Dr. Judith Lichtman on Researching Heart Disease in Young Women and Why It Matters

Under a grant from the Rippel Foundation, Dr. Judith Lichtman, Associate Professor and Chair of the Department of Chronic Disease Epidemiology at Yale School of Public Health, has been studying heart disease in young women. The results of her study were published last month in Circulation: Cardiovascular Quality and Outcomes revealing that younger women may ignore or dismiss the earliest symptoms of an impending heart attack, such as pain and dizziness, and delay seeking emergency medical care. Dr. Lichtman’s findings received extensive media attention. We sat down with her to learn more about the importance of her results for improving women’s health.

Most of the research on heart disease focuses on older patients. Why did you focus on younger women and what surprised you most about your findings?

DR. LICHTMAN: Younger women in the 18 to 55 age bracket tend to have worse outcomes and are a relatively rare population who suffer from heart disease. Women in this age group represent less than 5 percent of all heart disease patients, yet are twice as likely to die after being hospitalized for a heart attack compared to men their age. In fact, each year more than 15,000 women under the age of 55 die of heart disease in the U.S. Knowing that women tend to delay seeking care for a heart attack, I wanted to examine their recognition of symptoms, decision-making process to seek medical care, and interactions with the health care system. This had never been studied before.

We focused on women who were 30 to 55 years old. My research team and I explored how they responded during the crucial period when their first symptoms manifested. We found that women’s initial symptoms varied widely in both nature and duration. While most women experienced chest pain and pressure, the hallmark of a heart attack, they described other symptoms as well, such as fatigue, muscle pain and indigestion. Most did not experience the “Hollywood heart attack” that is commonly portrayed in movies and TV, and they did not realize the severity of their symptoms. In some cases, women waited days before seeking medical treatment. Some women, once they called their doctor, were triaged and deemed less urgent cases.

What can be done to better educate patients and make sure doctors pay more attention to the warning signs?

DR. LICHTMAN: Many of the women in our study had clear risk factors, including a family history of heart attacks, hypertension, high cholesterol and diabetes, but still did not think they were having a heart attack at first. Participants said they were concerned about initiating a false alarm in case their symptoms were due to something else, or they assumed that they were too young to experience a heart attack. We need to empower women to recognize symptoms and seek prompt care without stigma or perceived judgment. This is particularly critical for young women at increased risk for heart disease.

Because heart attacks are rarer in younger women, doctors may be missing important opportunities to identify the signs and symptoms of heart disease. If a woman has a strong family history of heart disease and has multiple risk factors, then health care providers should listen carefully and not dismiss her because of the small probability that she is having a heart attack.

What are the important messages doctors and patients can take away from your research?

DR. LICHTMAN: The big take-home message is that more women need to be aware of the possibility of having a heart attack at a younger age. If you’re a woman who has a family history of heart disease and some combination of risk factors, including diabetes, hypertension, high cholesterol, obesity, or being a smoker, then this should be on your radar. And doctors need to figure out how to withhold judgment when a patient shows symptoms of a heart attack that do not pan out. We need to be very careful about how we react, especially if a patient comes forward with a family history and risk factors. They should be taken very seriously and not judged.

What do you hope this study can contribute to public health and, more specifically, do you think that this study can have an impact on the delivery of care to women

DR. LICHTMAN: I hope this study will raise awareness for this subgroup of high-risk young women and encourage more research on heart disease in this population. This is not because it’s a novelty that these women are younger, but rather because the evidence shows that they have worse outcomes. We need to make sure that current media campaigns and prevention messages reflect all the potential symptoms of a heart attack.

As far as impacting care delivery, this study indicates a real need to empower women patients to not second-guess their symptoms or doubt taking a trip to the hospital. At the same time, health care providers have to find a better way to triage and treat them. Hopefully this research will lead to more discussions about how we make sure these women do not fall through the cracks of the health care system, and are provided with good, timely care.