Cardiovascular Disease in Women

What is cardiovascular disease (CVD) in women?

Cardiovascular disease (CVD) affects people assigned female at birth (AFAB) in unique ways. Sex-specific differences like anatomy, red blood cell count and hormones seem to impact a person’s risk factors, symptoms and other aspects of their cardiovascular health.

CVD is the leading cause of death in the U.S. and around the world. In 2019, CVD caused 1 in 3 global deaths. That’s almost 18 million people who died from CVD that year alone. CVD includes coronary artery disease (which most people simply call “heart disease”) and other issues affecting your heart or blood vessels.

Many people don’t know that heart disease is the leading cause of death for people AFAB. Yet, research shows it’s a silent killer. One study showed that only 50% of people AFAB under age 55 who had a heart attack thought they were at risk prior to the heart attack (even though they had many risk factors). That’s why learning your risk and taking action to reduce it is vital.

This article uses “people AFAB” and “people AMAB” to describe sex-specific differences. Using the term “women” excludes transgender men, non-binary people and others who don’t identify as women yet face risks due to the anatomy they were born with.

How is the cardiovascular system different in women vs. men?

Researchers have found many sex-specific differences in the cardiovascular system. These complex differences, often at a microscopic level, can affect how people AFAB experience heart disease compared to people assigned male at birth (AMAB). A few examples include:

• Anatomy. People AFAB have smaller blood vessels and heart chambers. The walls of their ventricles (pumping chambers) are also thinner.
• Blood count. People AFAB have fewer red blood cells. As a result, they can’t take in or carry as much oxygen at any given time.
• Cardiovascular adaptations. Changes in altitude or body position (like quickly standing up after lying down) are more likely to affect people AFAB. These changes can lead to sudden drops in blood pressure.
• Hormones. Estrogen and progesterone levels are typically higher in people AFAB, while testosterone is higher in people AMAB. These hormones can impact many aspects of your heart health and overall health.

How does a woman know she has heart disease?

People AFAB usually develop symptoms of cardiovascular disease about 10 years later than people AMAB. Many causes and symptoms are the same regardless of your sex assigned at birth. But there are some important sex-based differences you should know about, specifically in relation to heart attacks and heart failure.

Symptoms of a heart attack in women

Chest pain or discomfort is the most common symptom for everyone. But people AFAB are more likely to have some other type of symptom, in addition to chest pain (or instead of it). Also, they’re at a higher risk of having a silent heart attack. This is a heart attack that goes unrecognized as being a heart attack. People AFAB over age 65 are more likely to die from a silent heart attack than people AMAB over age 65.

People AFAB have reported many different kinds of symptoms during a heart attack. They may feel pain or discomfort in their:

• Chest (most common).
• Left breast.
• Back or between their shoulder blades.
• Neck or throat.
• Jaw or teeth.
• Arms (one or both).
• Shoulders.
• Legs (one or both).

People AFAB may also have other symptoms like:

• Unusual fatigue (most common).
• Shortness of breath.
• Feeling dizzy or faint.
• Feeling hot or flushed.
• Indigestion.
• Fast heart rate.
• Numbness in their hands or fingers.
• Nausea or vomiting.
• Loss of appetite.
• New vision problems.
• Headache.
• Coughing.
• Choking sensation.

If you experience any of these symptoms without another known cause — and especially if you have more than one symptom — call 911 or your local emergency number right away. A heart attack damages your heart muscle. Each minute that passes causes more damage. So, don’t wait to make the call.

Early warning signs of a heart attack in women

Many people AFAB have early warning signs before a heart attack. These are called prodromal symptoms, and they can happen hours, weeks or even many months before a heart attack. The most common early warning sign of a heart attack is unusual fatigue. If you feel fatigue that isn’t normal for you, or you can’t identify any other reasonable cause for it, call 911.

In addition to fatigue, other early warning signs of a heart attack include:

• Feeling anxious.
• Frequent indigestion.
• Fast heart rate.
• Change in thinking or remembering (feeling “off” or foggy).
• Loss of appetite.
• Trouble breathing at night.
• Trouble sleeping.
• Tingling in your hands or arms.
• Numbness or burning in your hands or fingers.
• Cough.
• More frequent or more intense headaches.
• Pain or discomfort in your chest.
• Discomfort in your jaw or teeth.
• Weakness or heaviness in your arms.

These prodromal symptoms happen off and on, and they may go away on their own. Many people wait to call for help until the symptoms persist or someone notices something is wrong. But don’t delay. Get help as soon as you notice any unusual symptoms.

Heart failure in women

Heart failure is a chronic condition in which your heart can’t pump blood as efficiently as it should. This condition causes fluid buildup in your body (sometimes leading to symptoms like swelling and weight gain) and usually gets worse over time. Heart failure affects people AFAB and AMAB at similar rates. But causes, symptoms and other aspects of a person’s experience may differ based on their sex assigned at birth. Here’s what researchers know:

• Diastolic heart failure (heart failure with preserved ejection fraction) is more common among people AFAB.
• Causes of heart failure in people AFAB include high blood pressure (hypertension), heart valve disease, diabetes and coronary artery disease. Hypertension and valve disease cause heart failure more often in people AFAB versus people AMAB. Coronary artery disease is the most common cause among people AMAB.
• Stress cardiomyopathy (broken heart syndrome) as a cause of heart failure is more common among people AFAB.
• People AFAB face a higher risk of developing symptomatic heart failure following a heart attack.
• Compared to people AMAB, people AFAB with heart failure are more likely to report lower quality of life and depressive symptoms.

Symptoms of heart failure in women

Signs and symptoms of heart failure are generally the same for everyone. But research shows people AFAB have a higher chance of experiencing:

• Shortness of breath with physical activity.
• Trouble exercising.
• Swelling (edema).

People AFAB usually develop symptoms at an older age and more commonly develop left bundle branch block (an irregular heart rhythm that can result from heart failure).

What are the risk factors for heart disease in women?

Traditional risk factors for heart disease, like high cholesterol and high blood pressure (BP), affect everyone no matter their sex assigned at birth. However, research has found that these risk factors have some sex-based differences. Plus, there are some risk factors and diagnoses unique to people AFAB.

High cholesterol: High cholesterol (hyperlipidemia) is a risk factor for heart disease that applies to everyone. A low level of HDL cholesterol (“good” cholesterol) may be more dangerous for people AFAB than for those AMAB age 65 and older.

Diabetes mellitus: People AFAB with diabetes are two to four times more likely to develop cardiovascular disease compared to people AMAB with diabetes.

High blood pressure (hypertension): People AFAB over age 60 are more likely than people AMAB to have hypertension but less likely to have it managed. That’s partly due to differences in:

• Responses to treatment. People AFAB are more likely to have adverse drug reactions. Such reactions can make it harder to find and stay with a suitable treatment plan.
• Sodium sensitivity. After menopause, your body is more sensitive to sodium. This means you need to restrict sodium in your diet even more than before to prevent your BP from going up.

Menopause: Estrogen helps reduce your risk of cardiovascular disease. But natural menopause or surgical removal of your ovaries causes your estrogen levels to drop. So, you face a higher risk of blood clots, atherosclerosis and high cholesterol.

Obesity: You have a higher risk of obesity (a body mass index, or BMI, greater than 30) when you go through menopause. You’re also more likely to gain abdominal (belly) fat, which research links to a higher risk for heart disease. In the U.S., 2 in 3 people AFAB have obesity. Obesity is more dangerous for people AFAB than people AMAB (64% vs. 46% increased risk of coronary artery disease). Obesity nearly triples the risk for a heart attack among people AFAB.

Lack of exercise: Exercise seems to help reduce heart disease risk among people AFAB more than among people AMAB. However, 1 in 4 people AFAB in the U.S. don’t exercise at all, and only 1 in 4 exercises enough to get the benefits.

Smoking: People AFAB who smoke are more likely to develop cardiovascular disease than people AMAB who smoke. They’re also three times more likely to have a heart attack.

Autoimmune diseases: People AFAB make up about 80% of people diagnosed with autoimmune diseases (such as rheumatoid arthritis and lupus) in the U.S. That number rises each year. Autoimmune diseases greatly increase a person’s risk for heart attack, heart failure and other cardiovascular problems.

Preeclampsia and pregnancy-associated hypertension: Preeclampsia greatly raises your risk of developing hypertension and/or diabetes later in life. It also raises your risk of a stroke. A preeclampsia diagnosis makes a person 75% more likely to die of cardiovascular disease down the road.

Gestational diabetes: A gestational diabetes diagnosis raises your overall lifetime risk of developing diabetes. Gestational diabetes also raises your risk of cardiovascular disease throughout life.

Peripartum (postpartum or pregnancy-associated) cardiomyopathy: Peripartum cardiomyopathy is a weakening of your heart that can lead to heart failure. This condition can cause serious complications and death.

Polycystic ovary syndrome (PCOS): PCOS raises your cardiovascular disease risk. People with PCOS often develop individual risk factors such as diabetes, high blood pressure, high cholesterol and sleep apnea. Estimates show that up to 5 million people of reproductive age in the U.S. have PCOS.

Oral contraceptive therapy (“the pill”): Use of “the pill” may raise your risk for cardiovascular disease if you have other risk factors such as obesity or smoking.

How are testing and treatment for heart disease different for women?

Tests and treatments have some sex-based differences. For example:

• Sometimes rather than having a large piece of plaque (obstructive coronary artery disease), an artery contains a smooth layer of plaque. This happens more often in people AFAB. A coronary angiogram can’t always catch this type of plaque. So, if you have symptoms and get tested, the results may come back fine. In this case, you need more tests to identify the cause of your symptoms.
• People AFAB are more likely to have ACE inhibitor intolerance.
• Statins reduce cholesterol levels for everyone, but people AFAB may be more likely to develop side effects. However, true side effects due to statins remain very rare, including in people AFAB.

It’s important to talk with your provider about your risks, symptoms, test results and responses to medication. Sex-based differences are sometimes less important than individual differences due to our unique medical histories and social environments.

How can women prevent heart disease?

In general, the most important thing you can do is learn your risk factors so you can work on changing them. The more risk factors you have, the more likely you are to develop heart disease.

You can compare risk factors for heart disease to the risk of getting a flat tire. If you run over one nail, you might get a flat tire after driving for a while. But you can probably make it to the repair shop before the tire is flat. If you drive over three or four nails, you won’t make it to the shop and will need to call for help.

Similarly, if you have one risk factor for heart disease, you might be OK for a while. But the more you have, the higher your odds of running into serious problems sooner rather than later.

To prevent a flat tire, you can drive around sharp objects when you see them. When it comes to heart disease, research shows that 4 out of 5 heart disease cases are preventable. That’s why it’s important to know what puts you at risk and work with your healthcare provider to dodge as many dangers as possible.

Here are some specific things you can do:

• Visit your provider for yearly physical exams.
• Work with your provider to manage your blood pressure, cholesterol and blood sugar. This may involve taking medications.
• Make an exercise plan that works for you. Slowly work up to 150 minutes per week of moderate-intensity exercise (like walking).
• Avoid tobacco products and limit alcohol.
• Follow a heart-healthy eating plan.

When it comes to heart-healthy eating, remember these simple steps:

• Plan. Write down your dietary goals and get advice from a healthcare provider or dietitian. Write down all the foods you want to eat more often and those you want to reduce or eliminate.
• Pick. Choose recipes you like and map out your meals for the week. Make a list to take to the store and stick to that list. If you prefer takeout, make your own personal menu of heart-healthy options and only choose from those.
• Portion. Even healthier foods can become unhealthy in large quantities. Keep an eye on your portions.
• Enjoy! Eating a heart-healthy diet can and should be enjoyable. If the recipes you’re using aren’t tasty to you, find new ones. Ask friends for recommendations. And remember that finding a healthy balance is more effective than strict rules or restrictions in the long run. Talk to your provider about ways to enjoy any favorite foods that may not be on the “heart-healthy” list in moderation.

A note from Cleveland Clinic

If you have risk factors for heart disease or a history of heart problems, you’re not alone. More than 18 million adults in the U.S. live with coronary artery disease. And every 40 seconds, someone has a heart attack. These numbers can be startling, but this knowledge also gives you the power to make changes. Research shows that 4 out of 5 heart disease cases can be prevented.

It’s not just up to you, though. Each person lives as part of neighborhoods and communities that influence what they eat, how they exercise and their stress level. Individual choices are never the full story. But choices can make a huge difference, especially when supported with the right resources. Talk with your healthcare provider about what you can do to help your heart health.