.
Just ask Kathy Kastan, 43, a psychotherapist in Memphis, Tenn., who suffered both classic and less common symptoms. "I noticed that I would get tired more quickly," says Kastan, who was and still is very active--biking, swimming, running, walking. "I would sometimes have to stop because I had shortness of breath." After a couple of trips to the doctor, who failed to pick up on her heart problems, she collapsed in the street while on a vacation in Colorado. "I clutched my chest, had profuse sweating, chest pains from the front to the back, down my arm, up into my jaw." When the symptoms went away, she attributed them to the altitude. Finally, after collapsing one more time, she underwent a more comprehensive and rigorous stress test, which revealed a blockage that required bypass surgery after earlier treatments ended in failure. Now when Kastan talks to women's groups about heart disease, she tells them they need to know their risks and insist that doctors take them seriously.
To be fair, denial isn't the only thing working against women. "More than men, women have stress-related chest pain and pain when they are resting," says Dr. Randolph Martin of the Emory University School of Medicine in Atlanta. Sometimes the pain results from sore chest muscles or monthly variations in a woman's sensitivity.
Also, women frequently have abnormal ECG readings during the classic treadmill test even when their hearts are functioning normally. But before you decide that treadmill tests are worthless, consider the latest research from the WISE study, short for Women's Ischemic Syndrome Evaluation. Data from WISE suggest that false positives in women may be not so much an error as an early warning of a problem, perhaps in the smaller blood vessels, that could become significant in 20 to 30 years, according to Bairey Merz.