Heart attack never crossed Cindy Bennett's mind.
Swamped in a cold sweat, nauseated and consumed by what she called the shakes, Bennett, 53, of Port Jefferson said she never felt worse.
For Vanessa Cuellar, 49, it was jaw pain for nearly a year. The Lake Grove woman endured numerous dental procedures, some under anesthesia. Treatment for possible temporomandibular joint pain -- excruciating discomfort associated with arthritis, jaw injury or even clenching of the teeth -- proved fruitless.
No matter what she did, Cuellar said, the pain persisted.
Neither Bennett nor Cuellar knew it, but each was in the throes of a heart attack -- female-style. Symptoms smoldered, they later learned, as their hearts weakened.
Women do not always develop the classic heart attack symptom -- excruciating chest pain, the feeling of an elephant sitting on the chest. Instead, symptoms may be vague, easily confused with other maladies.
Divide among doctors, too
Gender differences in symptoms have inspired debate among doctors. Some say there isn't a sharp divide between the sexes; others contend that not only are the differences real, but disturbing disparities persist in cardiac care as a direct offshoot.
The scientific literature is replete with examples, including medical investigations reported recently. An international study last month found that men with chest pain are treated faster in emergency rooms on two continents.
In addition, an analysis last month unmasked a disparity in preventive care. Women, that study found, were less likely to be prescribed statin drugs, such as Lipitor, Crestor and Mevacor.
"Doctors respond promptly to chest pain," said Dr. Suzanne Steinbaum, director of the women and heart disease program at Lenox Hill Hospital in Manhattan.
Women are more likely to experience so-called atypical symptoms -- those that don't fit the male model of a heart attack, she said. It's vital for women to know their symptoms because within the first year after a heart attack, women are more likely to die of the event than men, Steinbaum said.
The American Heart Association estimates that heart attacks strike someone -- man or woman -- every 34 seconds. Annually, an estimated 720,000 people nationwide have a heart attack, and about 515,000 are first heart attacks, according to the Centers for Disease Control and Prevention. About 600,000 people die annually of all forms of heart disease.
Not all doctors are convinced of differences in cardiac symptoms that cut sharply along a gender divide.
"I don't see a difference in women," said Dr. Richard Shlofmitz, director of cardiology at St. Francis Hospital in Roslyn. He said the women he treats generally report the same chest tightness as their male counterparts.
Steinbaum, citing data, pointed to a range of esoteric female heart attack symptoms.
"When we talk about symptoms in women, it's the shortness of breath, arm pain, jaw pain and back pain that stand out," Steinbaum said.
But women are also likely to have nausea, indigestion and severe palpitations, she said. A harbinger for many is sleeplessness that may begin a month before the attack.
"I am not saying that women do not get chest pain," Steinbaum said. "But overall, women have a much subtler presentation than the stereotypical 'elephant sitting on my chest.' To me, that's really Hollywood's depiction of a heart attack."
Dr. Michael Poon, director of advanced cardiac imaging at Stony Brook University Hospital, said sex hormones influence the heart. "With men, testosterone tends to make [a heart attack] worse, and unfortunately emergency department doctors tend to go after the severe symptoms."
"What we have to do," he said, referring to the medical community, "is heighten awareness that heart attack can manifest differently in women."
Narrow focus seen
Steinbaum thinks the focus on chest pain also permeates the public's perception. When women were polled about seeking care, more than half indicated they would not phone 911 unless they had classic chest pain, she said. "They also said they would not call 911 if they were having shortness of breath," she said.
Bennett of Port Jefferson phoned 911 while on her job as a bookkeeper in Riverhead last August. "I had no idea what was wrong," said Bennett, who was rushed to an East End hospital.
"All the EKGs came back normal," she said.
Doctors, however, detected elevated levels of the cardiac protein triponin, which rises in the blood during a heart attack. Bennett was admitted to the hospital, but when levels declined overnight, she was discharged to go home.
"They gave me a clean bill of health," Bennett said.
By September, her health declined precipitously. "I was home. I started profusely sweating. I was nauseous, but didn't throw up. My head was hurting, and my neck was killing me. I just thought I had food poisoning," Bennett said.
She called a friend who summoned an ambulance, which took her to Stony Brook University Hospital. There, doctors ordered blood tests and an electrocardiogram, which revealed a heart attack in progress.
Poon recommended a cardiac CT -- coronary-computed tomographic angiography -- to view Bennett's heart in real time. He discovered that her right coronary artery was 95 percent blocked.
He said it took only seconds to find the blockage, which doctors missed at the other hospital.
Bennett, who smoked for three decades, said that without a family history of heart disease, she didn't know she was at risk.
Another saved by CT
Poon, meanwhile, also recommended cardiac CT a few months later for Cuellar, whose left coronary artery was 70 percent blocked.
Cuellar, a psychiatric nurse, had no idea her jaw pain was a telltale sign of something amiss with her heart. "I never thought the jaw pain had anything to do with my heart. I am overweight; I have insulin-dependent diabetes," she said of two heart disease risk factors. "But my cholesterol levels are fine. I have low blood pressure."
But suddenly one day in January, her jaw pain not only worsened, a crushing pain rose in her chest and radiated through one arm. Cuellar asked her family to take her to an emergency room. Upon arrival, she was given a nitroglycerin pill, which banished her jaw pain.
Cuellar received two stents, opening the blockage.
Though she had a positive outcome, problems persist for women in cardiac care.
Medical investigators in March revealed that most women arriving in an emergency room tend to be more anxious than men and often do not display symptoms of so-called "acute coronary syndrome."
The American Heart Association defines the syndrome as an umbrella term for any cardiac condition that suddenly compromises the heart's blood supply.
Lead author Dr. Louise Pilote of McGill University in Montreal uncovered a gender divide in cardiac emergency care in Canada, the United States and Switzerland. She studied 1,100 patients, focusing on men and women in the prime of life: ages 18 to 55. Men, Pilote found, underwent electrocardiograms, on average, within 15 minutes and received clot-busting medication within 21 minutes. By comparison, it took half an hour for women to undergo an electrocardiogram and 36 minutes to receive a clot buster.
In a separate study, medical investigators in Boston found another stark gender disparity.
Examining the fate of 25,000 patients, the team compared high-risk men and women treated with statins and similar medications between 2008 and 2012. High-risk women, researchers found, were less likely to be prescribed the drugs.
Poon says it's time to end the gender divide. "A heart attack is irreversible," he said. "Once the tissue is damaged, it's gone.
"Some people are totally disabled after a heart attack. That's why women have to know their symptoms."