Judy Mingram felt a burning pain in her chest, a weird sensation that seemed to flood up into her lower jaw. Her teeth felt as if they were coming loose.
Heartburn, she thought. A comeuppance from too many hasty meals, too many cups of coffee and too many cigarettes.
The pain subsided. The 40-year-old single mother went on with her work.
A couple of weeks later, at her family doctor's office for a gynecological exam, Ms. Mingram mentioned the burning pains. Heartburn, her doctor said. She got a prescription.
Two nights later, the pain was so bad that it awakened her. She stumbled down the hall to her daughter's room and pounded on the door.
Ms. Mingram didn't realize what was wrong. She felt nauseous. It hurt to breathe. She was soaked in sweat. She remembers the paramedics asking her if she had taken cocaine, and fighting to get enough air to reply no.
Shortly after she arrived in the emergency room of St. Joseph's Hospital, her heart stopped. They used electric paddles to bring her back. She had an emergency heart catherization and bypass surgery.
Ms. Mingram had suffered a major heart attack.
Her experience is not unique, said Dr. Edward B. Diethrich, author of "Women and Heart Disease," a book that refutes the belief that women don't get heart disease.
What women and their doctors don't realize is that heart disease is the leading killer of women, Dr. Diethrich said. Each year, 245,000 U.S. women die of heart disease. An additional 90,000 women die of strokes. By comparison, breast cancer will kill an estimated 46,000 women this year.
But women at risk of heart disease tend to shrug off symptoms, Dr. Diethrich said. Doctors are trained that men are more likely to have heart attacks and heart disease than women.
"It's not intentional. It's just a mind-set. I see it every day," said Dr. Diethrich, director of heart surgery at the Arizona Heart Institute.
"A doctor won't think that it's coronary disease in a woman, but if a male patient comes in with the same symptoms, a doctor thinks automatically that it's possible coronary disease."
The thinking is rooted in the fact that women usually don't have heart attacks until about 10 years later than men, a delay most doctors attribute to higher levels of the hormone estrogen in women. A woman's chances of heart trouble don't equal a man's until after menopause, when estrogen levels drop.
Recent studies suggest that women who smoke may cancel out the benefits of estrogen and face a midlife heart attack risk similar to men, said Dr. Mary Ann Malloy, a cardiologist with the Women Take Heart screening program in Chicago.
In practice, the 10-year delay means that a man with chest pains is likely to be evaluated for heart disease, while a woman with the same symptoms may be told it's heartburn brought on by stress.
That also means women are less likely to be pressed by their doctors -- or to take the initiative themselves -- to reduce heart-attack risks.
Thus, women who have heart attacks are more likely to have compound risk factors for heart disease -- combinations of smoking, cholesterol, family history, high blood pressure and diabetes, or a particularly bad combination, smoking while on birth-control pills.
Ms. Mingram now sees that she was a prime candidate; she smoked a pack-and-a-half of cigarettes a day for 20 years, she ate meat and other cholesterol-laden foods even though her cholesterol tested at above 350 -- 150 points above average. She had a strong family history, with her father and an uncle suffering major heart attacks.
"I think women tend to sit back and worry about their husbands not getting any exercise and eating too many hamburgers -- when they are doing the same things. They are just as much at risk, but not as early as their husbands," Ms. Mingram said.
As women and their doctors learn more about heart disease, preventive activities will increase, Dr. Diethrich said. He suggests that women talk to their doctors about heart health.
"If you put it on a very personal basis, you will get a physician's attention when you say it is of great concern to you," Dr. Diethrich said.
Addressing risk factors early is key because 60 percent to 80 percent of the people who will develop cardiovascular disease can be identified years in advance if their risk factors are known, says Dr. William Castelli, who spoke recently at the Second Annual Women and Heart Disease Conference in Chicago.
"Virtually all of these people feel well up until their first day of heart attack or stroke. They are not motivated to intervene on any of their risk factors . . . even when there is convincing evidence that therapy is very effective in reducing vascular disease rates," Dr. Castelli said.
Today, Ms. Mingram is a nonsmoker and a vegetarian. She gets regular exercise and has learned biofeedback, a relaxation method and therapy to reduce her reactions to stress. Coming close to death has made her set priorities.
She wants to warn other women.