Don't ignore women with atypical STEMI symptoms

Assess differently based on gender

After an elderly white female told ED nurses at Spartanburg (SC) Regional Healthcare System that she had been having abdominal pain for several days, the patient waited to be seen. By the time she was assessed by the physician, the woman was experiencing neck and jaw pain.

An electrocardiogram (ECG) showed that this patient was having an ST-elevation myocardial infarction (STEMI). The patient immediately went to the cardiac catheterization lab, a stent was placed in her right coronary artery, and she had a positive outcome.

"Thankfully we got to her in time, because this may have resulted in severe heart muscle damage," says Stephanie Adam, RN, an ED nurse at the hospital's chest pain center. "This prompted an inservice, and nurses were updated on the different symptoms women may present with."

If a woman came to your ED with "clear" arteries, could she leave with an undiagnosed heart attack? The new Women's Ischemia Syndrome Evaluation (WISE) study from the National Institutes of Health shows that many women come to the ED with atypical symptoms and clear coronary arteries upon cardiac catheterization — a condition named coronary microvascular syndrome in which the arteries are narrowed but not completely blocked.1

The plaque spreads evenly throughout the artery walls, which aren't totally obstructed as they are with typical STEMI, says Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for the ED at Cleveland Clinic. "Since the arteries are 'open,' many women do not get the same treatment as men following a heart attack such as drugs for cholesterol and angina," she says. "However, many of these women have ischemic heart disease and are at high risk for a heart attack."

Pain may be similar to that of people with blocked arteries, but the plaque may not show up on diagnostic tests, adds Fielden.

Get more specifics

ED nurses need to be educated on the WISE study's findings, says Adam.

"Many ED nurses who work triage are taught to just ask quick, simple questions in order to keep the floor going," she says. "So unless the patient complains of chest pain, they usually do not get an immediate ECG."

Ask questions that will prompt patients to be more specific, especially when they complain of pain that it is between the nipple line and the pelvis area, advises Adam. "Nurses also need to get a quick history of the patient, to see if he or she has any predisposing factors," she says.

Younger women also are presenting with chest pain with indications of coronary artery disease (CAD), notes Fielden. "Women with metabolic syndrome or Type 2 diabetes are at risk," she says. "These women have elevated blood pressures, central obesity, high blood glucoses and insulin resistance, and hypercholesterolemia."

African-Americans also are more at risk for CAD than Caucasians, and family history is important for everyone, says Fielden. "Pre-menopausal women with elevated systolic blood pressures and/or pulse pressures are also at risk for CAD," she says.

You must evaluate women with chest pain differently than the way you evaluate men, says Fielden. Women are more likely to experience atypical symptoms such as extreme fatigue, sleep disturbance, shortness of breath, back pain, upper abdominal pain, and nausea with or without vomiting, she explains.

"Women who do have typical symptoms such as chest pain or discomfort and diaphoresis are significantly associated with acute coronary syndromes. Women have more adverse outcomes as compared with men," says Fielden. "However, only about 50% of women present with chest pain."

Both elderly women and men may present with atypical symptoms such as syncope or shortness of breath without anginal pain, adds Fielden.

As for cardiac biomarkers, men are more likely to have elevated CK-MB and troponin levels, and women are more likely to have elevated C-reactive protein and brain natriuretic peptide (BNP) levels, says Fielden. "If your ED does not include BNP as a lab or bedside test, it may be useful to add this to the initial cardiac markers," she says.

In Cleveland Clinic's ED, women 50 or older with any of these symptoms or history get a rapid ECG:

  • chest pain or atypical pain such as upper abdominal or back pain;
  • persistent heartburn;
  • nausea, with or without vomiting;
  • new onset fatigue;
  • diabetes;
  • post-menopausal.

At Spartanburg Regional, patients get an ECG within 10 minutes or less and the results immediately are shown to the physician for review and orders. "Our ED nurses work very hard to ask appropriate questions for the atypical woman chest pain patient," says Adam.

Fielden says triage assessment for women who present with atypical symptoms should include:

  • evaluation of chest pain, blood pressure, and pulse pressure;
  • review of medications to see if she is on an antihypercholesterol drug such as a statin or hormone replacement therapy;
  • review of medical history including diabetes, family history, and menopause status:
  • questions about cigarette smoking.

"Any 'yes' answer should initiate your chest pain protocol, including ECG and cardiac markers," she says.


1. Shaw LJ, Merz NB, Pepine CJ. Insights from the NHLBI-sponsored women's ischemia syndrome evaluation (WISE) study: Part I: Gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol 2006; 47:S4-S20.


For more information about women with atypical heart attack symptoms, contact:

  • Stephanie Adam, RN, Emergency Department, Spartanburg Regional Healthcare System, 101 E. Wood St., Spartanburg, SC 29303. Telephone: (864) 560-6000. E-mail:
  • Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, ED, Cleveland Clinic Foundation, 9500 Euclid Ave., E19, Cleveland, OH 44195. Telephone: (216) 444-0153. Fax: (216) 444-9734. E-mail: