Each year, more than 15,000 women younger than age 55 die from heart disease, ranking it among the leading causes of death in this age group. “Young women have twice the risk of dying during hospitalization for an acute myocardial infarction (AMI) as similarly aged men,” says Judith H. Lichtman, PhD, MPH. Research suggests that delays in recognizing AMI symptoms and seeking medical care may contribute to poorer outcomes for women, but most of these studies involve patients older than 55.
Few studies have examined the perceptions and actions of women younger than 55 who experience AMI symptoms. “With a better understanding of the perspective of these women with regard to AMI symptoms and their interactions with healthcare providers, clinicians can gain valuable insights into factors that influence prompt care-seeking behaviors,” Dr. Lightman say. To address this research gap, Dr. Lichtman, and colleagues had a qualitative study published in Circulation: Cardiovascular Quality and Outcomes in which 30 younger women (aged 30 to 55) who were recently hospitalized with AMI described their experiences with AMI symptoms and their decision-making process to seek medical care. The purpose was to identify factors that may contribute to delays in recognizing symptoms and engaging the healthcare system.
According to the results, five themes characterized the experiences of women. First, prodromal symptoms varied substantially in both nature and duration. Second, women inaccurately assessed their personal risk of heart disease and commonly attributed symptoms to non-cardiac causes. Third, it appeared that competing and conflicting priorities influenced decisions about seeking acute care. Fourth, the healthcare system was not consistently responsive to women, which resulted in delays in workup and diagnosis. Lastly, women tended to not routinely access primary care, including preventive care for heart disease.
The study also found that many women did not pay attention to early warning signs of AMI, such as pain and dizziness, and wide variations were seen with regard to the type of initial AMI symptoms (Table). “Most women had chest pain, but other AMI symptoms were also present and may have contributed to delays in care-seeking behavior,” says Dr. Lichtman. Stereotypical depictions of AMI symptoms—based on common profiles among men—may lead women to characterize atypical symptom as non-cardiac in origin, which in turn may delay seeking care.
Overall, women tended to delay seeking prompt medical care for longer times than men. “Younger women with multiple risk factors and a strong family history of heart disease sometimes assumed that they were too young to have an AMI,” Dr. Lichtman says. “This indicates a critical need to develop targeted educational campaigns for women so that they prioritize their own health in terms of managing traditional risk factors, particularly within the context of familial history.”
In addition, women in the study noted that competing family and work responsibilities were frequent causes for delays in seeking care. “Strategies are needed to empower women to recognize symptoms and seek care without stigma or perceived judgment, especially for those who are younger and have a higher risk for heart disease,” Dr. Lichtman says.
Connect the Dots
The study by Dr. Lichtman and colleagues provides novel insights about perceptions of AMI symptoms and factors contributing to delays in seeking prompt care. “It’s clear that efforts are needed to better educate women about the early symptoms of heart attack,” says Dr. Lichtman. “We need to change the way that women and medical teams respond to AMI symptoms. Many patients in our study had three or more AMI risk factors but never made the connection that these risk factors could signify a heart attack. Clinicians should take the time to connect the dots for patients and ensure that they understand the components that increase their risk for AMI.”
Dr. Lichtman also recommends that greater efforts be made to educate patients about preventive care. “Young women should not assume they are too young to have an AMI if they have several risk factors for heart disease and a strong family history of it,” she says. “Physicians should encourage women to be forthright about their symptoms early when they emerge and then be proactive about managing them rather than waiting to seek care.”
Ultimately, information from the study may be used to develop targeted interventions for improving the promptness with which patients present for care and receive a timely, accurate AMI diagnosis. “Identifying opportunities to improve the detection of AMI symptoms and receipt of timely acute care represents an important target to improve outcomes for younger women,” says Dr. Lichtman.
For a free PDF of the study on symptom recognition and healthcare experiences of young women with acute myocardial infarction, go to http://circoutcomes.ahajournals.org/content/early/2015/02/24/CIRCOUTCOMES.114.001612.full.pdf+html.
Lichtman JH, Leifheit-Limson EC, Watanabe E, et al. Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2015 Feb 24 [Epub ahead of print]. Available at: http://circoutcomes.ahajournals.org/content/early/2015/02/24/CIRCOUTCOMES.114.001612.full.pdf+html.
DeVon HA, Saban KL, Garrett DK. Recognizing and responding to symptoms of acute coronary syndromes and stroke in women. J Obstet Gynecol Neonatal Nurs. 2011;40:372-382.
King KB, McGuire MA. Symptom presentation and time to seek care in women and men with acute myocardial infarction. Heart Lung. 2007;36:235-243.
Løvlien M, Schei B, Hole T. Women with myocardial infarction are less likely than men to experience chest symptoms. Scand Cardiovasc J. 2006;40:342-347.
Mochari-Greenberger H, Miller KL, Mosca L. Racial/ethnic and age differences in women’s awareness of heart disease. J Womens Health (Larchmt). 2012;21:476-480.
Lichtman JH, Lorenze NP, D’Onofrio G, et al. Variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study design. Circ Cardiovasc Qual Outcomes. 2010;3:684-693.