Helen Dandurand (Host): Welcome back to the Well Within Reach podcast.

I'm your host, Helen Dandurand, and today I'm going to be joined by Dr. Phil Chapman, Emergency Department doctor at Riverside, to talk about heart attack and stroke symptoms in women.

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Host: We're back with Dr. Chapman. Thanks for joining me today.

Johne Philip Chapman, MD: Thanks for having me, Helen.

Host: Of course. So to get started, you've never been on the podcast before. Could you tell us a little bit about yourself and your background?

Johne Philip Chapman, MD: Sure. Yeah. As you said, I'm an emergency medicine doctor here at Riverside. I'm the Director of the department, in fact. And in addition to that, I have a background in public health. I have a public health degree as well. That'd be the extent of it.

Host: Yeah. Yeah. How long have you been here?

Johne Philip Chapman, MD: I've been at Riverside for two years. Almost exactly.

Host: Great. Oh, that's awesome. Okay, so getting onto the topic to start us off, can you explain why it's important to recognize that heart attacks and strokes can present differently in women than men?

Johne Philip Chapman, MD: Yeah, of course. I mean, recognizing, the signs of illness are always important. Heart attacks being the leading cause of death in both men and women, makes it ever more important. And I think that illustrates one of the keys to the conversation today is that heart health or heart disease is the leading cause of death among women, which I think is a, misconception amongst many people.

We think of it as a male disease.

Host: Yeah. I definitely think that's the first thing that comes to mind. So that's a good thing to address right off the bat here. So to start off, we're going to talk about heart attack side of it all and what is happening, generally when someone is having a heart attack?

Johne Philip Chapman, MD: Sure. When, when you're having a heart attack, it means you've lost blood flow to a portion of your heart. There are several blood vessels within the heart. We think of the heart as pumping blood to the rest of the body, which is its main job. But the heart itself needs its own blood flow. So not only does it pump blood to the rest of your body, it pumps blood to itself. And if you have a blockage of blood to the heart muscle, then that is a heart attack. And, potentially that heart muscle would die. And then your heart's not pumping very well to the rest of your body. And then that leads to a cascade of problems to the rest of your body because it's not receiving blood flow.

Host: Okay. And what are some of the common heart attack symptoms that women might experience that people don't expect, and how do they kind of contrast from the typical?

Johne Philip Chapman, MD: Sure. So, in medicine we divide heart related symptoms, specifically for heart attacks into what we call typical and atypical.

Atypical just means the unusual, and there's two aspects to this. One is that, women can experience or do experience atypical or those unusual heart related symptoms more than men do. However, it is also important to note that it is still more common for a woman to experience the classic chest pain. Right?

Host: Okay.

Johne Philip Chapman, MD: So, don't think that every discomfort in your chest is a heart attack. And this is also just as important for providers, doctors and nurse practitioners and PAs to know that if a woman comes in with unusual symptoms, it may be a heart attack.

But for you at home, it's also important to know that if you're having certain symptoms, which we can discuss in a moment, just because it's not your classic crushing chest pain, doesn't mean it's not a heart attack.

Host: Okay.

Johne Philip Chapman, MD: So, what are those? Well, we will start by describing the typical symptoms. That's going to be the one like you see in the movies. You, clutch your chest, you describe intense pain. Usually almost, in fact, almost always, the pain in a heart attack is not sharp or stabbing. It's almost always crushing pressure like. Patients will say, I feel like somebody's sitting on my chest. I feel like I've got an elephant on my chest. I feel like I can't take a deep breath, et cetera. That's your typical classic chest pain. Your atypical is going to be vague symptoms that are similar, but, can be misconstrued as other things like just really bad indigestion. Right. I got the worst heartburn in my life.

It's not pressure, like it's not crushing your chest. Just kind of, uh, I feel like I got an upset stomach kind of symptoms. Intense nausea, can also be that as well. And then there's a few others that are even more vague and so what do you do with that information at home? And it's hard. You can't, you don't want to come to the hospital every time you have heartburn or an upset tummy. Right? And so I don't necessarily think that's the take home today. It's just that if you are having new and unusual symptoms, especially if they're related to exertion, meaning, every time I walk up a flight of stairs, I get this really bad indigestion. Every time I walk down the street to the mailbox, I get really bad heartburn or nausea. That may be a heart attack, waiting to happen. So, I would say in those instances it would be reasonable to come to the ER or if it's mild and you're just not sure and you don't feel like you're sick enough to come to the ER, you can always start with your primary.

Host: Okay. Alright. That makes sense. I feel like I've also heard of, jaw pain or arm

Johne Philip Chapman, MD: Yeah.

Host: Left side.

Johne Philip Chapman, MD: So usually, so the, the classic, textbook, you're taking your board exam as a doctor, the question would be, patient presents with crushing substernal, meaning under your sternum chest pain, and it radiates to their jaw, right?

And yes, heart attacks often, but not always come with a radiation of pain. It can be to your jaw, it can be to your right shoulder, it can be to your left shoulder. It can be to your back. And part of that is that the inside of your body was just never designed to sense pain. Your fingertips are good at sensing things.

Your, the tip of your tongue is very good at sensing things, the inside of your body not made for sensing. And so we get a lot of referred pain, right? The nerves and other parts of the, the body are feeling the pain too, just because it wasn't designed for that purpose.

Host: Okay. That's very interesting. So, moving on to kind of the stroke side of it all. What is happening when someone is having a stroke?

Johne Philip Chapman, MD: So just like a heart attack, a stroke is a loss of blood flow, in this case to the brain, and so, I should say, you can divide strokes into two kinds. The, the classic and, and one that represents 85% of all strokes is a blockage.

Just think of, a blocked pipe in your house, a blocked pipe in your heart, would be a heart attack. A blocked pipe in your brain would be a stroke. And that's where you lose blood flow to that part of the brain because it's a blockage there. And, the longer you go without blood to that part of the brain, the more likely it is for that tissue to die.

In a stroke, obviously your symptoms, and I think most people have some semblance of a an understanding of what that is; you have some kind of visible symptom from it. And the way it works is whatever part of the brain is having the loss of blood flow, that's the part of the brain that has the problem.

Host: Got it. And are there any subtle or silent signs of a stroke that women, you've found experience, that they might ignore or misinterpret?

Helen Dandurand (Host): Yeah. Less so than the heart stuff, right?

Host: Okay.

Johne Philip Chapman, MD: For strokes, I guess I, I can't speak to all of the literature there the, in the world of medicine, but it's not as well described as heart attacks. Heart attacks, it's not uncommon for a woman to come in with more vague symptoms than a man. For strokes, though, it's usually my right arm doesn't work, but my left arm does work, or my right side of my face is droopy, but not the left, or I can't speak. Now, I will say, regardless of gender, one of the more difficult strokes to identify both on the outpatient setting by the patient themselves or by a doctor when evaluating them is, a stroke and the part of the brain that does balance.

Obviously balance is something that's kind of, hard to grasp and understand. You can feel balance, but it's hard to measure balance. And so sometimes patients will come in with really intense dizziness or vertigo, and that can be a stroke, although I will also caution everybody, that vertigo is most commonly not a stroke. It's very common to have vertigo, to wake up, feel lightheaded, dizzy, turn your head to quickly, feel dizzy. That's almost certainly not a stroke. But there are, as far as you know, to your question about, silent strokes, that would be one of them I suppose, is just this feeling of like off balance this.

Host: Gotcha. What are the typical signs then of strokes?

Johne Philip Chapman, MD: Yeah, so a stroke, again, it's just really gonna depend on what part of the brain is affected. If the part of your brain that moves your left arm, Loses blood flow, then your left arm won't work. Right. It's very focal. Strokes are not global, generally speaking.

There's a few exceptions to that. But strokes are almost always focal, meaning just one specific part of who you are. Your right arm, your left arm, your right leg, your left leg, your right face, your left face, speech, things like that.

Host: Got it. Okay. So we talked about heart attack, we talked a little about stroke. With those, how do hormonal factors like menopause or pregnancy influence kind of these heart attacks or strokes in risk in women?

Johne Philip Chapman, MD: The literature doesn't say definitively, although there may be some doctors who disagree. But the idea is that estrogen has some protective effect for heart disease. And obviously as you go through menopause, your hormones change, specifically your estrogen levels will go down.

And the thought there is that, that can, accelerate heart disease. And I, I did see that early menopause, menopause before the age of 45 actually has a fairly high correlate to, heart disease. It does not mean that if you do go through early menopause, you're going to have a heart attack. It's just that you're a higher risk than somebody who did not.

Host: That's very interesting. And does pregnancy kind of play, play?

Johne Philip Chapman, MD: So p no. So pregnancy comes with a lot of risks then it's prior to modern medicine and modern obstetric care, childbirth was the leading cause of death in women. Uh, fortunately we don't live in that kind of world anymore. And so pregnancy can come with a lot of complications. Heart attack, not really one of them. Uh, you have a, you'd have a slight increased risk of stroke and some other things, but again, they're incredibly rare.

Host: Okay. We are going to take a quick break, to talk about primary care at Riverside. Consistency is being able to count on someone to be there when you need them. At Riverside Healthcare, your primary care provider is dedicated to being in your corner, helping you and your family stay healthy and thrive.

 Find the right primary care provider for you at myrhc.net/acceptingnew. From annual screenings to well checks and everything in between, having a primary care provider that you can trust makes all the difference.

 All right, and we are back. So do you find that women are more likely to delay seeking care for heart related symptoms?

Johne Philip Chapman, MD: As physicians, we try not to use anecdotal medicine, meaning we try not to base our medical decision making based on our own experience. And that can sound counterintuitive because in most careers you use your experience to build your future knowledge. And you certainly do that to a degree. However, a good physician will use empiric data because it's possible that you didn't see a disease before. You saw a very weird presentation of it.

And so I will say that in relation to this question, what I find isn't is important as what the data says. And the data says that yes, women delay in seeking care. They will present sometimes years later, right when they were starting to have some, perhaps have some heart symptoms at a younger age, maybe they had some of that, the mild indigestion or something like that at a young age. And instead of seeing their primary, they put it off. And then, years go by and their heart disease, when they do need some kind of an intervention, it just more further advanced than the male counterpart would've been. So you might need more aggressive forms of treatment.

Host: Okay. That's really interesting. I feel like, just when you're thinking of women, I feel that women are typically those who make the decisions in the household about, uh, healthcare and things like that. So it's interesting that they would put that off, put themselves off.

Johne Philip Chapman, MD: Yeah. Yeah, it's a fair point because, I would say that women do tend to come to the doctor for pretty much everything else, more, urgently than men. And, I don't know, I don't know what the, the social implications of that are. Perhaps it's because, again, men were seen as having heart disease as their disease. It may be changing now that was the, data at one point. I will say, g oing back to my experience, I do see quite a few women coming in for, chest related symptoms, in the ER. And so I dunno, per perhaps we're in a new era.

Host: Okay. That's good. That's good to hear. This is kind of going off script here a little bit, but how often are those things like correlated when someone comes in with those kind of symptoms, maybe just like anxiety versus.

Johne Philip Chapman, MD: It's a fantastic question because I get it every day. So anxiety is almost never a diagnosis of inclusion, meaning there's no diagnostic criteria that you can do to just diagnose anxiety. Usually you have to rule out other things. And as an ER, emergency room provider, we're very good at ruling out. People think of us as taking care of car crashes and gunshots and things like that, but really what we spend most of our time doing is ruling out things, right? We order a bunch of tests and can come into the room and tell you, you don't have X, Y, or Z. You don't have a heart attack today. And so the diagnosis of anxiety is almost certainly a big proportion of our patients. However, that's not my job. Right. That would be inappropriate to me.

My job is to look for things that'll make you very ill or kill you if I don't do something about it. And so, I was not prepared as a doctor for, when I came out of my training a decade ago of the number of patients that come in saying, Hey Doc, can my symptoms be anxiety?

And the answer's almost always, yes. I say it can cause constipation. It can cause diarrhea, right? It can cause chest pain, it can cause nausea, it can cause shortness of breath. And so, the mind is powerful. And so certainly a fair proportion of patients, probably after they leave the ER probably end up with a diagnosis of anxiety. But that, again, not appropriate of me as an ER doctor to do that. But yes, anxiety can be a great mimicker of other disease.

Host: Interesting. Okay, cool. I'm glad that I brought that up. So as far as risk factors, we kind of talked about that a little bit with the, I asked about the hormones before, but are there risk factors that are more unique or common in women when it comes to heart disease and stroke?

Johne Philip Chapman, MD: More risk factors. So the risk factors for heart disease are pretty universal. And again, we talked about menopause and that's a very good one. Outside of that, no, it is the classics, that everyone has probably heard by now because we, I think the American Heart Association and the medical community at large has done a very good job of making sure everyone knows these things.

And so I'm just going to tell you stuff that you probably already know. Which is smoking, obesity, diabetes, and then of course family history of heart disease. Oh, hypertension and then high cholesterol, of course. So all of those things, some of those are modifiable. I mean, you can do something about them and some of them are not like family history of heart disease. Not much you can do. You can try to minimize your risk for heart disease though by not smoking. By eating carbohydrate and fat smart diets, and being active and exercising.

Host: Got it. So how can women advocate for themselves in a medical setting if they feel like something's wrong, but maybe their symptoms aren't being taken seriously?

Johne Philip Chapman, MD: Yeah. So I will say that often what can seem as not being taken seriously is just a matter of miscommunication. And, as providers, our job and, and our vocation and why we went through all the schooling is because we want to help people. So if you feel like a provider is not addressing an issue that you're having, my recommendation would just say what you're thinking.

 If you're coming in because you're concerned about heart disease, it's, entirely appropriate to say, Hey, I'll be honest, my main concern here is heart disease. I do hear this on occasion. I had a friend who died last month from heart disease. My mother died at this exact age that I am right now of heart disease. Right. And you can say that, and then it gives us a clue as to what may be going on in your mind. And then we can address it directly.

Host: Good. So just say, say what you're thinking,

Johne Philip Chapman, MD: Say what you're thinking.

Host: And I feel like to, for me, it sometimes helps to write that in my notes in my phone or something so I can look back and be like, oh yeah. Because sometimes you walk in the room and you're like, I don't know what I wanted to say.

Johne Philip Chapman, MD: And, and it's well, well described. I mean, every, every provider in training learns the, oh by the way, question when you're, like, you have your, you're the doctor's leaving the room. They've got your hand on the door handle, and the patient goes, oh, by the way, and that's just human nature, right?

Yeah. So, yeah, writing it down is also a good idea.

Host: So what advice do you have for women and their loved ones to better recognize and respond to kind of these early warning signs of heart attack particularly, or stroke?

Johne Philip Chapman, MD: Again, what we kind of just talked about today. If you're having new or different symptoms, if for heart attack, specifically, if it's related to exertion, you should come to the ER for that, right?

If you're having chest discomfort and it's doesn't have to be related to exertion, but in the case that it is, I would say come to the ER right away. If you're kind of having some mild nagging symptoms here or there, I'm less good at that. In the ER, I only get to see you for two to four hours. So if there is some concern and you don't feel that ill, it's also reasonable to go to your primary doctor or if you have a cardiologist talking to them and they can do some tests that I may not have access to in the ER to risk stratify you for heart disease.

Host: Got it. Okay. That makes sense. Is there anything else that you wanted to add today?

Johne Philip Chapman, MD: No, this has, uh, I think been fairly comprehensive.

Host: Good. Thank you so much for being here.

Johne Philip Chapman, MD: Absolutely. Thank you.

Host: Yeah. And thanks listeners for tuning into the Well Within Reach podcast brought to you by Riverside Healthcare. For more information, visit riversidehealthcare.org.