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Panic Attack or Heart Attack?

Diagnosing heart disease in women

A Healthy Hearts Guide  WHF red heart corporate logo ®

picture of sad and upset woman

  • Heart disease in women is often mistaken for panic attack with shortness of breath, anxiety, palpitations and indigestion.

  • Only by having testing beyond the standard EKG can a correct diagnosis be made.

  • When in doubt about symptoms, seek care without delay to rule out heart disease.

Heart disease affects your heart's muscle, blood vessels, and electrical system and is the leading cause of death among women. The most common form of heart disease is coronary artery disease in which plaque (a fat-like substance) deposits on artery walls. Plaque build-up is called atherosclerosis. This is a chronic condition that occurs in people with risk factors such as diabetes, obesity, smoking, abnormal levels of blood fats, high blood pressure, a family history of heart disease and older age. When a plaque ruptures, it causes a blood clot to form and suddenly block an artery. If this happens in a heart artery, it results in a heart attack. This is an Acute Coronary Syndrome (ACS) and getting life-saving treatment - within the first 30 minutes of an attack - is crucial to prevent permanent heart damage or even death.

Chest pain and difficulty breathing are common symptoms in both panic attack and heart attack as they trigger the body's "fight or flight" response, but these are also signs of ischemia - a lack of blood flow to the heart muscle. Other common symptoms include rapid, pounding heartbeats (palpitations), sweating, feeling of impending doom, transient burning sensation in the chest, dizziness, nausea, severe indigestion and unusual fatigue (sudden onset of unusual fatigue is women's chief symptom of heart attack, yet it often goes unreported to emergency room staff). If symptoms last for more than 2-3 minutes or if the pain leaves and then returns, it could be heart disease with ACS and you need to call 9-1-1 and get to the emergency room right away. Only by having testing beyond the standard electrocardiogram will you know if the pain is coming from your heart.

Diagnosing Heart Disease in Women
Diagnosing heart disease in women is more difficult than it is in men. Test results may not be as reliable. In addition, women often present with milder symptoms like unusual fatigue, shortness of breath and only mild "chest discomfort", but these symptoms are not to be taken lightly and deserve prompt attention. Advocacy plays an important role in women getting emergency care. Described below are some of the tests that are available to diagnose a heart attack and ACS, and how these tests are interpreted in women.

  • Electrocardiogram     An electrocardiogram (EKG or ECG) measures your heart's electrical activity by placing small electrodes on your chest, either while you are lying down or during stress testing. It records your heart's rate and rhythm and can detect evidence of a heart attack or inadequate blood flow to the heart muscle. It may not reveal a heart attack in every case, and may not show that the heart is starved for oxygen, especially if you are not having any symptoms when being tested.

  • Blood Tests     In conjunction with an ECG, blood tests screen for a variety of proteins found in the blood that are known to be associated with heart attacks. These proteins include creatine kinase, myoglobin, and most recently, troponin - if these are abnormally elevated they are indicators that a heart attack is taking place and that heart cells have begun to die. The goal of emergency room staff is to take blood tests within 30 minutes of your arrival with test results within one hour so that appropriate treatment can begin. Care within the first hour greatly improves outcome. If a heart attack is looming, but no cell damage has taken place, this condition is called Unstable Angina. Vessel spasm, which is more common in women, contributes to this precarious state.

  • Stress Tests    The routine diagnostic test - the treadmill stress test - is walking on a treadmill to stress the heart with exercise while having an electrocardiogram (the heart can also be stressed by administering certain drugs intravenously if a woman is unable to walk due to arthritis or other condition). The stress test is not entirely reliable for a man and is even less reliable for a woman. Research studies funded by the National Institutes of Health have demonstrated that the treadmill stress test gives false results in up to 40 per cent of women. Accuracy improves greatly- as high as 85% - when the stress test is combined with nuclear or echo imaging. Stress Echo combines the stress test with echocardiography. It is a good first-line test for a woman with symptoms and risk factors for heart disease. Echocardiography uses sound waves technology to give detailed information about the heart muscle, valves, chamber, and major blood vessels around the heart. It measures your "ejection fraction" - the functional status of your left ventricle, which is the main pumping chamber of the heart. Nuclear Imaging is a scan (also called myocardial perfusion imaging or "MPI") that uses a nucleotide tracer (e.g. Thallium) that is injected into your veins to view blood flow to your heart muscle. MPI is used in combination with the stress test to improve accuracy in diagnosing heart disease. Women of child-bearing age may wish to opt for ultrasound imaging to avoid exposure to radiation . Although stress tests are non-invasive, they are not without risk. Patients who are actively experiencing symptoms should not undergo this test.

  • Electron beam computed tomography (EBT)     Also called simply "EBT" or "ultra-fast CT scan of the heart", detects calcium build up in coronary arteries. Plaque consist of calcium and the test produces a 3-D picture of the heart that allows scoring of plaque to determine relative risk of heart attack. The test may incorporate a dye to view large arteries and veins around your heart and other structures. EBT is classified as a low-risk screening tool to detect early signs of plaque in women with several risk factors or symptoms and can help guide your healthcare professional on further treatment. Since it involves exposure to x-ray, tell your practitioner if you think you might be pregnant. learn more

  • Magnetic resonance imaging (MRI)     Magnetic resonance imaging of the heart uses strong magnets to detect energy signals from your heart muscle. Magnetic resonance angiography (MRA) is a variation of this test, incorporating the use of gadolinium dye. Although the gadolinium dye may be less damaging to the kidneys than the dye used in conventional angiography, it can still be dangerous to those with diabetes or renal disease1 . These tests are currently under investigation as possible new diagnostic tools to determine coronary artery disease and may become available in the future.

  • Angiography   This test, also called "cardiac catheterization", allows doctors to visualize the blood flow through the coronary arteries. A long, thin tube called a "catheter", is inserted into your arm or leg artery and is advanced to the arteries supplying the heart muscle. A dye is then injected into the catheter to visualize 2-D images of blockages in the coronary arteries. This has long been known as the "Gold Standard" for diagnosing heart disease with the most accuracy in both women and men, however recent studies suggest test results are not as accurate in women who may have plaque distributed more diffusely rather than in discrete areas, as is more common in men. Using intravascular ultrasound in the course of coronary angiography may improve the diagnostic accuracy in this situation. More accurate and safer testing methods are currently being explored for women with heart disease symptoms.

Call 9-1-1 if you think you are having a heart attack.   If you have chest pain, discomfort that lasts more than a few minutes, difficulty breathing or other symptoms which seem life-threatening, get to the emergency room. Treatment results are best for those who arrive in the emergency department shortly after symptoms begin. Newer tests can diagnose a heart attack more quickly and accurately. Even if your test results in the emergency room are normal, if you are still in discomfort or having persistent pain, you should be assertive and insist on being admitted into the hospital overnight for observation.

Plan a visit to your practitioner to discuss your risk factors for heart disease.   Heart disease is the number one killer of women age 35 and older. If you think you are at risk, or you have any symptoms which cause you concern, see your doctor without delay and ask for testing to rule out heart disease.

1Gadolinium side effects could result in the development of a rare and potentially fatal disorder for those with moderate to end-stage renal disease.

Note 1:   More research is needed to identify heart attack triggers. Contributors of acute risk factors and vulnerable plaques with onset of myocardial infarction, acute coronary syndrome and sudden cardiac death are areas of research neglect. Stressers that produce hemodynamic, vasoconstrictive and prothrombotic forces in the presence of a vulnerable atherosclerotic plaque, cause plaque disruption and thrombosis. Research may clarify these mechanisms and measures to sever the link between a potential trigger and its consequence. (procor)

Note 2:   More research is needed to investigate epithelial changes that take place within artery walls - changes that are different in women. This holds the key to earlier diagnosis of women's heart disease.

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1999-2000; updates: 2002, 2004, 2005, 2007 Women's Heart Foundation, Inc. All rights reserved. Unauthorized use prohibited. The information contained in this Women's Heart Foundation (WHF) Web site is not a substitute for medical advice or treatment, and WHF recommends consultation with your doctor or health care professional.