On April 16, 2024, Toniya Farmer was driving on a highway in Atlanta when she experienced severe chest pains. She called 911, feeling pain and difficulty breathing, believing she was in immediate danger. When she arrived at the local emergency room, she stated she was having a heart attack. However, no one from the hospital staff responded until a man in the waiting room loudly asked if anyone had heard her. „I guess I looked too young to have a heart attack,“ Farmer said. Her story highlights the larger issue of gender disparities in the diagnosis and treatment of heart diseases.
Results from the National Hospital Ambulatory Medical Care Survey from 2014–2020 showed that American women visiting emergency rooms wait an average of 29% longer to be examined for a heart attack compared to men. These delays can be life-threatening, especially for younger women who are at risk of spontaneous coronary artery dissection (SCAD), a type of heart attack responsible for up to one-third of acute cardiac events in women under 50 years old.
„There are still biases that heart attack patients simply look like older, white men,“ said Dr. Erin Michos, Director of Women’s Cardiovascular Health and Associate Director of Preventive Cardiology at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore. „SCAD patients don’t have the risk factors we typically associate with heart attacks; they have normal cholesterol and blood pressure, tend to look healthy, engage in regular exercise, and eat well.“
Getting to the heart of SCAD
Unlike most heart attacks caused by plaque buildup or blood clots in the arteries, SCAD occurs due to a tear in the middle layer of the arterial walls, leading to blood pooling and the separation of the wall layers. This eventually restricts blood flow. The average patient is premenopausal and between 44 and 53 years old, but SCAD also accounts for 15 to 43% of heart attacks in postpartum women. Researchers believe SCAD may be related to hormones and their influence on connective tissue or pre-existing connective tissue disorders like Ehlers-Danlos syndrome or abnormal cell growth in the arterial walls (fibromuscular dysplasia), leading to arterial bulging. Another theory involves immense emotional or physical stress. „In about 50% of cases, we see extreme emotional stress, and in about 20 to 30%, very intense exercise,“ said Michos. „We hypothesized that these stress factors activate the sympathetic nervous system, raising blood pressure and heart rate, leading to an adrenaline rush; this could trigger the event if the artery is already fragile or prone to tear,“ she said.
Faces of SCAD
The lack of answers and information about SCAD has significant effects on affected women. „The frustration of these patients is real,“ said Dr. Sharonne Hayes, founder of the Women’s Heart Clinic at the Mayo Clinic in Rochester, MN. „They don’t get answers. They fear they will die because they’ll have another SCAD,“ she said.
Nakeia Jackson is a traveling nurse living in Alton, IL. At 28, she had her first cardiovascular issues. The 34-year-old Jackson said she doesn’t trust small community hospitals to do the right thing. „They don’t know how to handle them,“ she said. After 24 hours of stabbing chest pains and no response, she went directly to Barnes Hospital in St. Louis and the doctors who would save her life. „I was blindsided,“ said Jennifer Maxwell from Cedar Rapids, IA. She had her first of three SCADs at 40. The now 55-year-old Maxwell said she was training for an outdoor marathon in Iowa’s cold winter when one day she woke up with tightness and pressure in her chest and shortness of breath. She went to a local hospital.
„The hospital didn’t take it seriously,“ she said. „They didn’t monitor me, didn’t call a cardiologist, didn’t do an EKG,“ she said. „I felt unheard,“ she said. „The treating doctor told me I was 40 and healthy and that it was just anxiety.“
SCAD Sisterhood
SCAD leaves indelible marks. Initial treatments range from watchful waiting to medication management and advice to avoid extremely strenuous activities and lifting heavy loads, all aimed at avoiding potential triggers. However, evidence for these treatments is incomplete and rather weak. „We’re working off incremental evidence. We’ve had some major breakthroughs, but we’re not there yet,“ said Hayes. Doctors also cannot predict which women will have a recurrence of the disease, a dilemma that leads to mental health problems for many women as they cope with the consequences. „It’s understandable; they were young and did everything right, and then something terrible happened to them,“ said Michos. „They live with anxiety, but too much fear can exacerbate the situation. So, part of my counseling is to encourage patients to seek help for stress and anxiety.“
The lack of evidence and solid medical treatments has brought many of these women together far beyond the boundaries of clinics and emergency rooms. Connecting with others with similar experiences has significantly changed their lives. „I feel empowered,“ said JoAnn Girardo, a 61-year-old SCAD survivor. She credited much of her success to an organization called WomenHeart, where she found invaluable resources that eventually led her to volunteer as a „Champion,“ a group of advocates and educators. „Seeing other women doing well and not just surviving is very encouraging,“ she said. „Others have found solace through research, SCAD research fundraising a nonprofit organization that collects funds to support scientific research, offers education, and operates several Facebook groups for survivors and their families.
When asked what they wished they had known before their SCAD, their advice quickly comes to mind:
Girardo: „Learn to use your words correctly and don’t downplay your situation; the doctor only knows what you tell them.“
Farmer: „Find a doctor who resonates with you. If you see a doctor who doesn’t give you an answer or doesn’t address the questions you ask, move on to another and don’t stop until you get the answer you need.“
Jackson: „If you have symptoms that you suspect could be a heart attack, get checked out immediately. Many doctors are not familiar with SCAD, so you really have to advocate for yourself.“
Maxwell: „When in the emergency room, if you speak up and say you have chest discomfort, you can’t assume anyone knows it’s your heart. Women present heart symptoms differently than men. So, you have to make sure you’re fighting for yourself.“