Take Heart: Women and Cardiovascular Disease

Women’s signs of heart disease and myocardial infarctions are more subtle and unpredictable, often leading to detrimental outcomes.

It may come as a surprise to learn that cardiovascular disease is not just a man’s disease, but more women die from it than men. Heart disease is the leading cause of death for women in the United States, killing nearly 300,000 women in 2017, or about 1 in every five female deaths. The average age for the first myocardial infarction for men is 65.6 years and 72 years for women.

Approximately one in sixteen women age 20 and older (6.2%) have coronary artery disease (CAD), the most common type of cardiovascular disease. 80% of women ages 40–60 have one or more risk factors for developing coronary artery disease. Women are six times as likely to die of heart disease as breast cancer. Heart disease kills more women over 65 than do all cancers.

Coronary artery disease (CAD)

CAD is a complex chronic inflammatory disease caused by a build-up of plaque in the coronary arteries that supply oxygen-rich blood to the heart. As the arteries become atherosclerotic over time, blood flow is restricted, resulting in a weakening of the heart muscle, which increases the risk for angina, myocardial infarction, heart failure, and arrhythmias. Restricted blood flow or blockage may also trigger a heart attack. If blood supply does not get restored quickly, cardiac tissue will begin to die, resulting in death. 

These are the three main types of heart disease:

  1. Obstructive: 50% or more blockage of the large arteries
  2. Non-obstructive: The large arteries may be narrowed by plaque, but not as much as in obstructive CAD.
  3. Coronary microvascular disease (CMD): Plaque can develop in the small blood vessels. CMD is more common in women.

The role of estrogen

Exposure to changing estrogen levels during menstrual cycles, pregnancy, and peri/post menopause when estrogen levels decline can alter women’s blood vessels. Estrogen affects how blood vessels constrict and expand and their response to injury. Women’s blood vessels could potentially be programmed for more changes than men’s blood vessels, increasing the risk of developing problems in the endothelium of the arteries and smooth muscles of the artery walls. Women in several studies provide evidence of the increased risk of having damage to the smooth muscles in the small arteries.

Before menopause, estrogen plays a protective role in maintaining adequate levels of “good” high-density lipoproteins (HDL) cholesterol, which protects cardiovascular health. However, the beneficial effects of estrogen decline after menopause. 

Risk factors

The common risk factors for CAD among both men and women include:

  • High blood pressure
  • High LDL (low-density lipoprotein) cholesterol
  • Smoking

Other medical conditions, environmental, and lifestyle risk factors include: 

  • Diabetes
  • Obesity or being overweight
  • Eating an unhealthy diet
  • Physical inactivity
  • Excessive alcohol consumption
  • Air pollution
  • Work—toxins, radiation, other hazards
  • Increased work stress
  • Working more than 55+hours per week
  • Working long, irregular shifts or night shifts that affect sleep
  • Sitting for long periods
  • Family history/genetic risk
  • Mental health conditions—depression, anxiety, PTSD, bipolar disorder
  • Chronic kidney disease
  • Metabolic syndrome
  • Sleep disorders—sleep apnea or deprivation
  • Autoimmune and inflammatory conditions—affecting more women than men (rheumatoid arthritis, lupus, Crohn’s, ulcerative colitis, psoriasis)
  • Childhood trauma—Adverse Childhood Experiences (ACE)

Additional risk factors for women

Complications during pregnancy, such as gestational diabetes, preterm delivery, low/high birth weight of baby, miscarriage, and preeclampsia, can increase the risk of women developing CAD. Autoimmune disorders, most often found in women (RA and lupus), heighten the risk for CAD. Endometriosis and polycystic ovarian syndrome raise the risk in younger women. Radiation to the left breast, chemotherapies, and hormonal treatments can increase the risk of heart disease. As caretakers, women often prioritize their families’ well-being over their health, ignoring the warning signs of cardiovascular disease.

Prodromal signs of CAD

The prodromal or early signs of cardiovascular disease are different for women than for men. The symptoms tend to be more subtle for women. Women more often describe their symptoms as gastrointestinal distress, anxiety, or stress. 

In a questionnaire administered to 500 female cardiac patients who had suffered a heart attack within the past 4-6 months, almost all of them recalled early symptoms within the weeks before their attack. The most recurrent symptoms were unusual fatigue and sleep disturbance. Women who are unaware that these symptoms can become life-threatening are often dismissed and do not seek medical treatment.

The prodromal signs of heart disease in women include:

  • Unusual fatigue
  • Sleep disturbance
  • Shortness of breath
  • Chest discomfort-less than one-third report this symptom
  • Indigestion
  • Anxiety

Myocardial infarction signs

Most often, women do not experience the crushing chest pain that men report. At least 10% of women do not experience chest pain during a heart attack, and this statistic can vary from 8 percent to 42 percent, depending on the study. Symptoms of myocardial infarction in women are the following:

  • Nausea and vomiting
  • Shortness of breath with or without chest discomfort
  • Pain in one or both arms, upper back, neck, jaw, throat or stomach
  • Fainting
  • Cold sweats
  • Dizziness or lightheadedness
  • Inability to sleep
  • Paleness or clammy skin
  • Unusual fatigue
  • Discomfort or pressure in the middle of the chest lasting for a few minutes or goes away and then returns.
  • Bluish color or numbness in lips, hands, or feet

Recovery after myocardial infarction

Women have poorer outcomes in mortality and quality of life after a heart attack than men. The first year after a heart attack, women have higher rates of disability and death and reduced psychological adaptation than men. According to the American Heart Association, 26% of women will die within a year of a heart attack compared with 19% of men. Five years after a heart attack, nearly half of women die, develop heart failure, or have a stroke compared with 36 percent of men.

In a study exploring how chronic angina limits activity and diminishes quality of life, the researchers discovered that men and women experienced different types of pain due to chronic angina. Both men and women described their pain as aching, heavy, exhausting, and sharp. Men reported a higher number of recent angina episodes, while women reported a more significant intensity of pain, such as hot, burning, and tender limiting their activity. 

According to cardiologist Dr. Stephanie Coulter, women are more likely to become depressed after a heart attack than men. For those who were depressed pre-heart attack will be most likely to suffer from depression post-heart attack.

Barry Jacobs, a clinical psychologist, states, “People who are depressed are at a much higher risk of having a cardiac event, which could eventually kill them.” Those diagnosed with major depression or with symptoms indicating major depression, including impairment in the ability to function, face twice the risk of having a future heart attack and are one and a half times at higher risk for premature death.

Women are predominately less likely to be referred to a cardiac rehabilitation program, enroll in a cardiac rehabilitation program once referred, and to complete a full course compared to men resulting in poorer clinical outcomes. Barriers to enrollment include:

  • Age
  • Comorbidities
  • Depression
  • Diabetes
  • Obesity
  • Transportation
  • Family obligations
  • Lack of insurance and financial concerns
  • Lack of social support from family and friends

Disparities in health care

Numerous disparities exist in health care, which accounts for the higher mortality rate of heart attacks for women compared with men. Women heart patients under 55 years are seven times more likely to be misdiagnosed by emergency department physicians than men of the same age. Women are often diagnosed with anxiety or indigestion and told to go home.

Women are under-represented in research, with two-thirds conducted on white men. A survey of women with heart disease showed that only 35% told their physicians about early warning signs, and only 8% of physicians had correctly recognized health problems as potentially heart related. Women are far less likely than men to receive medications such as beta-blockers, statins, and ACE inhibitors crucial for preventing further cardiac events. 

Spontaneous coronary artery dissection (SCAD) heart attacks begin with a tear in the wall of an otherwise healthy artery. The tear tunnels within the wall of an artery, blocks the artery and blood flow to the heart muscles, leading to a heart attack. Tests such as blood work and an echocardiogram are not accurate in diagnosing SCAD. An angiogram is the only reliable diagnostic tool for diagnosing a heart attack with SCAD.

SCAD is responsible for 40 percent of heart attacks in women under 50, and more than 90 percent of SCAD patients are female. SCAD patients are generally healthy and fit without the usual risk factors for heart disease. Many SCAD patients are sent home in the middle of a heart attack that does not get diagnosed for several days, resulting in severe heart damage and potential death.


Women’s signs of heart disease and myocardial infarctions are more subtle and unpredictable, often leading to detrimental outcomes. Women are less likely to seek medical attention when experiencing distressing symptoms. Lack of education, awareness, and disparities in treatment for women in the healthcare system result in lower quality of life and premature death. Efforts to prevent and treat heart disease through lifestyle modifications, identifying risks, and more aggressive treatment are paramount for improving women’s health.


Editor’s note: This post was originally published on May 20, 2020 and updated on February 2, 2021.

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