Getting to the Hearts of Women


By Mary Carpenter

DC-BASED development expert R.C. was lying on the operating table, ready to receive anesthesia before a vaginal procedure, when suddenly she couldn’t catch her breath—and signaled frantically to medical staff, who raced her off to the I.C.U. Her diagnosis: Takotsubo cardiomyopathy, a kind of heart attack described by University of Chicago cardiology fellow Shirlene Obuobi as a “largely reversible” but potentially dangerous response to stress.

Takotsubo occurs more commonly among women—for whom heart attacks caused by obstructive coronary artery disease (CAD) can also produce different symptoms than for men. In one case, a 61-year-old woman, who ate well, didn’t drink, never smoked and ran half-marathons, complained of nausea and fatigue along with an ache in her right arm. After vomiting, she went to bed and the next morning died of a heart attack.

And patients with chest pain but no artery blockage observable on scans—especially women—often struggle to get physicians’ attention, writes Obuobi. Many women seen in the ER with atypical symptoms receive a diagnosis of anxiety and the advice to go home. Only recently recognized, MINOCA refers to “myocardial infarction with nonobstructive arteries.”  In fact, only 15 to 25% of patients reporting chest pain turn out to have a blocked artery.

The effects of intense stress on the body range from serious heart attacks to situational anxiety, the bane of public speakers, and respond to similar drugs, notably beta-blockers. Explains the Mayo Clinic website, stress prompts the hypothalamus to set off an alarm system that causes the release of hormones, such as cortisol and adrenaline, and “communicates with the brain regions that control mood, motivation and fear.”

Cortisol increases the body’s use of circulating glucose and raises energy levels, while excess adrenaline can speed up the heart rate and elevate blood pressure—and in some cases, lead to the shortness of breath, sweating and dry mouth that arises in situations such as stage fright. Adrenaline and other stress hormones overwhelm or “stun” the heart cells, causing Takostubo cardiomyopathy, also called “broken-heart syndrome.”

Massive amounts of adrenaline cause the heart to balloon, weaken and “quite literally” give out. Adrenaline can narrow the small arteries that supply the heart with blood or bind directly to heart cells, which can prevent the heart from beating properly. Both emotional and physical stress—such as asthma and low blood sugar—can cause broken heart syndrome. But, explains Johns Hopkins heart failure specialist Ilan Wittstein, “up to 30% of patients have no identifiable trigger at the time of their initial symptoms.”

The risk of developing Takotsubo increases five times after the age of 55 . . . and the vast majority of patients are post-menopausal women,” according to the Hopkins site. “It is believed that because the female hormone estrogen helps to protect the heart from the harmful effects of adrenaline, women become particularly vulnerable to the effects of sudden stress as they grow older and their estrogen levels decline.”

“Heart disease is the leading cause of death for women in the United States and can affect women at any age,” according to the CDC. Over 60 million women (44%) in the United States are living with some form of heart disease [and in] 2020, it was responsible for . . . about 1 in every 5 female deaths. Research has shown that only about half (56%) of US women recognize that heart disease is their number 1 killer.” 

What women in particular should do is “pay attention to any symptoms above the waist, which means above the belly button, that are new to you,” Barbra Steisand Women’s Heart Center director C. Noel Bairey Merz told the Washington Post. For talking with medical staff, Obuobi advises being specific when describing the pain, starting with what it feels like and where it occurs. Heart attack patients often describe “pressure-like squeezing or heavy” sensations that last several minutes and worsen with exercise; and cardiac pain that moves up the jaw or down one arm.

Also more common for women, signs of a heart attack can include new discomfort or pain occurring in the neck, jaw or throat, or in the upper back or abdomen —as well as indigestion or heartburn; dizziness or shortness of breath; and profound fatigue—with symptoms that linger and intensify over a period of hours. Sharp pain, on the other hand, especially if it worsens with exercise, is less likely to be caused by a heart condition.

And while heart attacks occur at any time of day, any pain that arises early in the morning most often signals a different problem: microvascular dysfunction or spasms in arteries feeding the heart, which results in depriving the heart of oxygen. Heart spasms can occur in response to cold weather or other stressors, or spontaneously, but do not involve adrenaline and require different treatment from other heart conditions.

To combat adrenaline’s effects on the heart—from heart attacks to situational anxiety—beta-blocker drugs are among the most-prescribed medications in the U.S., used by some 30 million adults. The FDA has approved beta-blockers for heart-related conditions such as high blood pressure or irregular heartbeat; doctors also prescribe them “off label” for people who struggle with anxiety—most often the kind that arises in specific situations like public speaking, rather than for those living with a diagnosed anxiety disorder.

R.C. received a prescription for beta-blockers after her Takotsubo incident, while I take them before I need to speak in public. During a recent two-week period of almost daily presentations, I believe beta-blockers helped reduce my worst reactions—dry mouth that can make it hard to talk and sometimes shortness of breath and dizziness.

While the body’s stress response is usually self-limiting, high cortisol levels can continue to curb functions that would be nonessential or harmful in a fight-or-flight situation, which can result in altered immune responses. For me, a little cut or scratch that takes longer to heal is a clue that I haven’t entirely recovered from a stressful period —and a signal that I should try to get more sleep.

—Mary Carpenter regularly reports on topical subjects in health and medicine.


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