The Surprising Truth About Heart Disease in Women

"I thought I was just exhausted. I'd been tired for weeks. I never had chest pain, so I didn't think it was my heart."

I have heard some version of that from so many women after a heart attack. They waited. Their families waited. Sometimes their doctors waited, too, because the symptoms didn't look like the heart attack we all picture: a man clutching his chest.

Heart disease is the leading cause of death for women in the United States. Yet women are more likely to have a heart attack without chest pain, more likely to have warning signs that get brushed off, and less likely to receive the treatments that save lives. Let's change that. Here is what the research shows, with the key studies redrawn so they are easy to read.

Medical note: This article is for general education and is not a substitute for advice from your own doctor. If you think you might be having a heart attack, call 911 right away.

Key takeaways

• In a registry of more than 1.1 million heart attack patients, 42% of women arrived at the hospital without chest pain, compared with about 31% of men.
• In a study of 515 women, 95% had warning signs weeks before their heart attack. The most common was unusual fatigue (71%). Only 30% had chest discomfort.
• Diabetes raises heart disease risk 44% more in women than in men, and smoking raises it 25% more.
• Preeclampsia, gestational diabetes and menopause before 40 all raise a woman's future heart risk.
• Heart attacks are rising in younger women, and young women are less likely than young men to get stents, cholesterol medication and other proven treatments.

Different Sexes, Different Symptoms

Figure: percent of heart attack patients who came to the hospital without chest pain. Redrawn from Canto JG, et al. JAMA. 2012 (Results).

This chart comes from the National Registry of Myocardial Infarction, which tracked 1,143,513 people hospitalized with a heart attack in the US. Here's what it shows:

• The pink bar is women. 42% of them had no chest pain when they arrived, compared with 30.7% of men.
• The gap was biggest in younger women. Under age 45, women had 30% higher odds than men their age of having a heart attack without chest pain. By 75 and older, the difference had almost disappeared.
• The side note is the part that should worry you. 14.6% of the women died in the hospital, compared with 10.3% of the men. Younger women who came in without chest pain had the highest risk compared with men their age.

When a heart attack doesn't look like a heart attack, people wait longer to call for help, and the diagnosis takes longer once they arrive. Time is heart muscle.

When Does Heart Disease Strike Women? The 10-Year Gap

On average, heart disease shows up in women about 7 to 10 years later than in men. Before menopause, estrogen helps keep LDL cholesterol lower and blood vessels more flexible. After menopause, LDL rises, blood pressure climbs and the risk catches up fast.

That 10-year delay created a dangerous myth: that heart disease is an older woman's problem, or a man's disease. It isn't. Heart attacks happen in women in their 30s, 40s and 50s, and as you'll see below, those younger women often fare the worst.

In a study of more than 384,000 heart attack patients in the National Registry of Myocardial Infarction, women younger than 50 were more than twice as likely as men the same age to die in the hospital. The difference narrowed with age and disappeared after 74. Differences in medical history, the severity of the heart attack and early treatment explained only about a third of the gap.

The Symptoms: Why "Typical" Chest Pain Isn't So Typical for Women

Figure: symptoms reported by 515 women before and during their heart attack. Redrawn from McSweeney JC, et al. Circulation. 2003 (Results).

Researchers interviewed 515 women a few months after their heart attack and asked what they had felt, both in the weeks before and during the attack itself.

• The top bars are warning signs from more than a month before. 95% of the women had at least one. The most common was unusual fatigue (70.7%), followed by trouble sleeping (47.8%) and shortness of breath (42.1%).
• The grey bar is chest discomfort. Only 29.7% of women had it in the weeks before, the symptom most people think of first.
• The bottom bars are during the heart attack. Shortness of breath (57.9%) and weakness (54.8%) were the most common. 43% had no chest pain at all.

Other heart attack symptoms that are common in women:

• Pain or pressure in the jaw, neck, back, shoulders or either arm
• Nausea, vomiting or what feels like indigestion
• Breaking out in a cold sweat
• Lightheadedness
• A sudden, overwhelming sense of dread or anxiety

New fatigue that is out of proportion to what you're doing, or new shortness of breath with everyday activities, deserves a call to your doctor. Sudden symptoms deserve a call to 911.

The Hidden Danger: Different Disease Mechanisms

Most heart attacks in men come from a cholesterol plaque that ruptures in a large coronary artery and blocks it. That happens in women too, and it is still the most common cause. But women are more likely to have heart attacks from causes that a standard test can miss:

• MINOCA, a heart attack with no major blockage on the angiogram. Some women are told "your arteries are clean" and sent home, when they really did have a heart attack.
• Coronary microvascular disease, where the tiny blood vessels of the heart don't open properly. It can cause chest pain and shortness of breath with a "normal" angiogram. It's often called INOCA.
• SCAD (spontaneous coronary artery dissection), a tear in the wall of a coronary artery. It mostly affects younger women with few traditional risk factors, often around pregnancy, after childbirth, or after intense physical or emotional stress, and it is linked to a blood vessel condition called fibromuscular dysplasia.
• Takotsubo cardiomyopathy, or "broken heart syndrome," a sudden weakening of the heart after severe stress, seen most often in women after menopause.

If you've been told your arteries look fine but you keep having symptoms, ask your cardiologist whether testing for microvascular disease makes sense.

Risk Factors: Not Created Equal

Figure: top, extra coronary heart disease risk from diabetes and smoking in women compared with men; bottom, higher future risk with female-specific risk factors. Redrawn from Peters SA, et al. Diabetologia. 2014; Huxley RR, Woodward M. Lancet. 2011; Wu P, et al. Circ Cardiovasc Qual Outcomes. 2017; Kramer CK, et al. Diabetologia. 2019; Zhu D, et al. Lancet Public Health. 2019.

The same risk factors that drive heart disease in men drive it in women: high LDL cholesterol, high blood pressure, diabetes, smoking, excess weight and inactivity. But some of them hit women harder.

• Diabetes. In 64 studies with 858,507 people, diabetes nearly tripled the risk of coronary heart disease in women (2.82 times) and doubled it in men (2.16 times). After adjusting for other risk factors, that is 44% more extra risk for women.
• Smoking. In 75 groups of studies with 2.4 million people, smoking raised coronary heart disease risk 25% more in women than in men. The good news: women who quit had no extra risk compared with men who quit.

Female-Specific Risk Factors

The bottom half of that chart shows risk factors only women can have. Many standard risk calculators leave them out, so you have to bring them up.

• Preeclampsia. High blood pressure in pregnancy is a stress test for your blood vessels. In more than 6.4 million women, preeclampsia was linked to 2.5 times the risk of coronary heart disease later in life, about 4 times the risk of heart failure, and nearly twice the risk of stroke.
• Gestational diabetes. In 5.4 million women, diabetes during pregnancy doubled the risk of future heart attacks and strokes, and the risk was already 2.3 times higher in the first 10 years after giving birth. It stayed 56% higher even in women who never developed type 2 diabetes.
• Early menopause. In 301,438 women, menopause before age 40 raised cardiovascular risk by 55%, and menopause at 40 to 44 by 30%, compared with menopause at 50 or 51. The risk was highest before age 60.
• Other pregnancy problems, like preterm delivery, also signal higher risk, as do autoimmune diseases like lupus and rheumatoid arthritis, which are far more common in women.

If you had any of these, your heart risk is higher than your age and cholesterol alone suggest. Tell every doctor you see. If you're weighing hormone therapy around menopause, I cover the benefits and the heart risks in detail in my article on hormone therapy and heart disease.

The Diagnostic Challenge: Why Women Are Underdiagnosed

For decades, women who came in with fatigue, shortness of breath or a strange feeling in the chest were told it was stress, anxiety or hormones. Some still are. I wrote about the research behind this in Why Women Are Undertreated for Heart Disease.

Part of the problem is the symptoms. Part of it is the tests. A treadmill test is less accurate in women, and an angiogram can miss microvascular disease entirely. And part of it is bias: heart disease was seen as a man's disease, so doctors didn't look for it.

Troubling Trends: Progress Stalled for Women

Figure: how much less likely young women (35 to 54) were than young men to receive standard heart attack care. Redrawn from Arora S, et al. Circulation. 2019 (Results).

The ARIC study tracked heart attack hospitalizations in four US communities from 1995 to 2014. Over those 20 years, the share of heart attacks in people aged 35 to 54 rose from 27% to 32%, and the biggest increase was in young women. Heart attacks rose in young women while they fell in young men. More of these young patients also had high blood pressure and diabetes.

When those young women did have a heart attack, they were less likely than young men to get:

• a stent or bypass surgery (21% less likely)
• non-aspirin blood thinners (17% less likely)
• cholesterol-lowering medication (13% less likely)
• a coronary angiogram (7% less likely)

These are the treatments that prevent the next heart attack.

The fine print

• The symptom studies are older. The registry data run from 1994 to 2006, and the symptom survey was published in 2003, mostly in white women with an average age of 66. Women of color and younger women may describe symptoms differently.
• Symptoms were remembered after the fact. In the 515-woman study, women were asked 4 to 6 months later, which can blur memory. It also didn't compare women with men directly.
• The risk factor studies are observational. They show strong, consistent links, but they can't prove that preeclampsia or early menopause causes heart disease, rather than revealing an underlying tendency.
• Men and women share most symptoms. Chest pain or pressure is still the most common heart attack symptom in both. The difference is how often other symptoms show up, and how often chest pain doesn't.

The myth: "Women are protected from heart disease"

Estrogen delays heart disease. It doesn't prevent it. Once women catch up after menopause, heart disease is still their leading cause of death. And when a woman does have a heart attack, especially a younger woman, she is more likely to be missed and more likely to die in the hospital than a man her age.

What This Means for You: Action Steps

1. Know the symptoms. Unusual fatigue, shortness of breath, jaw or back pain, nausea, a cold sweat or a sense of doom can all be a heart attack. Call 911. Don't drive yourself.
2. Know your numbers. LDL cholesterol (and ideally apoB and a one-time Lp(a)), blood pressure, blood sugar or A1c, and waist size. If your LDL is high, treat it early and aggressively, even in your 30s and 40s.
3. Tell your doctor your pregnancy history. Preeclampsia, gestational diabetes, preterm delivery and early menopause all count.
4. Ask about a coronary calcium score if you're 40 or older and unsure where you stand.
5. Reduce saturated fat, increase fiber, and take your medications if you need them. These move the needle most.
6. Then: do cardio, lift weights, reduce stress and improve sleep. And don't smoke. Smoking hurts women's hearts even more than men's.
7. Speak up. If you're told "it's just anxiety" and something still feels wrong, ask for a heart workup, or a second opinion.

Frequently asked questions

What are the first signs of a heart attack in a woman?
In one study, the most common warning signs in the weeks before were unusual fatigue, trouble sleeping and shortness of breath. During the heart attack, shortness of breath, weakness, and pain in the chest, jaw, back or arm are common. Many women have no chest pain at all.

What is a silent heart attack?
It's a heart attack with mild or unusual symptoms that the person doesn't recognize as a heart attack, so it often isn't treated in time. It may only be found later on an EKG or an imaging test.

Can anxiety feel like a heart attack?
Yes, and a heart attack can feel like anxiety. That's exactly why you should never assume. If you have new or unexplained symptoms, get checked.

Does preeclampsia really affect my heart years later?
Yes. It was linked to 2.5 times the risk of coronary heart disease and about 4 times the risk of heart failure later in life. Make sure your doctor knows.

Do statins work as well in women?
Yes. I go through the data in Do Statins Work In Women?

The Bottom Line For Women And Heart Disease

Heart disease is the number one killer of women, and heart attacks in women often don't look like the movies. Fatigue, shortness of breath and pain in the jaw, back or arm can be your warning. Diabetes and smoking hit women harder, and pregnancy problems and early menopause raise your risk for decades. Know your numbers, tell your doctor your full history, and never let anyone talk you out of getting your heart checked.

"Is it just anxiety?" No. It's your health.

If you take one thing from this article, let it be this: you know your body. If something feels wrong, trust that feeling and get checked. Ask the question out loud: "Could this be my heart?"

Related Cardiovascular Prevention Posts

• Heart Disease in Women: Symptoms, Tests, and Prevention Guide
• Why Women Are Undertreated for Heart Disease
• Is HRT Safe for Your Heart?
• Do Statins Work In Women?
• Dr. Alo's Dietary Guidelines – Complete prevention framework
• Blood Pressure Management

Still have questions? Stop Googling and ask Dr. Alo.

You've read the science, but applying it to your own life can be confusing. That's exactly what the Heart 2 Heart VIP Community is for. You can ask me questions directly, join live video calls where we talk through your labs and situations like this one, and get physician-level guidance based on your actual numbers.

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Dr. Alo

References

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