Q&A: First responders need to be trained in how women present with heart attack
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Key takeaways:
- Women are more likely than men to have their heart attack symptoms missed or misdiagnosed.
- An initiative to train first responders to recognize heart attack signals in women has been launched.
Too often, heart attack signals are missed or misdiagnosed in women, not just by patients and providers, but by first responders as well.
When Jolie Busch, a member of the board at the Women’s Cardiovascular Health Center at UCLA and a former emergency medical technician (EMT), was serving as an emergency department volunteer, she noticed an unexpectedly high number of young women presenting with symptoms that turned out to be heart attacks but were often not initially diagnosed as such. Realizing that the best chance of a prompt correct diagnosis was through better education of first responders about heart attack signals in women, she embarked on a mission to create a continuing education course. She worked with the Los Angeles Fire Department to incorporate those teachings into their protocols. She consulted with Marcella Calfon Press, MD, PhD, associate clinical professor of cardiology at the David Geffen School of Medicine at UCLA and Tamara Horwich, MD, MS, health sciences clinical professor of medicine/cardiology at the David Geffen School of Medicine at UCLA, to develop a 30-minute online training protocol to help first responders recognize and respond to heart attack signals in women.
Healio spoke with Busch and Calfon Press about why so many women have their heart attack signals recognized late or not at all, how the initiative was conceived, what the protocol consists of and what they hope the program accomplishes.
Healio: Why are heart attack signals missed or misdiagnosed in women?
Calfon Press: We think it is because heart disease is underrecognized as a leading cause of death in women. There is a knowledge gap. Also, women can present with atypical symptoms that may be less common. The most typical symptom is pain or discomfort in the chest. But women may instead present with symptoms like throat pain, arm pain, jaw pain, epigastric pain, sweatiness or nausea. The symptoms can be more vague and traditionally less typical than a classic symptom like pressure in the chest. They are often missed both by the patients and by their providers.
Busch: There are so many reasons. In the training and historically, heart disease is considered to be a disease of men. Women present differently. Traditionally, even doctors were not taught about symptoms in women. Very often, a woman will go to the emergency room and be misdiagnosed with anxiety because she is having typically female symptoms rather than terrible chest pain. Those less traditional symptoms have historically been attributed to anxiety or less serious outcomes. Proper training should start from the ground up, with the very first person to respond to the emergency. I also believed that EMT, paramedic and medical students should have this training, and that is why it is also being offered to them in their initial education.
Healio: What prompted the initiative to train first responders in recognizing heart attack symptoms in women?
Busch: What initially sparked my interest was that when I was a volunteer in the emergency room at UCLA and I saw a lot of young women having heart attacks. One of the common denominators had been breast cancer. Chemotherapy and radiation treatments can potentially damage the heart. When I started researching what I was seeing, that was exactly the case. A number of women with breast cancer who receive radiation can have damage to their heart. Because I was trained as an EMT, among other things, I had relationships with the fire department, and when I reviewed their protocol for dealing with different medical emergencies, there was nothing in many of their sections about what could conceivably be female heart attack symptoms.
Calfon Press: Often the diagnosis is first made upon arrival. That initial contact with health care is very important for the pathway to begin. If our front line is aware of the challenges that women face in terms of their presentation, diagnosis and treatment, then they may be better able to diagnose a heart attack or reduce the amount of underdiagnosed heart attacks.
Healio: What does the initiative consist of?
Busch: It initially was a written guideline that I brought to the Los Angeles Fire Department in 2019. Before the COVID-19 pandemic, I had met with those who do the continuing education for the fire department, and they said they would incorporate it into their courses. After the pandemic, I wanted to pick this up again, and I realized there was a way to reach a broader audience, the people in the first rung of their training such as EMT students, paramedic students and medical students. Why not reach them as well from the ground up and not later in their careers? So I had the idea to make it an educational computer module to reach more people.
Calfon Press: It’s basically an educational PowerPoint module that’s narrated by Dr. Horwich. I helped design the clinical content to help train the front-line workers to recognize the symptoms of heart disease and make them aware of the challenges that women face in the diagnosis and treatment of heart disease.
Healio: What do you hope the initiative accomplishes?
Busch: I hope it saves lives.
Calfon Press: I really hope that fewer women are misdiagnosed. Diagnosing a heart attack can help save a life. Missing a diagnosis can be devastating. The more we educate the community at large and our own health care community, the better the outcomes will be. Improving the education of front-line health care workers is key to minimize and reduce the amount of misdiagnosed and undertreated heart attacks in women so we can save lives. That is the main goal.
I am appreciative of the UCLA Women’s Cardiovascular Center and our board members, particularly Jolie, to commit to something that I devote my life to. I am very grateful for that opportunity.
Healio: What are the next steps?
Calfon Press: This is an initiative starting locally with the L.A. County emergency medical services (EMS). Ideally, if this is well received by our local first responders, then we would want to expand it more broadly, whether across California or nationally.
Busch: The course is now available to most first responders in Los Angeles, and I would like to make it available to all emergency department personnel, particularly triage nurses, and take it nationally to students, firefighters and first responders everywhere.
For more information:
Jolie Busch and Marcella Calfon Press, MD, PhD, can be reached at mcalfonpress@mednet.ucla.edu; X (Twitter): @mcalfonpressmd.
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