Include women in focus on heart attacks

Mary "Mo" Hicks - Juneau, Alaska

Thanks for the cover story "When a heart attack goes undiagnosed." This problem is much more common in women older than 50 — that would be me — and in those who don't exhibit normal chest pain — that would be me again (News, Wednesday).

I live in Alaska and am an avid ocean kayaker. Indeed, I was living in the Arctic and pulling in a whale with an Inupiat hunting party a week before my triple bypass. I showed very odd signs for four years, and several doctors misdiagnosed me repeatedly: I gave up acidic drinks for four years thinking fruit juices were creating acid pains; I even learned to walk in stints, stopping with pain, then walking 10 feet. I actually adapted to this walking style, thinking it was nothing!

(Survivor:  Rick Gustafson, whose heart attack was misdiagnosed, shown with his wife, Connie, in Indianapolis. / By Tom Strickland for USA TODAY)

The only reason I am alive today is because when I put on 5 pounds in one month, I went to the hospital in Seattle to see whether I had esophageal lining problems — yes, another misdiagnosis — when I truly felt I had circulatory problems. I was shocked to hear that one main artery had already bypassed and that I needed a triple bypass immediately.

Two years after my heart surgery, I am a spokesperson for women's heart disease in Alaska, after being trained by the Mayo Clinic in conjunction with WomenHeart, the national coalition for women with heart disease. Did you know 267,000 women die each year from heart attacks, which kill six times as many women as breast cancer does?

My story is absolutely normal for women in the USA, even if it sounds a bit exotic. If it can happen to me, it can happen to anyone. Thanks for your focus, but we need to include women in the discussion. Did you know that older African-American women, for example, are twice as likely as white women to have a heart attack? New tests are out there, but doctors aren't screening well enough yet.

Challenge 'deadly myths'

Saralyn Mark, MD - Washington, D.C.

USA TODAY missed a golden opportunity to dispel common deadly myths surrounding heart disease in women. While the story's pictures depicted women whose hearts are broken by the loss or potential loss of their loved ones, basic facts on women's heart health were blatantly ignored.

Heart disease is the leading cause of death for women as well as for men. Symptoms of a heart attack in a woman might differ from what a man experiences, such as crushing chest pain, and can include shortness of breath, nausea, jaw pain and fatigue. Furthermore, stress tests and angiograms could be falsely negative in women.

So while it is challenging to make an accurate diagnosis of a heart attack in a man, the situation is much worse for a woman. All of this can lead to a delay in appropriate therapy for women, resulting in higher morbidity and mortality rates compared with men. Awareness about these sex differences is the critical first step toward saving lives.

'I am a survivor'

Meridith Lally - Mesquite, Texas

One morning four years ago, when I was only 37, I experienced pain that felt as if an elephant was sitting on my chest. My mother called 911; when the paramedics arrived, they asked what I thought was wrong. I told them I thought I was having a heart attack. They gave me nitro and took me to the hospital.

While in the emergency room, I was given an EKG, which came back normal. I was asked what made me think I was having a heart attack. Again, I said, "I am having a heart attack!" After a few more of these conversations — and as they worried more about the fact that I was anemic — they ran a blood enzyme test. It came back and confirmed that I was having a heart attack. I needed a stent. I now have congestive heart failure.

I consider myself blessed because my regular doctor found that I had heart problems before this, and I was aware of heart attack symptoms in women. Because of that early detection, my knowledge and eventual proper treatment, I am a survivor.

Use resources wisely

David Messerly, MD - Durham, N.C.

As a practicing emergency room physician, I wanted to comment on USA TODAY's missed heart attacks story.

First, the case USA TODAY chose regarding the patient with chest pain, shortness of breath and sweating is an anomaly. I would agree totally that, as the case was explained, it was a mistake to send such a patient home without further testing. Very few of the "misses," however, are that straightforward. Most are "dizzy," or "weak," or have other very non-specific complaints that can have a laundry list of possible diagnoses.

Such patients are among many others most ER physicians are caring for at any one time. Trying to wade through the chronic problems to get to the actual reason for a visit can sometimes be nearly impossible; these patients are the usual "misses." Couple this with the unimaginable cost of admitting everyone with a remote suspicion of a heart problem, and you have a real dilemma. Because our society has determined that we won't accept any misses, cautious ER physicians end up admitting hundreds of very low-risk patients to find one who has a heart problem.

This illustrates a much larger issue. There are only so many resources for health care. We, as a society, need to figure out where our priorities lie and put our energies and resources into those areas. Emergency departments have become a safety net, catching all those who fall through the cracks of our crumbling health care infrastructure. Policies have led to the use of the ER for any and all complaints — chronic problems, general health issues and silly little complaints.

We all must come to an understanding that we have only so many resources to spend for health care. If we want to spend them admitting every 25-year-old with chest pain, or every 30-year-old who is "dizzy" or "weak," or who had "a funny feeling in his chest," then the waits in the ER will continue to grow, and the cost of health insurance will continue to rise, and the number of insured patients in this country will continue to fall.

The downward spiral will eventually end, and probably not so well.

Fighting for admission

Todd Fredricks, DO - Amesville, Ohio

As a practicing emergency physician, I can fully relate to the diagnostic dilemmas posed by cardiac patients. The emergency room standard of care is very good but not perfect. It is for this reason that my ER group's risk management program simply states, "Admit ALL chest pain patients." This advice is all the more important as our nation ages and the "classic" symptoms of heart attacks just don't apply for many elderly patients.

The bigger problem that I face comes when I call a patient's admitting physician, as I did with a patient recently. I am told to send the patient home because "all the labs are normal. Are you going to admit every patient with some chest pain?" This is not a query. It is an angry statement directed at my clinical judgment without consideration for the statistics of a missed diagnosis. In this case, I stood my ground and the patient went into the hospital, but the toll it takes on an ER doctor is high. You get tired of fighting with doctors who don't want yet another admission. They will point out that most chest pain admissions amount to nothing. Unfortunately, lacking better diagnostics, all that ER physicians have to go on is patient history and some very basic tests.

The nation must start viewing health care as a strategic resource and mandate national standards for admission. My philosophy is that if people feel the need to come to the ER for chest pain, shortness of breath, weakness or uncontrolled blood pressure, then I have to find a reason not to admit them for observation. That strikes many physicians as "canned" or uninspired, but in the absence of better diagnostics, it is the only method that allows me to sleep at night.