How Young Women Are Being Let Down By Heart Attack Protocols

Heart disease doesn't have an age limit, but you wouldn't know it from the way younger women are treated in emergency rooms across the country. Despite being the leading cause of death overall, heart attacks in women under 50 are routinely misdiagnosed, dismissed, or undertreated because, quite simply, they don't fit the picture doctors expect to see.

Now, a major new scientific statement from the American Heart Association is sounding the alarm: Current clinical practices may be costing women their lives.

The statement, published this week in the journal Circulation, represents a comprehensive global review revealing critical care gaps that leave premenopausal women vulnerable to worse outcomes than men of the same age. 

The statistics are sobering: Premenopausal women (typically under age 50) who experience acute coronary syndromes, including heart attacks, face a significantly higher likelihood of death or complications compared to men of the same age. Yet these women are the ones most likely to be sent home from the emergency room, told their symptoms are anxiety, or given delayed diagnoses that can prove fatal.

The problem runs deep. Current clinical guidelines are typically lacking in detail when it comes to the various causes of heart attacks in premenopausal women, particularly non-atherosclerotic causes.

 In other words, the system is designed to catch heart attacks caused by the usual suspects, like high cholesterol, high blood pressure, fatty plaque buildup, but fails to recognize the types of heart attacks that disproportionately affect younger, otherwise healthy women.

Heart attacks in premenopausal women often don't look like the classic picture doctors expect. The new guidance emphasizes that better recognition and more clinical research focused on women is essential to ensure these different presentations are understood and incorporated into guidelines, so that every woman gets the correct diagnosis and optimal treatment.

Two conditions in particular are revolutionizing our understanding of heart disease in younger women, and both are frequently overlooked.

Spontaneous coronary artery dissection (SCAD) occurs when a tear develops in a coronary artery wall without any traumatic injury or medical procedure. Blood can then get trapped between the layers of the artery wall, creating a bulge that narrows or blocks blood flow to the heart muscle. 

SCAD predominantly affects young to middle-aged women, often those who are healthy, active, and have few traditional risk factors for heart disease. The condition can be triggered by pregnancy, intense physical or emotional stress, or it can happen without any obvious cause. Research estimates that up to 35% of heart attacks in women under age 50 can be attributed to SCAD.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is exactly what it sounds like: a heart attack that occurs even though coronary angiography shows no major blockages in the arteries. 

MINOCA accounts for 5-10% of all heart attacks and disproportionately affects younger women. The causes can include coronary vasospasm (sudden constriction of an artery), microvascular dysfunction (problems with the smallest blood vessels in the heart), SCAD, or small blood clots—none of which show up as obvious blockages on standard imaging.

Initially thought to be relatively benign, research has revealed that MINOCA patients1 face serious risks, patients having a prognosis similar to those with traditional obstructive heart disease.

Part of the problem is symptom recognition, both by women themselves and by emergency medical providers. While chest pain remains the most common sign of a heart attack, the AHA statement emphasizes that women frequently experience "subtler symptoms" that are easily overlooked.

Women experiencing these symptoms may not immediately think "heart attack," and staff in busy emergency departments may not either, particularly if the patient is young, physically fit, and doesn't match the traditional cardiac risk profile. These atypical presentations lead to critical delays in care that can be the difference between life and death.

The statement also calls attention to pregnancy-associated SCAD, which, while representing a small percentage of all SCAD cases, is the most common cause of heart attacks during pregnancy and the postpartum period. 

Evidence suggests that hormonal changes, particularly fluctuations in estrogen and progesterone, affect the coronary arteries during this vulnerable time, potentially triggering dissection.

Pregnancy-related heart attacks2 generally have worse outcomes compared to other cases, yet many healthcare providers don't have SCAD on their radar when treating pregnant or postpartum women with cardiac symptoms. 

As patients, this research offers both validation and a call to action. If you experience symptoms that concern you, even if they don't match the "traditional heart attack" you've seen on TV, trust your body and advocate for appropriate testing. Don't let yourself be dismissed or told it's "just anxiety" without a proper cardiac workup, especially if symptoms persist or worsen.

For women who've felt unheard, dismissed, or told their symptoms weren't serious enough to warrant concern, this guidance offers something powerful: validation. Heart disease in premenopausal women is real, it's dangerous, and it demands the same clinical attention given to any other cardiac emergency.