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Wakisha (Kisha) Stewart remembers the thrill of being invited to a close friend’s dinner party. Stewart, who lives in Cape Coral, Florida, had given birth to her second child two weeks before and was eager to have adult company and a brief reprieve from the haze of round-the-clock feedings and poor sleep. She was sure spending a few hours with her friends while relatives watched her newborn and older son would make for a perfect evening.
In fact, the night would be one of the worst experiences of her life.
After arriving at the dinner party with her husband, Stewart nibbled on appetizers of shrimp, crab, and pasta salad and nursed half a glass of Chardonnay. Then she sat down to have a conversation with a dear friend she hadn’t seen in a while.
Suddenly, Stewart felt a wave of disorientation and fatigue. She chalked it up to exhaustion and hormonal changes and, after splashing water on her face in the bathroom, she returned to continue chatting. But not two sentences in, she felt a stabbing pain in her chest — as if someone were putting a knife through her torso. Within minutes the pain had migrated to her jaw, her left arm started tingling, she had trouble catching her breath, and she began to vomit.
Stewart knew something was seriously wrong, but at 31, she never thought it might be her heart. “I didn’t know what it was. I just knew I needed release,” Stewart recalls a decade later.
Young Women’s Heart Attacks Are Often Overlooked
Stewart’s partner rushed her to the nearest emergency room, and Stewart hurriedly explained all her symptoms to the receptionist.
But, as experts say too often happens to young women, especially young Black women like Kisha Stewart, the receptionist blamed her symptoms on anxiety and told her to take a seat in the waiting room. Stewart sat a full 10 minutes before she was ushered back to the triage area.
Even then her complaints were minimized, despite her continued pain and vomiting. A nurse took her vital signs and performed an electrocardiogram (EKG), but the results were inconclusive. Nobody seemed to be in much of a hurry to get Stewart diagnosed and treated, she felt.
Fortunately for her, a seasoned nurse walked by her bed and immediately recognized what was going on: Stewart was in the midst of a heart attack.
A Rare Type of Heart Attack
The hospital did not have a cardiac intervention unit, so Stewart was transferred to another one nearby, all the while fearing she would not live to see her infant son, Diego, again. At the new hospital Stewart was diagnosed with a rare heart attack called a spontaneous coronary artery dissection, or SCAD.
Most heart attacks are caused by plaque-blocked arteries, but according to the American Heart Association (AHA), SCAD is caused by a spontaneous tear in the wall of the coronary artery. This results in little to no blood flow to the heart muscle, which can lead to heart attack, abnormal heart rhythm disorders, or even sudden death.
In Stewart’s case, the artery that tore was found to have 100 percent blockage, something so few people survive it is referred to as a “widow maker.”
No One Knows Why SCAD Occurs
An athlete all her life — a runner, high school volleyball player, and ballet, jazz, and lyrical dancer — Stewart could not believe she was having a heart attack. But as soon as the cardiologist inserted a stent into her artery she felt relief. With 15 percent of her heart damaged by the attack, Stewart would be a cardiac patient for life.
“The worst thing was that no one could tell me why it happened. ‘Spontaneous’ is in the name. All I could think was if it could happen once, it could happen again,” and that thought weighed on her for years, Stewart says.
According to the AHA, it isn’t clear what causes the artery to tear. But it’s more likely to happen in young, previously healthy women. One possible link is hormones. Nearly a third of patients with SCAD have recently delivered a child. Other women have an attack during or near their menstrual cycle. Another possible association, according to the Cleveland Clinic, is fibromuscular dysplasia, an abnormal growth of cells in artery walls that can narrow blood vessels and block blood supply to the heart.
Since researchers aren’t sure what causes SCAD, they couldn’t promise Stewart that it wouldn’t happen again. Fortunately, in the decade since, it hasn’t.
Young Women’s Heart Disease Rates Are Rising
Heart disease was once thought of as a man’s disease, but over time doctors have recognized that post-menopausal women are at high risk, too.
Now heart disease is appearing in much younger women, says Nanette Wenger, MD, a cardiologist and a professor emerita at the Emory University School of Medicine in Atlanta.
One large community-based study documents this shift. Over the course of two decades, young women rose from 21 percent to 31 percent of the hospitalizations for heart attacks, with Black women rising even more dramatically, according to research published in Circulation in November 2018.
A key reason for the increase is that young women today have more risk factors for classic types of heart attacks, such as obesity, sedentary behavior, and depression and anxiety, Dr. Wenger says.
The Circulation study documented the fact that the young women who have experienced a heart attack in recent years are more likely to have a history of hypertension or diabetes, two other key risks, than their counterparts did 20 years ago.
Doctors Don’t Often Discuss Heart Health With Young Women
Because they are young, young women are less likely to talk to their doctor about their heart, Wenger says. “They don’t perceive themselves to be at risk for heart disease, so they don’t pay much attention,” she says.
And primary care doctors, especially the ob-gyns who provide much of women’s regular care, generally don’t spend time discussing heart health with this group, Wenger says.
“These doctors focus on preventive measures like Pap smears, but they should also be doing cardiovascular risk screening,” she says. Even women who develop hypertension, preeclampsia, or gestational diabetes during pregnancy are not usually made aware that these put them at increased risk for later cardiovascular events, she says.
Key messages Wenger would like young women to understand: Heart disease is the nation’s leading killer of women, more than cancer or stroke, according to the Centers for Disease Control and Prevention (CDC).
Women must also learn the symptoms of a heart attack, Wenger says. While both men and women generally mention chest pain when describing their heart attack, women are more likely to also experience shortness of breath, nausea, vomiting, or pain in the back or jaw, according to the AHA.
Women Have More Unusual Types of Heart Attacks
Along with being more prone to SCAD than men, women are also more likely to experience other less-common types of heart attacks.
For example, as the AHA describes, women make up the bulk of cases of what is known as myocardial infarction with nonobstructive coronary arteries (MINOCA). In these cases, the arteries leading to the heart may appear normal, so the angiogram test used to detect blockages can leave doctors perplexed.
But extra sleuthing can reveal the underlying reason for these heart attacks, as researchers at New York University discovered. Different imaging tests can often identify the cause of MINOCAs, such as spasms in the arteries or hidden plaque ruptures, according to a study published in Circulation in November 2020.
Research Says Women and People of Color Wait Longer in the ER
With the rise of heart attacks among young women, one might hope things have improved in the decade since Stewart’s emergency room experience — that perhaps young women presenting with heart attack symptoms now might be immediately treated.
But a recent study says that’s not so.
When researchers examined more than 4,000 records of younger adults, ages 18 to 55, who came to the ER with chest pain, they found that men were more likely than women to be identified as needing immediate attention, to be given an EKG, and to be admitted to the hospital rather than sent away, according to results reported in the Journal of the American Heart Association in May 2022.
People of color waited longer for an evaluation by a doctor than white people, although there were no racial differences in rates of EKGs or the odds of being admitted to the hospital.
Stewart isn’t surprised by these findings. She herself went to the ER again four years ago with chest pains and was dismayed when the doctor asked her several times if she had anxiety or depression. “I pointed out my history of a heart attack, but he still scheduled a psych consult in addition to cardiology,” Stewart says. (It turned out she was having premature ventricular contractions, or PVCs, which are extra heartbeats that in most people are not dangerous.)
A longer wait in the ER can have huge health repercussions, says Harmony Reynolds, MD, the director of the Sarah Ross Soter Center for Women’s Cardiovascular Research at New York University in New York City and the lead author of both the ER and MINOCA studies.
“Minutes count when someone has a heart attack. The sooner the diagnosis is identified, the sooner treatment can be started,” Dr. Reynolds says.
Having their problem dismissed by a physician can also cause women to doubt themselves, she says. “Longer wait times and less-thorough evaluations may exacerbate women’s tendency to minimize their chest pain.”
Darcy Banco, MD, an internal medicine physician at NYU Langone Health in New York City and a coauthor of the ER study, says the researchers were especially surprised to see how wait times differed by race. “The prevalence of ischemic heart disease in people of color versus white adults is similar,” she says.
This wait-time disparity needs to be researched so interventions to eliminate it can be developed and implemented, she says.
Women Must Learn About Their Own Hearts
Because of her experience, Stewart is certain that women of all ages need to pay closer attention to their hearts. This includes talking to your doctor about risk factors for heart disease and taking active measures to reduce them. It also means knowing the symptoms that may indicate a heart attack.
This way, should you find yourself in a situation where your symptoms are being doubted, you will be in a better position to demand the treatment you need.
“If you are the woman who has to go to the hospital and advocate for yourself, you need to know your body well enough to be able to fight,” she says.
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