6 Ways Heart Disease Is Different for Women, Cardiology Experts Say
Heart disease is the leading cause of death for men and women—but it often doesn't manifest the same in both. Here's what experts know about heart disease in women, and possible ways to reduce your risk.
Heart disease is the number one killer of both men and women in the United States, according to the American Heart Association (AHA.) Beyond this shared statistic, some differences begin to emerge.
“Women are not little men,” says Jennifer H. Mieres, MD, FACC, MASNC, FAHA, and volunteer medical expert for the AHA’s Go Red for Women initiative. First off, Dr. Mieres says, women tend to have smaller hearts than men, with finer veins, thinner chamber walls, and a faster heart rate. Other gender-based factors are significant to heart disease risk as well—”And we’re really just beginning to scratch the surface in understanding why,” she says.
Dr. Mieres calls out the fact that women have historically been underrepresented in research, so the information doctors have to diagnose and treat heart disease in women is largely based on studies conducted on men. Even today, she says that less than 40 percent of cardiovascular clinical trial participants are women. So, while research continues—and much more is needed—here’s what we do know about how heart disease in women is different.
Brush up on your heart disease knowledge: Read Cardiologists Just Cleared Up 7 Common—but Inaccurate—Beliefs about Heart Disease
A woman’s heart disease risk spikes with age
Everyone’s risk for developing heart disease increases with age. But on average, the onset of heart problems tends to happen a little later in life for women compared to men, says Kathryn Lindley, MD, FACC, chair of the American College of Cardiology (ACC) Cardiovascular Disease in Women Committee and director of Washington University Center for Women’s Heart Disease.
This is because the female sex hormone, estrogen, helps protect the heart and cardiovascular system, according to research published in the Journal of Cardiovascular Development and Disease. So, as estrogen levels decline during a woman’s menopausal years, her risk factors for heart disease rise. (Read more here about what health risks women face after menopause.)
Certain types of heart disease are more common in women
Heart disease can develop and progress differently in men and women, too. “Heart failure in men is more likely to be the result of a heart attack and the weakening of the heart muscle,” Dr. Mieres says.
On the other hand, women are more likely to experience heart failure from conditions like high blood pressure or heart muscle stiffening. Dr. Lindley adds that females are also at greater risk for coronary artery dissection, which the American Heart Association describes as a rare but severe type of heart attack resulting from a spontaneous tear in your heart’s main blood vessel.
Other heart problems are more common in men but can pose a greater danger to women. As an example, Dr. Mieres points to atrial fibrillation (AFib,) a condition that causes the heart to beat in an irregular, often rapid rhythm. While it’s more common in men—occurring twice as often, according to a study published in BMJ—women tend to have more symptoms and a higher likelihood of an adverse outcome, such as stroke.
Women have some different heart disease risk factors than men
Many major heart disease risk factors apply to both men and women, Dr. Mieres explains, like high blood pressure, high cholesterol, obesity, diabetes, smoking, and family history. Still, women are more vulnerable to several of these shared threats:
- Cigarette smoking creates a bigger heart disease risk for women, according to research in Nature Reviews Cardiology.
- Women with diabetes are twice as likely to develop heart disease than men with the condition, according to the American Heart Association.
- High blood pressure is more dangerous for women, according to research published in Therapeutic Advances in Chronic Disease.
Women face risk factors independent of men, as well. Dr. Lindley says that many pregnancy complications are associated with a greater risk of heart disease later in life, including high blood pressure in pregnancy (like preeclampsia, gestational hypertension, eclampsia, and HELLP syndrome), gestational diabetes, and preterm birth.
And research in the American Heart Association’s Cardiovascular Quality and Outcomes adds another to the list: A 2016 study found that women with endometriosis are three times more likely to develop coronary heart disease.
Certain types of hormonal contraceptives, like the low-dose birth control pill, can amplify a woman’s risk factors for heart disease, too, according to a study published in the International Journal of Reproductive Biomedicine. “Autoimmune or inflammatory conditions such as lupus, rheumatoid arthritis, and scleroderma are also associated with an increased risk of heart disease,” Dr. Lindley says. “These conditions are much more common in women.”
It can be trickier to diagnose heart disease in women
Thanks to physiological differences, heart attack symptoms are often very different for women. This inconsistency contributes to misdiagnosis rates that are way higher for women than men. According to the British Heart Foundation, women with heart disease are misdiagnosed up to 50 percent more frequently than men. (Read 8 heart attack warning bells women might miss.)
But it’s not just about misreading symptoms. The diagnostic tests used to detect heart disease rely on data from clinical studies. Because women are underrepresented in heart disease research, this gap carries over into the doctor’s office. For example, cardiac catheterization is a test that’s one of the gold standards for detecting a heart attack—but it fails to diagnose women correctly about half of the time, according to Yale School of Medicine.
Treatment approaches may vary for women
Many of the treatments for routine coronary artery disease, heart failure, and stroke are similar in women and men, Dr. Lindley explains. But she says that the context of a woman’s heart disease can dictate the right treatment protocol, including considerations like:
- Do we need to think about medication safety during pregnancy?
- Do we need to be thinking about a safe birth control method to help her plan pregnancies in light of her heart disease?
- Are her menopausal hormone changes contributing to her symptoms?
That said, heart disease treatment for women still lags behind men. A study published in the Journal of the American College of Cardiology found that even when diagnosis rates are equal, women are about half as likely as men to receive recommended heart attack treatments.
Heart disease prevention for women
“The good news is the majority of heart disease can be prevented,” Dr. Mieres says. Over the past decade, progress in understanding heart disease in women has led to a 30-percent decrease in deaths.
The best way to keep this death rate in decline is to focus on risk factors within our control, like eating healthy, staying physically active, and quitting smoking. And the earlier these lifestyle choices take root, the better. “Heart disease starts silently in our 20’s with the silent buildup of plaque in the arteries, which supply the heart with blood and nutrients,” Dr. Mieres explains.
But as a woman goes through different stages of life, she may have other considerations when it comes to heart disease prevention, too. Pregnancy complications, early menopause, polycystic ovary syndrome (PCOS), or autoimmune conditions can all raise a the female heart disease risk—and so in these cases, it’s worth having your doctor reassess your risk level and even consider an earlier start to preventative therapies, Dr. Lindley says.
It’s important to pay closer attention to a cardiovascular risk factors once menopause begins, too. She says a woman’s cardiologist and gynecologist can and should collaborate to adjust her lifestyle and medication therapies to reduce the risk of heart problems from developing—and determine if treatments like hormone replacement therapy (HRT) would be beneficial.
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- Jennifer H Mieres, MD, FACC, MASNC, FAHA, volunteer medical expert for Go Red for Women and Sr. Vice President, Center for Equity of Care Northwell Health & Professor of Cardiology Zucker School of Medicine at Hofstra Northwell
- Kathryn Lindley, MD, FACC, chair of the ACC Cardiovascular Disease in Women Committee, Associate Professor of Medicine; Associate Professor of Obstetrics and Gynecology; Director, Washington University Center for Women's Heart Disease at Washington University in St. Louis.
- Journal of Cardiovascular Development and Disease: "Cardiovascular Risks Associated with Gender and Aging."
- BMJ: "Men develop atrial fibrillation 10 years earlier than women, finds study."
- Nature Reviews Cardiology: "Cigarette smoking increases the risk of coronary heart disease in women more than in men."
- Therapeutic Advances in Chronic Disease: "Hypertension in women: latest findings and clinical implications."
- Cardiovascular Quality and Outcomes: "Endometriosis and Risk of Coronary Heart Disease."
- International Journal of Reproductive Biomedicine: "Effects of low-dose contraceptive pills on the risk factors of cardiovascular diseases among 15-35-year-old women: A retrospective cohort."
- Journal of the American College of Cardiology: "Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome."
- American Heart Association: "2021 Heart Disease and Stroke Statistics Update Fact Sheet."
- American Heart Association: "Coronary Artery Dissection: Not Just a Heart Attack."
- American Heart Association: "Why are women with diabetes at greater risk for poor heart health?"
- British Heart Foundation: "Women are 50% more likely than men to be given incorrect diagnosis following a heart attack."
- Yale School of Medicine: "Improving the Diagnosis of Heart Disease in Women."