Heart Disease in Women

Cathryn Bigham and Winnie Zhao*, National Center for Health Research

*Both co-authors contributed equally to this article

Cardiovascular disease is the #1 cause of death for both men and women in the United States. This includes heart attacks and chronic diseases such as congestive heart failure. Almost 700,000 people in the U.S. die from heart disease each year, about half of them women.[1] Heart disease can last for many years, and is often caused by a blockage of the blood supply to the heart, so that it does not get enough oxygen.[2] Inherited deformities, irregular heartbeats, and muscular or valve defects also cause heart disease.[2]

Heart disease can sometimes cause a medical emergency. The sudden loss of blood flow to the heart causes what is commonly known as a heart attack. This can be caused by a chronic condition or occur suddenly, but must be diagnosed and treated immediately.[3]

Although there is a great deal of research studies on symptoms, diagnosis, and treatment, most have focused on men. There is evidence that the causes, symptoms, and treatment for women may be quite different than for men.[4] Here is what you need to know to understand how heart disease affects women, and ways to reduce chances of developing heart disease.

What Makes Heart Disease Different in Women?

It is often said that a heart attack often causes tremendous chest pain (compared to an elephant on your chest). However, many women do not experience chest pain during a heart attack. Instead, many women report discomfort in the jaw or neck, nausea, shortness of breath, or overwhelming fatigue.[5] Women who have these symptoms usually do not realize they are having a heart attack, and so their diagnosis and treatment is delayed. That can be dangerous.

The causes of heart attacks vary by sex. About one-third of women who have a heart attack are diagnosed with MINOCA, a type of heart damage that is not caused by blocked arteries. In women, it’s often caused by gradual fatty buildup in the arteries or by tiny blood vessels that don’t open properly. These problems are more common in women than in men. [5]

Two other forms of heart attacks that are more common in women are spontaneous coronary artery dissection (SCAD) and stress cardiomyopathy. SCAD occurs when the inner lining of the artery tears. Stress cardiomyopathy, also called broken heart syndrome, can be caused by a very emotional event that causes the heart to change shape. Both of these are more common in women.[6]

Because of these differences, women are 20% more likely than men to develop heart failure or die within five years after a major heart attack. So why are women less likely to be referred to a cardiologist, prescribed statins or beta-blockers, or receive procedures that restore blood flow? [7]

Are women atypical?

Women’s symptoms and causes of heart disease are often referred to as ‘atypical.’[8] But even though their symptoms are not typical of men, they are common in women. Unfortunately, only about one-third of patients studied in cardiovascular research are women. [9]  When treatments are not evaluated separately for women and men, but instead evaluate the combined group of a relatively small number of women with a much larger number of men, the results will not accurately represent which treatments are best for women.[8, 10] That is one of the reasons why heart disease can be more harmful to women than men. Underrepresentation is an even greater problem contributing to the lack of good data for racial minorities.[11] The participation of women, including women of color, in clinical trials is likely to increase when researchers are encouraged to recruit them and there are telehealth options and other ways that make it easier for women who are responsible for caring for children or other family members to participate.[11]

Are Women’s Hearts Different from Men’s?

Some differences in heart disease for men and women may be due to the heart anatomy. For example, the arteries on the outside of the heart are smaller in women than men, even when accounting for body size and heart size.[12,13] Women also have thinner walls in their hearts and a greater amount of blood flowing through the arteries in the heart.[12] One theory is that women’s thinner arteries and greater blood flow are more likely to cause sudden tears in the arteries of women’s hearts.

Coronary artery disease is usually defined as obstruction to the arteries. In reality, it is an insufficient blood supply to the muscle of the heart.[13] When researchers and doctors think of it as artery obstruction, they do not realize the difference in anatomy between men and women and may fail to properly diagnose and treat women.[13]

Treatment Differences

The two most common emergency treatments for heart attacks try to reduce a blocked artery by improving blood flow during a heart attack. Women are less likely to have a blocked artery and so less likely to benefit from those treatments. Moreover, when women with blocked arteries undergo these treatments, they are more likely than men to suffer from bleeding complications.[8]

Some types of cardiac emergency require valve replacement surgery. A recent study found that women are more likely to suffer disabling strokes after this surgery, probably because women have smaller blood vessels than men. The bottom line is that current treatment options are more appropriate for the male body than for the female body.[14] Research also shows that cardiac imaging exams are less accurate in women.[12]

Why Heart Disease Becomes More Likely After Menopause

Women usually develop blocked arteries about a decade later than men.[15] Estrogen increases HDL, which is considered ‘good’ cholesterol, and decreases LDL, which is the ‘bad’ cholesterol.[16] Cholesterol can build up in the arteries and block blood flow. In contrast, estrogen widens blood vessels, increasing blood flow, and prevents damage. When estrogen levels drop during menopause, LDL climbs, artery walls stiffen, and the chance of a heart attack or stroke increases. [See “hormone therapy and menopause” for more information]

The Social and Environmental Pressures That Affect Women’s Hearts

A woman’s heart health is shaped not only by biology but also by daily life. Growing evidence shows that the stress from work, family responsibilities, or juggling both will injure the lining of women’s blood vessels more than men’s.[17] This damage increases the chances of a heart attack or heart failure. Pregnancy adds to physical stress. Pregnancy complications such as pre-eclampsia or gestational diabetes can double a woman’s long-term chance of heart disease or stroke if doctors do not provide follow-up care.[18] Social isolation, which surged during the pandemic, also affects heart health. In a group of nearly 58,000 U.S. women, those who were lonely as well as isolated had a 13% to 27% higher chance of developing cardiovascular disease.[19] A 2024 review found a similar 16% increase in cardiovascular disease for women who were socially isolated.[20] Everyday exposures also matter. Fine-particle air pollution from traffic or cooking fires, along with hormone-like chemicals such as BPA and PFAS in some plastics and cosmetics, can raise blood pressure and make arteries stiffer over time.[20, 21]

Recommendations – What can you do to stay healthy?

Know your pregnancy history. If you have ever had pre-eclampsia, gestational diabetes, or delivered early, tell your doctor and schedule a blood-pressure, cholesterol, and glucose check within three months of giving birth (and at least yearly after that). Early follow-up may help reduce the chances of developing heart disease.[22]

Know your numbers. The U.S. Preventive Services Task Force recommends cholesterol screening for women age 45 and older, and for younger women with certain health conditions. It also recommends diabetes screening for adults ages 35 to 70 who are overweight or obese. These problems don’t have symptoms, so catching them early gives you and your doctor the chance to adjust diet, activity, or medication before damage starts.[23,24]

Healthy daily habits make a difference. Try to get 150 minutes of moderate exercise each week, or 75 minutes of more intense activity. Even light movement, like standing up or stretching, can help reduce the effects of sitting for long periods.[25] Eating more fruits, vegetables, whole grains, and less salt and added sugar also helps.[26] Women who stay active and eat a heart-healthy diet are more likely to live longer and less likely to die from a heart attack or stroke.[27]

Quit smoking and limit alcohol. Smoking harms your heart and stopping smoking lowers the chance of heart problems within a few years, even for people who have smoked for a long time.[28] Drinking alcohol can also affect heart health by raising blood pressure. To stay healthy, try to limit it to no more than one drink per day, or skip alcohol entirely if your blood pressure is already going up.[29]

Get enough sleep and manage stress. Try to sleep 7 to 9 hours each night. Develop simple habits that help you relax, such as taking a brisk walk, doing a short meditation, or talking with a friend. People who sleep poorly or feel stressed for long periods are more likely to develop high blood pressure and heart disease.[30]

References

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