The familiar description of a heart attack involves crushing central chest pain radiating to the left arm. That pattern occurs in women too, but the range of presentations is wider, and part of the reason is anatomical.
The classic description came from a narrow sample
Early characterisation of heart attack symptoms drew heavily on studies conducted predominantly in middle-aged men.
The resulting description became the template taught to clinicians and communicated to the public.
A template built from one group functions poorly as a filter for presentations that differ from it, and both patients and clinicians use that filter.
Additional symptoms are more common
Women more frequently report shortness of breath, nausea, vomiting, pain in the jaw, neck, back or upper abdomen, unusual fatigue and lightheadedness.
Chest discomfort is still the most common single symptom, but it is more often described as pressure, tightness or an ache rather than as pain.
Symptoms that overlap with indigestion or exhaustion are easier to attribute to something else, by the person experiencing them and by whoever they first speak to.
The underlying disease can be different
The standard model involves a plaque rupturing in a large coronary artery and blocking it.
Women more often have disease affecting the small vessels of the heart, or a pattern where plaque erodes rather than ruptures, or spontaneous tearing of an artery wall.
These produce reduced blood supply through different mechanisms, and the symptoms they generate need not match those of a large-vessel blockage.
Standard tests were built around the standard model
Coronary angiography visualises the large arteries well and the smallest vessels poorly.
A woman with small-vessel disease can therefore have an angiogram reported as unobstructed while genuinely having reduced blood supply to heart muscle.
Specific tests exist for microvascular function, and awareness of when to use them has developed more recently than the standard pathway.
Delay is where the harm accumulates
Treatment for a heart attack is time-critical, since heart muscle deprived of blood supply is progressively lost.
Delay arises both before contacting emergency services and within the system, and any presentation that does not match the template contributes to both.
Sudden shortness of breath, chest pressure, or unexplained severe symptoms of the kinds described are reasons to seek emergency care immediately rather than to wait and observe.