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The predominant image of a heart attack has focused on males, says Dr. Anna Catino. “An older man, typically a smoker, shoveling snow, who experiences crushing pain ‘like an elephant on his chest.’ That mantra is even present in our classic medical school textbooks.”

So when men go to the emergency room or to urgent care complaining of intense chest pain, shortness of breath, sweating and nausea, it’s clear that they are probably having a heart attack.

But when women go to an ER with the same problem their symptoms may not be so explicit.

“Most of the time, the common symptoms are actually very similar,” says Catino, an assistant professor in Cardiovascular Medicine and medical director of the Echocardiography Lab at the University of Utah School of Medicine, namely shortness of breath, sweating and nausea.

But while most men present with these symptoms, some women can be more atypical. Catino paints a portrait of a woman in her sixties, “battling stress, diabetes, hypertension. She may well present with different symptoms. It can be a little more subtle and vague. It’s not always that crushing chest pain. It’s more sort of a general malaise, a feeling of fatigue or being unwell, or nausea.”

The history of cardiovascular disease has long been defined by men’s symptoms. “Historically our understanding of cardiovascular disease has been patterned on male coronary artery disease, since that’s where all the research was done,” says Dr. Rashmee Shah, an assistant professor in Cardiovascular Medicine at the University of Utah School of Medicine. The research disparity also includes animal studies, which often serve as the foundation for our understanding of a disease.

That’s changed though to some degree in the last decades as recognition has gained ground that sex disparities in the treatment of cardiovascular disease are far more complex than perhaps first thought.

Dr. Lillian Khor, medical director of Preventive Cardiology and Cardiac Rehabilitation, says that in the face of such a complex issue as women and medicine, “we should not be surprised that there is a difference in presentation and outcomes,” between the sexes. Particularly, she notes, given how socio-economic and cultural under-representation of women and ethnic minorities have shaped disparities in medicine and beyond.

“One issue regarding presentation between men and women with cardiovascular disease is that women tend to underestimate it and don’t seem to seek medical care as quickly,” says Catino. “It is important that both women and we as a medical society recognize the symptoms, even if they seem less classic.”

Part of the issue is that women can experience heart attacks typically 10 years older than males, which can mean already subtle or complex symptoms may be lost amidst other medical conditions the patient is addressing.

Shah is hesitant to attribute sex-based disparities solely to women presenting later than men. “I don’t think the fix is limited to asking women to seek care sooner,” she says. Rather she sees the answer to some degree in the push by the National Institute of Health to have as many women present in clinical trials as men — who historically have made up 80 percent of such trials. She also highlights the recent drive nationally to get patients quicker to the cath lab to have a stent put in to open up a blocked blood vessel. That, she says, “has forced the system to treat men and women the same.”

Khor takes heart in statistics leveling off between men and women in recent years. She credits education programs such as the American Heart Association’s Go Red for Women campaign for successfully educating communities about the need to pay attention to maintaining a healthy heart.

With February designated as American Heart month, Go Red’s campaign for more research and faster action for women’s heart health continues to draw on “the energy, passion and power women have to band together and collectively wipe out heart disease and stroke,” according to the movement’s website.

National wear red day is Friday, February 1, 2019.