Ground-breaking research uncovers that over half of heart attacks in women under 65 stem from non-traditional causes, challenging decades of medical assumptions and highlighting dangerous diagnostic gaps
A landmark Mayo Clinic study has revealed that more than half of heart attacks in women under 65 are caused by factors completely unrelated to the clogged arteries typically associated with cardiovascular disease, fundamentally challenging how doctors diagnose and treat younger female patients experiencing cardiac emergencies.
The research highlights the need for improved diagnosis and treatment of nontraditional heart attack causes, such as SCAD, to improve patient outcomes. The findings, published in the Journal of the American College of Cardiology, examined over 15 years of data from the Rochester Epidemiology Project, providing the most comprehensive evaluation to date of heart attack causes in people aged 65 and younger.
The implications are staggering for women’s health. Research published in the Journal of the American Heart Association found that women under 55 were seven times more likely than men to be sent home from the emergency room without proper cardiac testing. This disparity, combined with the new understanding of hidden heart attack causes, suggests thousands of young women may be experiencing misdiagnosed or undiagnosed cardiac events each year.
The Hidden Culprit: SCAD and Other Non-Traditional Causes
The study’s most striking revelation centres on spontaneous coronary artery dissection (SCAD), a condition where a tear develops in a heart artery’s wall, creating what doctors call a “false lumen” that blocks normal blood flow. SCAD was nearly 6 times more common in women than men. Unlike traditional heart attacks caused by cholesterol buildup, SCAD typically strikes young, healthy women with no conventional risk factors for heart disease.
SCAD primarily affects women 50 and younger, according to a 2018 American Heart Association scientific statement, and can strike people with few obvious risk factors. The condition accounts for approximately 25 to 35 per cent of heart attacks in women under 50, yet it remains frequently misdiagnosed as a typical plaque-related cardiac event.
Dr Claire Raphael, an interventional cardiologist at Mayo Clinic and first author of the study, warned of the serious consequences of misunderstanding these hidden causes. “When the root cause of a heart attack is misunderstood, it can lead to treatments that are less effective — or even harmful.”
The research identified several non-traditional heart attack triggers beyond SCAD. Heart attacks caused by stressors such as anemia or an infection were the second-most common cause overall, and the deadliest, with a five-year mortality rate of 33%. Other hidden causes included blood clots travelling from elsewhere in the body (embolism), hormonal factors, autoimmune conditions like lupus and rheumatoid arthritis, and stress-induced heart problems.
Pregnancy and Hormonal Connections
Perhaps most concerning for women of childbearing age, the research confirms strong links between pregnancy, hormonal changes, and heart attack risk. While SCAD heart attacks can occur in men and women of any age, approximately one-third of all SCAD cases occur in women during pregnancy or the postpartum period.
Although it’s often thought of as a threat during pregnancy, the most dangerous period in the study was in the month after delivery. This finding is particularly crucial as new mothers often attribute symptoms like chest pain, shortness of breath, and fatigue to the normal challenges of caring for a newborn rather than recognising them as potential cardiac warning signs.
The hormonal connection extends beyond pregnancy. Birth control pills, polycystic ovary syndrome (PCOS), and menopausal hormone therapy have all been identified as potential risk factors for non-traditional heart attacks in younger women. The complex interplay between hormones and heart health remains an active area of research, with scientists working to understand why these typically protective hormones can sometimes trigger catastrophic cardiac events.
Recognising the Warning Signs
One of the study’s most critical implications involves symptom recognition. While both men and women experiencing heart attacks may have classic chest pain or pressure radiating to the arm, jaw, or back, women often present with atypical symptoms that healthcare providers frequently misinterpret.
Women are more likely to experience fatigue, anxiety, or what feels like indigestion. They may have pain in the upper back or neck, jaw discomfort without any chest pain, or simply feel unusually tired. These non-specific symptoms often lead to misdiagnosis as panic attacks, acid reflux, or musculoskeletal issues.
Because these symptoms do not fit the standard heart attack narrative, they are frequently mistaken for panic attacks, acid reflux, or musculoskeletal issues. The result is delayed treatment that can mean the difference between full recovery and permanent heart damage or death.
Dr Rajiv Gulati, chair of the Division of Interventional Cardiology and Ischemic Heart Disease at Mayo Clinic and senior author of the study, emphasised the need for both medical professionals and patients to reconsider their approach. “Clinicians must sharpen their awareness of conditions like SCAD, embolism and stress-related triggers, and patients should advocate for answers when something doesn’t feel right.”
The Diagnostic Crisis
The Mayo Clinic findings expose a troubling diagnostic crisis affecting younger women. Women who had a final diagnosis of STEMI had a 59 per cent greater chance of a misdiagnosis compared with men. Women who had a final diagnosis of NSTEMI had a 41 per cent greater chance of a misdiagnosis when compared with men.
This diagnostic gap has deadly consequences. When doctors misidentify SCAD as a traditional plaque-related heart attack, standard treatments like stents or aggressive interventions can actually worsen the arterial tear, potentially causing catastrophic complications. Conservative treatment with blood pressure medication and careful monitoring often proves more effective for SCAD patients, but only if the condition is correctly identified.
The problem extends beyond individual diagnoses to systemic issues in medical training and research. CVDs have been commonly perceived as ‘men’s disease’ and this misconception has contributed to under-diagnosis and treatment for women worldwide. Historically, cardiovascular research focused predominantly on men, leaving massive knowledge gaps about how heart disease manifests differently in women.
Advocating for Your Heart Health
Given these alarming findings, women must become fierce advocates for their own cardiac care. If you experience any concerning symptoms, experts recommend using specific phrases to ensure proper evaluation. Tell emergency staff: “I’m worried this could be my heart.” This simple statement can trigger protocols that might otherwise be overlooked.
Don’t hesitate to request specific tests if you’re concerned about cardiac issues. Ask for an ECG (electrocardiogram), troponin blood test to check for heart muscle damage, and potentially an echocardiogram or CT angiogram if SCAD is suspected. Bring detailed family history information, particularly noting any relatives who experienced heart problems at young ages.
If you’re dismissed or told your symptoms are anxiety-related without proper cardiac testing, seek a second opinion immediately. Women should feel empowered to advocate for themselves in medical settings. If something doesn’t feel right, trust your instincts and speak up—ask your doctor directly if your symptoms could be heart-related.
Prevention Strategies for Hidden Heart Attack Causes
While traditional risk factors like high blood pressure, high cholesterol, diabetes, obesity, smoking, and sedentary lifestyle remain important for overall heart health, preventing non-traditional heart attacks requires additional awareness and strategies.
For women with autoimmune conditions, working closely with rheumatologists and cardiologists to manage inflammation becomes crucial. Those considering pregnancy should discuss their cardiac risk with healthcare providers, particularly if they have conditions like fibromuscular dysplasia, which has been linked to increased SCAD risk.
Stress management takes on new importance given the strong connection between emotional stress and SCAD. Physical or emotional stress are often reported to have happened before SCAD. Emotional stressors have been reported more in women. Regular exercise, meditation, therapy, and other stress-reduction techniques may help reduce risk, though more research is needed to confirm protective strategies.
Women should also be cautious about extreme physical exertion, particularly if they’re unaccustomed to intense exercise. While regular moderate exercise is beneficial, sudden intense physical activity has been identified as a potential SCAD trigger.
Changing the Future of Women’s Heart Health
The Mayo Clinic study represents a watershed moment in understanding women’s cardiovascular health. For too long, the medical establishment has applied a one-size-fits-all approach based primarily on research in older white men. This new research demands fundamental changes in how doctors evaluate, diagnose, and treat younger women with cardiac symptoms.
Medical schools must update curricula to include comprehensive training on non-traditional heart attack causes. Emergency departments need protocols that account for the different ways heart attacks present in younger women. Research funding must prioritise studies that specifically examine women’s unique cardiovascular risks and develop targeted treatments.
“Our research highlights the larger need to rethink how we approach heart attacks in this patient population, and for younger adult women, in particular.” The study’s authors call for immediate action from the medical community to prevent continued misdiagnoses and potentially fatal treatment delays.
The Road Ahead
This ground-breaking research offers both sobering realisations and genuine hope. While it’s alarming to learn that over half of heart attacks in younger women stem from causes doctors might not immediately recognise, awareness is the first step toward change. Every woman armed with this knowledge becomes better equipped to recognise symptoms and demand appropriate care.
For the thousands of women who have experienced unexplained cardiac events or been dismissed when seeking help for concerning symptoms, this study provides validation. Their experiences were real, their concerns were justified, and the medical system failed them, not the other way around.
As Dr Raphael noted, “Understanding why a heart attack happened is just as important as treating it. It can mean the difference between recovery and recurrence.” With this new understanding of hidden heart attack causes, doctors can move beyond generic treatments to targeted therapies that address the actual underlying problems.
The message for young women is clear: trust your instincts, know the signs, and never allow anyone to minimise your symptoms. Your heart health matters at every age, and you deserve medical care that recognises and addresses the unique ways cardiovascular disease affects women.
Heart disease remains the number one killer of women, claiming more lives than all cancers combined. But with ground-breaking research like this Mayo Clinic study illuminating previously hidden dangers, we finally have the knowledge needed to protect younger women from these devastating cardiac events. The challenge now lies in translating this research into real-world changes that save lives.
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