Heart Attacks in Black Women

February 23, 2024|PCNA

Rethinking How We Recognize and Address Acute Myocardial Infarction among Black Women

Thank you to Raven Pierre MSN, RN, Jacqueline Nicolas MSN, FNP-C, and Diana Baptiste DNP, RN, CNE, FPCNA, FAAN for this article on heart attacks and Black women.

Cardiovascular disease (CVD) remains the leading cause of death among women in the United States.1 The prevalence of CVD among non-Hispanic Black women remains disproportionally higher, with 60% living with some form of coronary heart disease, hypertension, and stroke.1 Additionally, Black women aged 35 years and older are experiencing a slower decline in mortality and a higher prevalence of acute myocardial infarction (AMI).2 Black women are more likely to have heart attacks than any other racial/ethnic group, often as a result of chronic stress and increased allostatic load.3,4 Other causes of AMI are related to limited access to healthcare and pre-existing CVD risk factors such as hypertension, diabetes, smoking, physical inactivity, hypercholesterolemia, and being overweight or obese.2,5,6

Common symptoms of AMI are chest pain or tightness; jaw, neck, back, or shoulder pain; tachypnea; shortness of breath; lightheadedness; nausea; and vomiting.6 For women, it is not uncommon for AMI to present with a myriad of atypical symptoms that include dyspepsia, breathlessness, back or neck pain, fatigue, and/or epigastric discomfort. This different symptomology increases the risks of misdiagnosis and under-treatment.7

Whether typical or atypical, these symptoms indicate a potential heart attack and require immediate medical attention. ST-elevation myocardial infarction (STEMI), a serious complication of AMI, is typically suspected when an individual presents with persistent ST-segment elevation in two or more anatomically contiguous ECG leads in the context of a consistent clinical history.8 Creatine Kinase MB (CK-MB) and cardiac-specific troponins confirm the diagnosis; however, invasive testing and treatment should be started immediately in patients with a typical history and ECG changes without waiting for laboratory results.9

Previous research asserts that social determinants of health play a more significant role in the increasing prevalence of all types of CVD, especially among underserved persons—including those with persons with low socioeconomic status, education, employment, and neighborhood characteristics.10 However, even though people of color, including those who identify as Black, Asian, Native American, or Hispanic, as well as other ethnic minority populations, are more likely to experience adverse social barriers, these limitations do not apply to all individuals.4,10  

Often, people of color are preemptively associated with these social determinants, which can foster implicit bias and harmful stereotypes and place patients at risk for misdiagnosis and under-treatment.9,10 Additionally, this association can result in lower quality of care and communication from healthcare providers, including intentional and/or unintentional use of condescending tones and dismissiveness.11,12

The aforementioned interactions create a barrier that impedes patients from making informed decisions, effectively communicating symptoms, and participating in shared decision-making. Unfortunately, these scenarios are not uncommon, especially for Black women. “Anna” (concealed identity) is a real person who recently visited an emergency department in a large trauma-one academic medical center in the United States.

Anna’s Story

Accompanied by her younger brother, Anna is a 59-year-old Black woman who presented to her local emergency department (ED) for the first time with an acute onset headache described as “the worst headache of my life,” left shoulder pain radiating to her back, dizziness, and nausea. Anna reported that the pain began 2 days ago and had progressively worsened since its onset.

Photo of a mature Black woman sitting on examination table in modern clinic while female Black doctor listening to her heartbeat

She currently takes Omeprazole 20mg daily for GERD (Gastroesophageal Reflux Disease). Anna denied chest pain, productive cough, and upper respiratory infection symptoms.

Anna consumes a low-fat and low-carb diet, has no history of diabetes or hyperlipidemia, has never smoked, consumes alcohol occasionally (during family social events), exercises 5 days a week for at least 30 minutes, has a BMI of 18.8 with no significant weight gain or loss.

Anna has a family history of hypertension, diabetes, and coronary heart disease.

Anna was evaluated in the ED by the attending physician, who performed a physical exam but initially did not order any diagnostic tests. She was given an anti-emetic for nausea and Tylenol for headaches. At the request of Anna’s non-medical younger brother, the ED physician ordered a head CT scan, which was negative.

Anna’s brother also requested that labs be drawn for further diagnostics, and the ED physician responded, “I guess we can do that if you want us to.” Then, the ED physician elected to discharge Anna with prescriptions for an anti-emetic, Tylenol for headaches, and a muscle relaxer for the left shoulder pain.

Anna’s brother was unsatisfied with this outcome, as he witnessed his sister appear increasingly weak and uncomfortable. Before leaving the ED, Anna’s brother called their older brother, an orthopedic surgeon, for advice. Alarmed by the situation, Anna’s older brother called the ED attending physician to advocate for Anna and requested a “full cardiac workup,” including an EKG and cardiac enzymes.

The EKG showed 4 mm ST segment elevation in leads V2 through V6 with a troponin of 42ng/L. Anna was then treated for an acute MI in the ED with cardiac catheterization on the same day.

Without her brother’s advocacy, Anna’s STEMI would not have been detected, and she likely would have experienced catastrophic health outcomes. Unfortunately, Anna’s experience is common.

Black women with typical and atypical symptoms are often dismissed and misdiagnosed, which can lead to detrimental outcomes. As illustrated by Anna’s presenting symptoms, even typical MI symptoms may be missed in certain populations. Only 39% of Black women are aware that chest pain can be a sign of AMI, and only 33% understand that pain spreading to their neck, shoulder, or back is also a potential sign of ischemia.12 It is imperative that nurses and other health care providers recognize this knowledge gap and refer to American Heart Association (AHA) algorithms for treatment—no matter who the patient is.

Guidelines for Managing AMI

The American College of Cardiology (ACC) and AHA guidelines provide a critical framework for the timely and appropriate management of AMI, including the prompt use of diagnostic tests and interventions. However, clinicians must go beyond guidelines and consider individual patient’s presentation and needs.

The ACC/AHA recommends performing a diagnostic electrocardiogram (ECG) within the first 10 minutes of a patient arriving at the emergency department with complaints of chest pain or other signs of ACS.13,14 This benchmark was set to ensure that all patients with STEMI receive treatment in the cardiac catheterization lab within 90 minutes of arrival to the ED to reduce the potential for damage to the heart muscle and decrease morbidity and mortality.5,13,14

Although ACC/AHA guidelines consider social determinants of health, race, and ethnicity as barriers to access and reaching optimal health outcomes for individuals with CVD, health disparities continue to persist among ethnic minority groups for reasons beyond social determinants of health, specifically among Black women.4,8  These health inequalities have detrimental effects on Black women, who often receive lower quality of care.10,11 It is imperative that healthcare providers recognize the importance of following the ACC/AHA guidelines for all patients, regardless of their perceived presentation.

Anna’s case serves as a poignant example of how advocacy and a comprehensive cardiac workup can be pivotal in ensuring an accurate diagnosis and timely intervention. To achieve meaningful reductions in CVD-related disparities, nurses and other healthcare providers must be vigilant in recognizing the unique challenges faced by Black women, addressing implicit bias, and prioritizing the delivery of high-quality, patient-centered care for all individuals.9, 10,11 Only through a concerted effort to eliminate disparities and biases can we strive for equitable cardiovascular health outcomes among all populations.

Takeaways for Heart Attacks in Black Women

The prevalence of CVD among Black women remains a significant concern, as evidenced by the slow decline in mortality rates and higher prevalence of heart attacks among Black women.

Despite the overall decline in CVD-related deaths, disparities persist, highlighting the urgent need for targeted interventions and improved understanding of atypical presentations of heart attacks among Black women.

It is critical that healthcare providers recognize both typical and atypical symptoms of a heart attack in this population, as illustrated by Anna’s case. Atypical symptoms, such as headache, nausea, and shoulder pain, present unique challenges in diagnosis and treatment, potentially leading to misdiagnosis and under-treatment.

Nurses and other healthcare professionals must bridge the knowledge gap by ensuring awareness of atypical MI presentation and adhering to evidence-based guidelines and AHA algorithms to ensure timely and accurate diagnosis, regardless of the patient’s sociodemographic background.

References

  1. Virani SS, Alonso A, Aparicio HJ, et al. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation. 2021;143(8):e254-e743. doi:10.1161/CIR.0000000000000950
  2. Mehta LS, Beckie TM, DeVon HA, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016;133(9):916-947. doi:10.1161/CIR.0000000000000351 
  3. Mehta LS, Velarde GP, Lewey J, et al. Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement from the American Heart Association. Circulation. 2023;147(19):1471-1487. 
  4. Javed, Z., Haisum Maqsood, M., Yahya, T., Amin, Z., Acquah, I., Valero-Elizondo, J., … & Nasir, K. (2022). Race, Racism, And Cardiovascular Health: Applying A Social Determinants Of Health Framework To Racial/ethnic Disparities In Cardiovascular Disease. Circulation: Cardiovascular quality and outcomes, 15(1), e007917. 2023;147(19):1471-1487.
  5. Kalinowski J, Taylor JY, Spruill TM. Why Are Young Black Women at High Risk for Cardiovascular Disease? Circulation. 2019;139(8):1003-1004. doi:10.1161/CIRCULATIONAHA.118.037689
  6. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association [published correction appears in Circulation. 2022 Sep 6;146(10):e141]. Circulation. 2022;145(8):e153-e639. doi:10.1161/CIR.0000000000001052
  7. Khan IA, Karim HMR, Panda CK, Ahmed G, Nayak S. Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports. Cureus. 2023;15(2):e35492. Published 2023 Feb 26. doi:10.7759/cureus.35492
  8. Anderson HS, Masri SC, Abdallah MS, et al. 2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Data Standards. Circulation: Cardiovascular Quality and Outcomes, 2022;15(10). https://doi.org/10.1161/hcq.0000000000000112
  9. Arnett DK, Khera A, Blumenthal RS. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Part 1, Lifestyle and Behavioral Factors. JAMA Cardiol. 2019;4(10):1043-1044. doi:10.1001/jamacardio.2019.2604
  10. Saluja B, Bryant Z. How Implicit Bias Contributes to Racial Disparities in Maternal Morbidity and Mortality in the United States. J Womens Health (Larchmt). 2021;30(2):270-273. doi:10.1089/jwh.2020.8874
  11. Gillette-Pierce KT, Richards-McDonald L, Arscott J, et al. Factors influencing intrapartum health outcomes among Black birthing persons: A discursive paper. J Adv Nu 11,rs. 2023;79(5):1735-1744. doi:10.1111/jan.15520
  12. Heart disease and stroke in black women. www.goredforwomen.org. December 19, 2022. Accessed August 18, 2023.
  13. Writing Committee Members, Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 2021;78(22), e187-e285.
  14. Members WC, Lawton JS, Tamis-Holland, JE, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Journal of the American College of Cardiology. 2022;79(2), 197-215.

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