A patient in her mid-forties arrives at an emergency department with pressure in the upper abdomen, shortness of breath and a sense that something is wrong. She waits two hours, receives a gastrointestinal diagnosis and goes home. Three days later, the hospital documents a heart attack that has already occurred. Such cases are not the rule. They are more common, however, when the patient is a woman, and the research has a name for them. This page sets out what the evidence shows, where the gap comes from, and which specific sentences you can use in an acute situation.

The short answer, before you read on

In brief
Statistically, women with acute heart attack symptoms are more often first assigned a non-cardiac diagnosis in the emergency department than men with comparable complaints. In the VIRGO study of patients under 55, 53.4 percent of the women who had previously sought medical care reported that the treating clinician had not initially considered their symptoms cardiac. Among the men, the figure was 36.7 percent [Lichtman JH et al., Circulation 2018]. The AHA statement on acute myocardial infarction care in women has named this gap explicitly since 2016 [Mehta LS et al., Circulation 2016]. In the VIRGO reperfusion analysis, women under 55 exceeded the recommended reperfusion time windows more often than men of the same age (41 percent versus 29 percent) [D'Onofrio G et al., Circulation 2015]. The 2023 ESC guideline on acute coronary syndromes defines the reperfusion windows independently of sex (primary PCI within 120 minutes of first medical contact in STEMI, a Class I recommendation) [Byrne RA et al., EHJ 2023]. If you or your partner go to an emergency department: name the specific symptom, explicitly ask for an ECG and troponin, and if you suspect a heart attack, dial 144 (the Swiss ambulance number).

What "missed" means in the data

A missed heart attack can mean two different things. First, the true failure: a patient leaves the emergency department with a wrong diagnosis and the infarction is found hours or days later. Second, the delay: the diagnosis is made, but later than in a comparable male case, with measurable consequences for the reperfusion window.

Both phenomena have been quantified. A multicentre US study of 10,689 patients with cardiac symptoms found that around 2.1 percent of infarction cases were initially not admitted from the emergency department. In the subgroup analysis, women under 55 were markedly more likely to be wrongly discharged than the reference group (odds ratio 6.7, 95 percent confidence interval 1.4 to 32.5) [Pope JH et al., NEJM 2000]. The confidence intervals are wide (a small subgroup), yet the point estimate is clinically meaningful and has been cited for two decades. In 2021, the Lancet Women and Cardiovascular Disease Commission placed this disparity in a global action plan and describes it as the product of patient, physician and system factors combined [Vogel B et al., Lancet 2021].

Three mechanisms that contribute to the delay

The delay rarely arises at a single point. Three mechanisms act together.

  1. Symptom presentation beyond the textbook. Chest pain remains the most common single symptom in women too. Yet around 42 percent of female infarction patients present without this classic chest pain [Mehta LS et al., Circulation 2016]. Atypical leading symptoms such as shortness of breath, nausea, upper abdominal pressure or unusual exhaustion fall outside a triage grid historically calibrated to a male-dominated symptom catalogue.
  2. Attribution of the complaints before triage. In the VIRGO study, women under 55 reported more often than men of the same age that they had initially attributed their symptoms to stress, muscle tension or a gastrointestinal cause. The initial medical assessment in the emergency department also more often proceeded without cardiac suspicion [Lichtman JH et al., Circulation 2018]. This early attribution shapes the next steps.
  3. A feeling that "something is wrong" as a finding to be taken seriously. Sudden-onset anxiety or a "sense of impending doom" is among the clinically described symptoms of acute infarction and is listed in the AHA statement on acute symptoms in women [Mehta LS et al., Circulation 2016]. It is no psychological side effect. It is a clinical clue that does not replace the ECG yet should raise the index of suspicion.

Door-to-ECG, door-to-balloon. What the clock shows.

The second part of the evidence concerns speed once the patient arrives. The VIRGO analysis by D'Onofrio and colleagues examined 1,465 STEMI cases in patients under 55 at 103 US hospitals. Women more often went untreated (9 percent versus 4 percent of men), and they exceeded the recommended in-hospital reperfusion time windows for percutaneous coronary intervention more often than men of the same age (41 percent versus 29 percent, odds ratio 1.65, 95 percent confidence interval 1.27 to 2.16) [D'Onofrio G et al., Circulation 2015]. In transferred patients the effect was even more pronounced.

The 2023 ESC guideline on acute coronary syndromes sets the reperfusion targets independently of sex: primary PCI within 120 minutes of first contact with the medical system in STEMI is a Class I recommendation. It applies equally to every patient, female or male [Byrne RA et al., EHJ 2023]. The gap does not arise in the guideline. It arises in its application.

Among young patients with myocardial infarction, women were significantly more likely than men to report that providers had not initially thought their symptoms were heart-related.

Lichtman JH et al., Circulation 2018, VIRGO sub-study

What you can actually say in the emergency department

In an acute situation, prepared, matter-of-fact language helps. There is nothing pushy about it; it is the language of an informed patient. Three sentences that put the triage conversation in the right order.

  • Name the suspicion as well as the symptom. "I have had pressure in my chest or upper abdomen, shortness of breath and cold sweats for 40 minutes. I am asking for an ECG and a troponin test because I would like a cardiac cause checked." This wording moves the diagnostics from the gut feeling of triage into structured acute cardiology.
  • Raise the time window directly. "If a heart attack is involved, the time window counts. Could you please tell me when the ECG will be taken and when the first troponin will be drawn." This makes the door-to-ECG time an explicit variable instead of leaving it to routine.
  • Have a second person with you. A companion listens in, notes the times and can ask questions if the patient herself cannot in the acute moment. For Marco, or any partner: this is the most important contribution a companion can make.

What you cannot do yourself, the clinic does. ECG and high-sensitivity troponin are the two tests that confirm or rule out an acute infarction at first contact. If the first troponin is unremarkable, a second follows after one hour (or three hours, depending on the algorithm). The 2023 ESC guideline sets out these algorithms [Byrne RA et al., EHJ 2023]. An emergency department that works in this order rarely misses a heart attack.

What is changing in Switzerland

The Swiss Heart Foundation (Schweizerische Herzstiftung) addresses the topic in a dedicated dossier ("Bei Frauen ist der Herzinfarkt anders", heart attacks are different in women). It names shortness of breath, nausea, back pain and unusual exhaustion as symptoms that can occur on their own in women, and urges people to consider a heart attack when in doubt, even without classic chest pain [Schweizerische Herzstiftung 2023]. This awareness has reached broad public health communication.

In acute care, the change is under way. The 2021 Lancet Commission names three measurable levers: a standardised ECG request for every female patient with thoracic or atypical symptoms, women-specific training for emergency teams, and sex-stratified door-to-balloon times as a quality indicator [Vogel B et al., Lancet 2021]. What you can do as a patient is half the distance. The other half is system work.

When a cardiac check-up makes sense (outside the emergency)

Perhaps you are reading this outside an acute moment, because an earlier episode still lingers or because of a family history. A planned cardiological assessment then brings clarity. Three situations in which we readily recommend it.

  1. An unexplained episode in recent months. You remember a phase of persistent chest or upper abdominal pressure, shortness of breath or unusual exhaustion lasting several hours, with no cardiac work-up at the time. An old ECG, a comparison ECG, a troponin test (even after the event), an echocardiogram and a targeted history usually give a clear picture.
  2. A family history of early heart attacks. A father under 55 or a mother under 65 with myocardial infarction among first-degree relatives is an independent risk factor that standard preventive care often misses. In our consultation, we supplement the classic risk analysis with Lp(a), screening for familial hypercholesterolaemia and, where appropriate, a calcium score.
  3. Peri- or menopause with new complaints. As oestrogen declines, blood pressure, lipid profile and vascular reactivity often change within a few years. An assessment in this phase lets the changes be placed in context before they become entrenched.

If none of these clearly applies but you still feel uncertain: the first consultation in the women's heart clinic (Frauenherz-Sprechstunde) serves exactly this purpose. First contact without a referral, appointment usually within a week.

Where to read on in this cluster

  • Heart attack symptoms in women. What the textbooks miss. The six most common female leading symptoms, with frequency figures from the AHA and the Swiss Heart Foundation.
  • Chest pain in women. When to see a doctor. The non-acute differential diagnosis. When reflux, muscle tension or an anxiety disorder is more likely, and when a cardiac work-up follows.
  • Microvascular angina (INOCA). When the catheter and exercise test are unremarkable and the symptoms persist regardless.
  • Cluster hub: the women's heart. The overview in which this article sits.

Frequently asked questions

Are women really misdiagnosed more often than men?
For acute heart attack symptoms, yes, with emphasis on the younger age group. In the VIRGO study of patients under 55, 53.4 percent of women reported that their clinician had not initially considered the symptoms cardiac, compared with 36.7 percent of men [Lichtman JH et al., Circulation 2018]. An older multicentre US study quantified the risk of wrongful discharge in women under 55 at an odds ratio of 6.7 (95 percent confidence interval 1.4 to 32.5) compared with the reference group [Pope JH et al., NEJM 2000]. Across all age groups the gap is smaller; in the younger cohort it is measurably wide.
What does "door-to-ECG" mean, and why does this number matter?
Door-to-ECG is the time between arrival in the emergency department and the first 12-lead ECG. International acute cardiology standards call for an ECG within 10 minutes of arrival. It is the quickest test that makes an ST-elevation infarction immediately visible. A longer door-to-ECG time also delays the door-to-balloon time, the start of reperfusion. In the VIRGO analysis, women under 55 exceeded the recommended reperfusion time windows more often than men of the same age [D'Onofrio G et al., Circulation 2015].
My GP says it is "just stress". Should I accept that?
Stress can trigger cardiac symptoms. But "stress" is a diagnosis of exclusion, sound only once infarction and a cardiac cause have been actively ruled out (history, ECG, troponin, and where appropriate echocardiography and an exercise test). If your symptoms persist or return, a cardiological work-up is appropriate.
What do I say when I or my partner go to an emergency department?
Three building blocks. First, the symptom in concrete terms: "I have had pressure in my chest or upper abdomen, shortness of breath and cold sweats for X minutes." Second, the suspicion: "I am asking for an ECG and troponin." Third, the time window: "Could you please tell me when the ECG will be taken." These sentences are clinically sound, and medical staff usually respond with the correct sequence.
When do I dial 144 instead of driving myself?
With persistent chest or upper abdominal pressure lasting more than ten minutes, new shortness of breath at rest, syncope, or sudden dizziness with cold sweats. 144 is the right number because an emergency physician team can record an ECG en route and alert acute cardiology in advance. Driving yourself delays both steps.
Am I too young for a heart attack in my early forties?
No. The VIRGO study was set up precisely to examine patients under 55 systematically [Lichtman JH et al., Circulation 2018]. A family history, elevated Lp(a), hypertension in pregnancy, a history of pre-eclampsia and early onset of menopause are independent risk factors frequently not captured systematically in this age group.
What if, looking back, I suspect I had a heart attack?
That happens too, especially with silent infarctions or an atypical presentation. An earlier episode of persistent pressure, shortness of breath or unusual exhaustion should be assessed by a cardiologist in the coming days. A comparison ECG, troponin, echocardiography and a targeted history usually give a clear picture.

Women's heart clinic at Dein Team

First contact without a referral. Appointment usually within a week. In case of acute symptoms, dial 144.

Book an appointment in the women's heart clinic

Author: Dr. med. (I) Roberta Leone, Specialist in training, Cardiology FMH, USZ + Dein Team Herzzentrum. Medically reviewed by: PD Dr. med. Caroline Kleinecke, Habilitation, FMH Cardiology, on 4 May 2026. Last updated: 4 May 2026.