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Heart Attacks in Women

heart attacks in women

Heart Attack: Under-Recognized Killer of Women

Heart attacks are by far the most common cause of death in females, three times greater than breast cancer, for example.

Signs and symptoms of a heart attack is vital information that should be known by every woman.

The most common symptoms of heart attacks in women are pain, pressure or discomfort in the chest. But it’s not always severe or even the most prominent symptom, particularly in women. And, sometimes, women may have a heart attack without chest pains. Women are more likely than men to have heart attack symptoms unrelated to chest pain, such as:

  • Neck, jaw, shoulder, upper back or abdominal discomfort
  • Shortness of breath
  • Right arm pain
  • Nausea or vomiting
  • Sweating
  • Lightheadedness or dizziness
  • Unusual fatigue

These symptoms can be less pronounced than the obvious crushing chest pain often associated with heart attacks. Women may describe chest pain as pressure or a tightness. This may be because women tend to have blockages not only in their main arteries but also in the smaller arteries that supply blood to the heart — a condition called small vessel heart disease or microvascular disease.

Women’s symptoms may occur more often when women are resting, or even when they’re asleep. Mental stress also may trigger heart attack symptoms in women.

If you suspect you are having a heart attack: Call 911 or your emergency services number immediately.

Know the Difference: Cardiac Arrest Vs. Heart Attack

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Do you know the difference between Cardiac Arrest and a Heart Attack?

Cardiac Arrest

Sudden Cardiac Arrest is when the heart malfunctions and suddenly stops beating unexpectedly. It strikes immediately and without warning.

The main sign is: Sudden loss of responsiveness (no response to tapping on shoulders.)

Heart attack

A heart attack is when blood flow to the heart is blocked.

Heart Attack Victims may experience a diversity of symptoms that include:

  • pain
  • fullness
  • squeezing sensation of the chest
  • shortness of breath
  • sweating
  • vomiting
  • indigestion or heart burn
  • arm pain (more commonly the left arm, but may be either arm)
  • upper back pain.

If you suspect someone is having a heart attack or has sudden cardiac arrest: Call 911 or your emergency services number immediately. Stay with the person until the ambulance arrives. DO NOT drive them, if they should need assistance you can not help them while driving.

Testosterone Replacement Therapy

Advertising hormone replacement therapies

There has been a fair amount of direct-to-consumer advertising for manufacturers of testosterone replacement therapies on the benefits of testosterone replacement. These ads foster the idea that age and a decline in sexual hormones (testosterone in men, estrogen in women after menopause) may contribute significantly to health issues such as:

  • vitality
  • strength
  • general well-being

Sexual health issues such as libido and erectile function have significantly contributed to an interest in these therapies.

Estrogen replacement therapy for women

With estrogen replacement therapy for women, it was thought that the therapy might not only affect women’s well-being and an improvement in menopausal symptoms such as hot flashing, but might also have significant benefits on bone strength and cardiovascular health. Unfortunately, the opposite has been shown. Use of estrogen or hormone replacement therapy (HRT) has been shown to increase cardiovascular risk and may also increase the risk of breast malignancy. These therapies are no longer recommended.

Testosterone replacement therapy for men – “Been there; done that.”

There have been two recent studies which have raised concerns about the safety of these testosterone replacement therapies for men. A Veterans Affairs study published in November of 2013 showed that the risk of death, heart attack or stroke was higher in men who received testosterone compared to men who were not treated with these therapies. There was a 5.8% absolute risk increase in these problems in the men who received testosterone. *

What does that mean? Every 17 men who are treated with testosterone would have one of these unfortunate outcomes.

A second study in June of 2014 of over 50,000 men showed the incidence of heart attack at 90 days after initially being treated with testosterone replacement therapies being significantly higher for heart attack risk. The authors of this study did an interesting comparison looking at whether use of drugs for treatment of erectile dysfunction like Viagra, Cialis or Levitra caused any increased hazard. There was no significant increased risk. **

Both of these studies have been criticized by physician and industry supporters of testosterone therapy because these studies were what is called “observational studies.” These studies do not strictly control the differences between the treated group and the group that does not receive the treatment. The FDA and others have called for randomized control trials to assess the definite safety and efficacy of testosterone replacement.
The Endocrine Society and American Association of Clinical Endocrinologists have included a testosterone therapy recommendation in the recently published “Choosing Wisely” guideline.

The statement on this issue is:
Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.

Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing (measurement of blood levels of testosterone). Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, a free or bioavailable testosterone may be of additional value.

The current consensus appears to be that we should clearly avoid testosterone replacement therapies in older patients, frail patients or patients who have definite coronary disease. In addition, use of testosterone replacement should be carefully guided with laboratory testing for other hazards.

In my practice, I have now recently seen two men less than age 60 on testosterone replacement therapy who had heart attacks. The linkage is suspicious since the patient did not have other significant coronary risk factors.
Caution is strongly recommended with this treatment until more information is known about its safety and efficacy.


* Vigen R, O’Donnell CI, Barón AE, et al. JAMA. 2013;310(17):1829-36.

** Finkle WD, Greenland S, Ridgeway GK, et al. PLoS One. 2014;9(1):e85805.

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Aspirin for Primary Prevention

How does your doctor help you avoid cardiac events like heart attacks or strokes? Establishing a prevention strategy is important to lessen the risk of such dangerous events. Doctors generally define prevention strategy as either primary or secondary:

Primary Prevention – No cardiac events have occurred in the patient. The doctor wants to prevent an initial cardiac event.

Secondary Prevention – A cardiac event has happened in the past. The doctor will try to prevent another event from occurring.

For instance, a patient who has had a heart attack or stroke is generally treated with secondary prevention using drugs like aspirin, cholesterol lowering medications to reduce the chance of another event occurring. Patients who have not yet had an event such as a heart attack or stroke are at much lower risk. Finding the appropriate level of prevention in these patients is often difficult because of this lower risk.

Aspirin for Primary Prevention

It has been the practice for decades now to use low-dose aspirin, particularly for adults over age 50. This approach has been felt to reduce the chance of a heart attack or stroke, mostly by providing a slight blood thinning effect. Aspirin acts as a blood thinner by inhibiting the actions of platelets in the blood. This antiplatelet effect has been shown to be very significant for patients having a heart attack or for after having a heart attack. The logic therefore was extended to include patients who are at risk for heart attacks.

We have generally recommended aspirin at low dose (81 mg) for primary prevention for patients over age 50. The data was felt to be reasonably strong for men and less strong for women.

New FDA Recommendations

Now, the FDA no longer recommends that this practice be continued. The May 2014 FDA statement says:

“The FDA has reviewed the available data and does not believe the evidence supports the general use of aspirin for primary prevention of a heart attack or stroke. In fact, there are serious risks associated with the use of aspirin, including increased risk of bleeding in the stomach and brain, in situations where the benefit of aspirin for primary prevention has not been established.”

Here is the link to the FDA statement from May 2014.

The FDA did caution patients not to stop aspirin without consulting their physician. They also tried to educate the public about the differences between primary and secondary prevention and have clearly stated that this new recommendation only pertains to primary prevention. Patients who had prior evidence of vascular disease with heart attack, stroke, prior angioplasty or other vascular procedure, or even with imaging evidence of significant vascular disease in the carotid arteries or vascular disease of the legs, should continue aspirin if recommended by their physicians.