Heart Attack Symptoms in Women and Diabetics: First Steps

Heart attack symptoms in women and diabetics are often softer and slower than the classic picture. Women tend to report jaw pain, back ache, breathlessness, nausea and extreme fatigue, sometimes over several days, while diabetics may feel much less chest pain. Any such patient should have an immediate ECG and troponin test, and be treated as having coronary artery disease until proved otherwise.

Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, spent the first part of his masterclass on this problem: the patients most likely to be missed are not those with crushing chest pain but those whose heart attack looks like indigestion, a flu or simple tiredness. This article covers how presentations differ, how to confirm the diagnosis with an ECG and troponin, and what to do in the first 120 minutes, including where no catheterisation laboratory is within reach. The wider picture of the disease, prevention and stable angina is in the complete guide to the diagnosis and management of coronary artery disease.

The classic heart attack

The textbook presentation is the one typically seen in adult men. Dr. Purkayastha describes it as:

• heaviness in the chest
• cold, sweaty palms or cold, clammy extremities
• pain in the neck, or pain in the left arm radiating down from the shoulder
• sudden, severe nausea, sometimes with vomiting
• sudden breathlessness and marked tiredness, to the point of being unable to speak

The onset is often abrupt. A patient may be sitting, walking or in the middle of a meeting when the breathlessness, sweating and nausea arrive. This presentation is more common in people over 40.

Heart attack symptoms in women and men: how they differ

Women more often report jaw pain, back ache and fatigue over several days; men more often report sweating and heartburn over a few hours. Dr. Purkayastha opened with this contrast, which he wants every general practitioner to hold in mind.

The heartburn in men is the trap. Heart attack pain can feel like gastro-oesophageal reflux, and patients often reach for an antacid. His rule is simple: if heartburn persists for more than half an hour after an antacid or another over-the-counter remedy for indigestion, the patient should see a general practitioner immediately.

The woman who has had symptoms for three days

The longer presentation in women is the point he stressed most. A man may come in with chest pain of a couple of hours. A woman may come in saying she has had discomfort for three or four days. The fact that she is alive and sitting in the clinic does not mean the episode is benign: more often than not, in Dr. Purkayastha's experience, it is a myocardial infarction in evolution, a heart attack still in progress. She needs blood tests and cardiac troponin, and should be treated as having coronary artery disease unless proved otherwise.

Heart attack risk after menopause

Before menopause, women are relatively protected against coronary disease, in part by the hormone oestrogen. Dr. Purkayastha stressed the shift that follows. A premenopausal woman's risk of coronary heart disease is several times lower than that of a man of the same age; after menopause, which typically occurs between 45 and 55, her risk climbs steeply and the gap with men narrows.

Postmenopausal women also present differently. They may describe a runny nose, a flu-like illness, a little chest tightness, indigestion or heartburn, lasting a few days. The danger is that this is read as a common cold and treated with over-the-counter remedies. His instruction: any woman over 45 who reports a few days of uneasiness should be assessed for coronary disease.

CT coronary angiography in women

For this group, Dr. Purkayastha considers CT coronary angiography the best investigation. Women generally have a lower calcium load in their coronary arteries, which makes CT coronary angiography particularly informative in women; its main strength is a very high negative predictive value, so a normal scan reliably rules out significant coronary artery disease. Rather than prescribing an over-the-counter remedy for occasional chest tightness, he asks physicians to consider a coronary angiogram.

Silent heart attacks in diabetics: why they feel less pain

People with diabetes may have far fewer symptoms of a heart attack. Long-standing diabetes can damage the autonomic nerves that carry pain signals from the heart (diabetic autonomic neuropathy), so the classic chest pain may be faint or absent. What usually remains, in Dr. Purkayastha's description, is nausea, extreme tiredness and cold, clammy skin and extremities.

The consequence is under-reporting. A diabetic patient may describe a little chest discomfort rather than a full-blown chest pain. He asks physicians to make diabetic patients aware of this, and to pick up coronary disease from a much more subtle presentation than in other adults.

Confirming the diagnosis: ECG and troponin

For women and diabetics in particular, he set a minimum standard: an immediate ECG, immediate blood tests and an immediate troponin T test. No single element is enough on its own. In his teaching, the diagnosis of a myocardial infarction is secure when three things come together:

1. symptoms of ongoing angina, chest pain or severe heartburn
2. an abnormal ECG
3. a positive cardiac enzyme (troponin)

A normal ECG does not rule a heart attack out: a rise in troponin with ischaemic symptoms is enough to diagnose a non-ST elevation myocardial infarction.

The three ECG patterns

Reading the ECG is, in Dr. Purkayastha's view, one of the key things a physician must understand. He teaches three patterns side by side:

• Normal: the standard P, QRS and T complex.
• ST elevation myocardial infarction (STEMI): the ST segment is raised, typically a sign of a fully blocked artery.
• Non-ST elevation myocardial infarction (NSTEMI): the ST segment is often depressed or the T waves inverted, although the ECG can be normal.

Anyone with chest pain and one of these abnormal patterns, with or without raised cardiac enzymes, should be treated with a very high index of suspicion for a heart attack.

The point-of-care troponin test

Troponin is a protein released into the blood when heart muscle is damaged. Rapid troponin T test kits, widely available, give a result at the bedside: the blood sample goes into a well, and two lines indicate a positive test. Dr. Purkayastha values them as an easy way to support the diagnosis, but repeats that a kit alone will not serve: it must be read with the ECG and the symptoms.

Pectoral muscle spasm or heart attack?

A question in the session raised spasm of the pectoral (chest wall) muscles, which can be mistaken for cardiac chest pain. Dr. Purkayastha's answer was clear: pectoral muscle spasm is not related to coronary artery disease. The two are separated in two ways:

• Troponin. Non-cardiac chest pain does not raise cardiac enzymes, so a pectoral muscle spasm returns a negative troponin test.
• Movement. Muscle pain is made worse by local movement, such as lifting the arm or moving the hands behind the back. Angina does not change with these movements.

Muscle spasm is treated with non-steroidal anti-inflammatory drugs (NSAIDs). Chest pain with a positive troponin or an abnormal ECG goes down the angiography pathway instead.

The first 120 minutes: responding to a suspected heart attack

Once a heart attack is suspected, the response depends on one question: can the patient reach a centre capable of percutaneous coronary intervention (PCI, opening the artery with a balloon and stent) within 120 minutes? Dr. Purkayastha described the old "golden hour" as having stretched: reaching the catheterisation laboratory within the first 120 minutes is still worth the effort.

Step one: 300 mg of aspirin

Aspirin comes first, in every setting. Dr. Purkayastha advises an adult with a suspected heart attack to take 300 mg, whether as three 100 mg tablets, two 150 mg tablets or a single 300 mg tablet. Aspirin is easy to find across the African continent, and he wants every patient at risk, and every general physician, to keep it at hand. Taken early, in his words, it buys valuable time to reach the nearest medical facility without collapsing.

If a PCI centre is within 120 minutes

Where angioplasty is possible within two hours, the patient should still take aspirin and then go down the primary angioplasty pathway: an angiogram, and a stent to open the blocked artery. In Dr. Purkayastha's words, primary angioplasty has a much better chance of resolving the heart attack. If the diagnosis is confirmed in a PCI-capable setting, he wants the angiogram done within the first two hours. Indicative costs are on the angioplasty with stent cost page.

If no PCI centre can be reached in time: antiplatelets or thrombolysis

Where angioplasty is not possible within 120 minutes, the patient goes down the medical pathway. For a STEMI within 12 hours of symptom onset, guidelines recommend fibrinolysis given together with dual antiplatelet therapy, unless fibrinolysis is contraindicated; antiplatelet drugs alone are for patients who cannot receive it. The two elements are:

• Dual antiplatelet therapy: aspirin with a second antiplatelet drug. He named prasugrel. Guidelines reserve prasugrel for patients who are going on to PCI; where fibrinolysis is given, or no reperfusion is possible, clopidogrel is the recommended partner to aspirin.
• Fibrinolysis (thrombolysis): a clot-dissolving drug. He deliberately chose streptokinase for his slides because it is available on every continent. The standard adult dose is 1.5 million units infused over one hour.

Thrombolysis carries a higher risk of bleeding than angioplasty. His judgement is pragmatic: in a resource-constrained setting, the higher bleeding risk is accepted because something is better than nothing.

When to escalate

The medical pathway is not the end of the road. If the cardiac enzymes keep rising, or symptoms persist despite antiplatelet drugs or thrombolysis, the patient needs an urgent specialist referral for an angiogram. Guidelines treat failed thrombolysis as an indication for immediate rescue angioplasty, and advise an angiogram within 2 to 24 hours even after successful thrombolysis. The referral criteria are covered in the complete guide, and the choice between a stent and bypass surgery that follows the angiogram is set out in the article on left main disease and bypass versus stenting.

Four habits that catch a heart attack early

Dr. Purkayastha's message on recognition comes down to four habits:

• Treat heartburn that does not settle within half an hour of an antacid as possible heart pain.
• Take a woman with several days of vague chest symptoms as seriously as a man with crushing pain.
• Expect diabetics to under-report, and test them on subtler signs.
• Keep aspirin at hand, and know where the nearest PCI centre is and whether it can be reached within 120 minutes.

His companion session on heart failure and coronary artery disease in the African population takes the same symptom differences into the wider context of the disease burden across the continent. Doctors' questions from this session are on the Live Discussion page, and more on the specialty is on the cardiology hub.