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The most common early warning signs of heart attack in minority and Caucasian women are general symptoms not specifically associated with heart disease, new research from the University of Arkansas for Medical Sciences (UAMS) finds.

Through a grant funded by the National Institute of Nursing Research, Jean McSweeney, Ph.D., professor in the UAMS College of Nursing, conducted a five-year study of early warning and acute heart attack symptoms in African- American, Caucasian and Hispanic women.

This research, presented at the American Heart Association’s scientific sessions but not yet published, combines and analyzes data from her previous work into early heart attack symptoms in Caucasian women with a similar study looking at the same symptoms in African-American and Hispanic women.

McSweeney has received international attention for her groundbreaking research that first identified early warning heart attack symptoms in women. In April 2007, she received the Leadership in Research Award from the Southern Nursing Research Society.

Using a list of symptoms developed by in-depth interviews with 300 women, researchers contacted over 1,500 women at 15 sites around the country, including Arkansas, to determine which symptoms the heart attack survivors remembered having in the weeks prior to their attack. Participants had the option of adding symptoms to those on the list, but McSweeney said the tool is comprehensive enough that none has needed adding in recent years.

The interviewers explained to participants that a relevant symptom would be anything that was new before they had their heart attack or a symptom that increased in intensity or frequency, if they had the symptom previously. The symptom also needed to be one that reverted to normal patterns after the heart attack.

Regardless of race, the most frequent symptom reported was unusual fatigue, McSweeney said.

Sleep disturbance, intermittent anxiety and shortness of breath rounded out the top of the list, though the order of the ranking for these symptoms varied by ethnicity.

Other commonly remembered symptoms by the female survivors included frequent indigestion, heart racing, a change in thinking or remembering in the month or so prior to their attack, vision problems including blurring and small incidents of temporary blindness, and loss of appetite.

“Those are not necessarily symptoms you would associate with heart disease,” McSweeney said, “yet these were the things they were complaining of the most.”
The study grouped all varieties and locations of chest pain or discomfort into one general symptom. She said that although chest pain or discomfort is the symptom most commonly associated with heart attacks, it did not rank as highly as expected. Hispanic women listed it as the fourth most common symptom they recalled experiencing. Caucasian women ranked it as sixth most frequent, and African-American women as the eighth.

Compounding that fact, even though Caucasian women listed chest pain or discomfort as their sixth most common symptom, only 30 percent of them complained of it versus 40 percent of African-American women. Minority women in the study tended to report the most symptoms, Caucasian women had the fewest symptoms of all,” McSweeney said.

Because the symptoms in women frequently are so vague, it is especially important that physicians consider not only their patients’ symptoms, but also their risk factors for heart disease, McSweeney said.

“Minority women, for instance, tend to have their heart attacks earlier than white women because of all the risk factors they have,” she said. “They tend to have more diabetes, more metabolic syndrome, be more overweight, have more sedentary lifestyle, etc.”

Statistics from the American Heart Association show that 34.4 percent of Mexican-American women and 49 percent of African-American women have cardiovascular disease. Overall, one in three female adults has some form of cardiovascular disease. It is the leading cause of death in the United States, and the leading killer of women.

Dr. Wynona Bryant-Williams, executive director of the Arkansas Minority Health Commission said healthcare professionals “should take an aggressive approach of making the women of both ethnicities aware of the risk factors associated with both of these illnesses and should become more culturally competent” by reaching out to minorities. For Hispanic patients, this means also ensuring bilingual materials and staff are available.

Arkansas minority women face a number of challenges to quality healthcare, even when they do get into the right doctor’s office. These include being even more intimidated by physicians’ expertise and social standing than white patients, which can lead to patients being hesitant to bring up questions, concerns or ailments outside of what the doctor specifically asks or tells them. She said physicians need to understand this dynamic and reach out more to minority patients who are more reticent to ask questions or offer additional details.
Patient empowerment and self-efficacy are key to this issue, she said. “We need to encourage our patients and clients to rid themselves of this ‘god-complex’ that many of them have towards those of us who have been positioned and charged with a duty to provide the best healthcare and information possible to improve the quality of their lives.”

McSweeney agreed that one implication of the study is that being more attentive and thorough with minority and Caucasian female patients can detect earlier the signs of cardiovascular disease that might otherwise be fatal.

“What typically happens is that these symptoms are rather vague and they end up not being referred for cardiovascular evaluation,” McSweeney said. Instead, doctors try treating them by other means such as prescribing antidepressants to treat the anxiety women report. Delay in referral for cardiovascular evaluation was a major factor for many of the study participants.

McSweeney said physicians should assess to what extent the vague symptoms are affecting the patient’s daily activities such as climbing stairs or doing routine housework.

“It can get so severe women can’t make a bed without sitting down before making the other side. They make one side, rest, make the other side, rest,” she said. “If we can question and determine how severe this is, I think that’s key to healthcare providers knowing who needs to be referred for further evaluation.”



February 2008

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