Each year, more than one million Americans experience a heart attack, and nearly half of them are fatal. Stroke is the leading cause of disability and the third leading cause of death for women and men.

Many people continue to believe that heart attacks represent a problem targeting solely older men, yet heart disease is the number one killer of both women and men in the United States. The difference is that among men, the risk for heart attack increases steadily after 45 years of age. In women, the risk increases after 50 years of age. However, younger women and men can also have heart attacks, and the current epidemic of obesity and inactivity among our nation’s youth will likely shift the risk toward occurrence at younger ages over the next one to two decades.

Chest pain is the most common symptom of a heart attack for both men and women; however, women often do not experience the sharp, stabbing chest pain characteristically described by male patients. Generally, women explain this symptom as chest pressure or tightness rather than pain, and therefore they often ignore this sign of a heart attack. Additionally, chest discomfort is not a symptom that is always present in women, which can make a heart attack difficult to recognize

Researches indicate that the three most frequently reported symptoms of a heart attack in men and womenare chest pain, shortness of breath and unusual fatigue. While chest pain and shortness of breath are considered typical symptoms of a heart attack, the researchers determined that women and physicians consider unusual fatigue an atypical symptom despite evidence supporting its commonplace occurrence in women.

A study published in Circulationfound that 43 percent of the women studied did not experience any chest pain, yet this symptom remains a key for diagnosing cardiac complications.

As reported in WebMD for example, on Monday morning in April, Merle Rose, a New Jersey woman, experienced what some doctors call "female heart attack symptoms;" a feeling of indigestion and extreme fatigue. Later, she had nausea, vomiting and fainting.

But she never had chest pain-a "typical" male heart attack sign. When she got to the emergency room, doctors couldn't find any sign of heart attack and Rose says, "They would have sent me home."

In the emergency room, physicians had assumed she had a gastrointestinal illness. But at the time, no one told Rose that she had suffered a heart attack.

When an outside cardiologist recommended by Rose's regular doctor ordered testing that uncovered major blockages, doctors still made no mention of heart attack, she says.

It was not until several months later, when she visited a new female cardiologist. This doctor told her in retrospect that she had suffered a textbook case of undiagnosed female heart attack.

"That's the first I ever heard," Rose says. "This doctor told me, 'They didn't connect the dots.'"

In the Circulation study on early female heart attack symptoms, researchers found that during a heart attack, 43% of the 515 women studied had no "acute chest pain... a 'hallmark symptom in men,'" according to study authors.

Nevertheless, the study cited evidence that many emergency room doctors still look mainly for chest pain. Only a minority check for the other types of symptoms that women tend to develop. As a result, doctors may miss heart attacks in women.

"Although women can have chest tightness as a symptom of a heart attack, it's also important for women to recognize that might not be their symptom," says Nieca Goldberg, MD, a cardiologist and chief of Women's Cardiac Care at Lenox Hill Hospital in New York City and author of "The Women's Healthy Heart Program."

"Women commonly have symptoms of shortness of breath, unexplained fatigue, or pressure in the lower chest, so they easily mistake it as a stomach ailment."

In the Circulation study, common female heart attack symptoms include:

• shortness of breath (57.9%)
• weakness (54.8%)
• unusual fatigue (42.9%)

Women also had these symptoms:

• Nausea
• Dizziness
• Lower chest discomfort
• Upper abdominal pressure or discomfort that may feel like indigestion
• Back pain

In the weeks preceding an actual heart attack, some of these symptoms may even appear as early warning signs, according to the Circulation study.

According to Goldberg, who is familiar with the study, says, "About six weeks before the actual heart attack, women were more likely to experience shortness of breath, unexplained fatigue or stomach pain as an early warning sign that they might have a blocked artery."

Rose was a prime candidate for a heart attack: a family history of heart disease, high blood pressure, high cholesterol and type 2 diabetes. Long before her heart attack, she had struggled with extreme fatigue.

"I felt like I was being rolled over by a steam engine-couldn't make plans," she says. Doctors put her on antidepressants. She also developed shortness of breath. "I was constantly gasping for breath." But because of the depression diagnosis, "I thought this was an anxiety issue."

"I did have symptoms of heart disease," Rose says. "They just didn't connect it and I didn't connect it."

If you get early warning signs, call your doctor and talk about the possibility of heart disease.
"That's the time to come in for an evaluation," says Goldberg.

On the day of a heart attack, these symptoms can strike without any provocation; for example, shortness of breath may come without physical activity. Symptoms can appear during rest or even awaken a woman from sleep, and they're much worse, Goldberg says.

"They just come on and they're severe. I had one patient describing that she was so short of breath that she could barely talk to the 911 operator."

What to do When you have a Heart Attack Symptoms

If you believe you're having heart attack symptoms, dial 911 right away for an ambulance to take you to the emergency room. Wait no more than 5 minutes.

"As a doctor, I know from experience that when chest pains or other symptoms occur, most women are reluctant to call 911," Goldberg says. "That's precious time that we could be saving your heart muscle."

Women often worry about being embarrassed if they're not having a heart attack after all, she says. But embarrassment will pass without causing long-term damage; a heart attack may not.

Others don't appreciate the seriousness of the situation. One of Goldberg's patients had heart attack symptoms at age 57 and insisted on straightening up her house before she let her husband call 911. "This delay could have been fatal," Goldberg says.

Calling for an ambulance is better than taking a taxi or having someone else drive you, Goldberg says. And unless you have absolutely no other option, you shouldn't drive yourself. "You don't want to pass out driving your car," she says.

A big advantage to calling 911: emergency medical personnel can start treatment, such as oxygen, heart medication, and pain relievers, as soon as they arrive, says Mohamud Daya, MD, MS, an associate professor of emergency services at Oregon Health and Science University.

One more compelling reason to go by ambulance: "When you come into the emergency room with the "cardiac" monitor hooked up, you're really taken seriously," Goldberg says. "You look the part."

When you reach the emergency room, describe your symptoms, but don't offer your own conclusions, Goldberg says. "I wouldn't go through this whole dissertation about how, 'Oh, I thought it was a stomachache, I thought it was this.' You should just tell the doctor how you feel. Don't interpret it for them."

If it doesn't occur to the emergency room doctor to check for heart attack, be bold. Goldberg tells women to say outright: "I think I'm having a heart attack." Because many doctors still don't recognize that women's symptoms differ, they may mistake them for arthritis, pulled muscles, indigestion, gastrointestinal problems, or even anxiety and hypochondria.

In short, female heart attack symptoms may be missed-and dismissed. When one of Goldberg's patients entered the emergency room with such symptoms, doctors gave her antacids. "She said, 'Listen, I'm diabetic and women's heart disease symptoms can be different, and unless you give me an EKG, I'm not leaving this place.' And the next day, she had a bypass."

Of course, stomach pain could prove to be nothing more than a bad case of gastrointestinal illness. "But what I tell all my patients is, 'It's best to check out your heart first because a potential heart attack is life-threatening,'" Goldberg says.

Even if your fear of heart problems turns out to be unfounded, don't sweat it, she adds. Doctors would much rather diagnose you with indigestion than a heart attack.