Cardiovascular Disease in Women
What is cardiovascular disease (CVD) in women?
Cardiovascular disease affects women and people assigned female at birth (AFAB) in unique ways. Differences between the sexes like anatomy, the number of red blood cells and hormones seem to impact the experience of cardiovascular disease in men and people assigned male at birth (AMAB) and women and people AFAB.
Cardiovascular disease (CVD) is the leading cause of death in the U.S. and around the world. In 2019, cardiovascular disease caused 1 in 3 deaths around the world. That’s almost 18 million people who died from CVD that year alone. In the U.S., about 1 in 4 deaths are caused by heart disease — around 659,000 each year.
Why it’s important to talk about cardiovascular disease in women
Many women don’t know that heart disease is seven times deadlier than breast cancer. In 2018, heart disease killed 300,977 women and people AFAB. By comparison, all forms of cancer combined killed 283,721 women, with 42,455 of those caused by breast cancer. To this day, cardiovascular disease is the leading cause of death among women in the U.S.
Every disease matters and deserves attention, awareness and action. But if you don’t realize heart disease is such a huge risk, you won’t know you need to learn more about it. And you might not begin to take steps to reduce your risk.
One study showed that only half of women under age 55 who had a heart attack thought they were at risk prior to the heart attack. Yet, those same women had many risk factors. They just didn’t know.
How is the cardiovascular system different in women vs. men?
Researchers have found many sex-related differences in the cardiovascular system. These complex differences, often at a microscopic level, can affect how women and men experience heart disease. A few examples include:
- Anatomy. Women have smaller blood vessels and heart chambers. The walls of their ventricles are also thinner.
- Blood count. Women have fewer red blood cells. As a result, women 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) affect women more than men. Women are more likely to have sudden drops in blood pressure or faint.
- Hormones. Estrogen and progesterone dominate in women and people AFAB, while testosterone dominates in men and people AMAB. These hormones can impact many aspects of heart health and overall health.
How does a woman know she has heart disease?
Women usually notice symptoms of cardiovascular disease about 10 years later than men do. For a heart attack, chest pain or discomfort is the most common symptom for everyone. But there are some important differences that affect women and people AFAB.
Women and people AFAB are more likely to have some other type of heart attack symptom, in addition to generalized 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 shows no obvious symptoms. Women over age 65 are more likely to die from a silent heart attack than men over age 65.
Symptoms of cardiovascular disease in women
Chest pain (angina) is the most common symptom for women and men. Chest pain can feel like:
- General discomfort.
Women are more likely to have additional, atypical symptoms that include:
- Unusual fatigue.
- Extreme weakness.
- Shortness of breath (dyspnea).
- Heart palpitations.
- Faster heartbeat.
- Sudden sweating or sweating with no cause (cold, clammy feeling).
Call your healthcare provider right away if you notice these symptoms or if they become worse.
Symptoms of a heart attack in women
Women have reported many different kinds of symptoms during a heart attack. They include:
- Unusual fatigue (most common).
- Shortness of breath.
- Feeling dizzy or faint.
- Feeling hot or flushed.
- Heart racing.
- Numbness in hands or fingers.
- Nausea or vomiting.
- Loss of appetite.
- New vision problems.
- Choking sensation.
Discomfort or pain symptoms
- Centered high in chest (most common).
- Left breast.
- Back or between shoulder blades.
- Neck or throat.
- Jaw or teeth.
- One or both arms.
- Top of shoulders.
- One or both legs.
If you experience any of these symptoms without another known cause — and especially if you have more than one symptom — call 911 right away. A heart attack damages your heart muscle. Each minute that passes causes more damage. So, don’t wait to make the call.
Women may have symptoms other than chest pain when having a heart attack.
What are the early warning signs of a heart attack in women?
Many women 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.
- Heart racing.
- Change in thinking or remembering (feeling off or foggy).
- Loss of appetite.
- Trouble breathing at night.
- Trouble sleeping.
- Tingling in hands or arms.
- Numbness or burning in hands or fingers.
- More frequent or more intense headaches.
- Pain or discomfort in your chest.
- Discomfort in your jaw or teeth.
- Arms feeling weak or heavy.
These prodromal symptoms happen off and on, and they may go away on their own. Women often don’t call for help until the symptoms persist or someone notices something is wrong and asks if they’re OK. But it’s important to get help as soon as you notice any unusual symptoms so you have a chance of preventing a heart attack.
What are the risk factors for heart disease in women?
You may have heard of some traditional risk factors for heart disease, like high blood pressure, high cholesterol or smoking. These affect everyone. However, research has found that these risk factors have some sex-based differences that can put women at a higher risk. Plus, women and people AFAB face other risks unique to them.
If women are more likely to have certain risk factors, that means they’re more likely to have multiple risk factors at the same time. This puts women in a dangerous position because risk factors compound. In other words, the more risk factors you have, the greater your overall risk of developing heart disease.
You can compare risk factors for heart disease to the risk of getting a flat tire. If you run over one nail in your driveway, 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 completely 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 just one risk factor for heart disease, you might be OK for a long time. 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 try to 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 your risk factors and work with your healthcare provider to dodge as many as possible.
Women face a higher risk of obesity when they go through menopause. They’re also more likely to gain abdominal (belly) fat, which is linked with a higher risk for heart disease.
In the U.S., 2 out of 3 women and people assigned female at birth have obesity. Having obesity is more dangerous for women than men. It increases a woman’s risk of coronary artery disease by 64% (compared with 46% in men) and nearly triples a woman’s risk for a heart attack.
High cholesterol (hyperlipidemia)
A low level of HDL cholesterol (“good” cholesterol) is more closely linked with death for women than for men age 65 and older. It is also important to make sure you have a low level of LDL cholesterol (“bad” cholesterol).
Women with diabetes are two to four times more likely to develop cardiovascular disease compared to men with diabetes.
Women and people AFAB generally live longer than men and people AMAB, so they’re more likely to have heart problems as they age.
High blood pressure (hypertension)
Women over age 60 are more likely than men to have hypertension but less likely to have it managed. Women are twice as likely as men to die from hypertension. Hypertension is more closely linked with heart attacks in women than in men.
Lack of exercise
Exercise seems to help reduce women’s risk even more than it helps men. However, 1 in 4 women in the U.S. don’t exercise at all, and only 1 in 4 exercises enough to get the benefits.
For this risk factor, your family member’s age at diagnosis matters. You have a family history of “early heart disease” if your male parent or sibling was diagnosed before age 55, or if your female parent or sibling was diagnosed before age 65.
Women who smoke are more likely to develop cardiovascular disease than men who smoke. Women who smoke are three times more likely to have a heart attack compared with men who smoke. Yet about 1 in 5 women in the U.S. use cigarettes.
Depression and stress
Women age 60 or younger are twice as likely as men in that age group to have symptoms of depression. Women who have a heart attack are much more likely than men to have symptoms of depression at the time.
Women are more likely to experience psychosocial stress, meaning their stress comes from work, home, money problems or major life events.
Women make up about 80% of people diagnosed with autoimmune diseases (such as rheumatoid arthritis and lupus) in the U.S., and that number rises each year. Pregnancy, hormonal changes, and stress play a role in these diseases. Autoimmune diseases greatly increase a person’s risk for heart attack, heart failure, and other cardiovascular problems.
One study showed that women 35 to 44 years old who had lupus were 50 times more likely to have a heart attack than women their age without lupus. Another study showed that women with rheumatoid arthritis are two to three times more likely to die of cardiovascular disease than those without.
Sleep apnea is common in both women and men, but many people don’t realize how it affects cardiovascular disease risk. Research on women with sleep apnea has shown that without treatment, these women have a higher risk of hypertension, coronary artery disease, stroke and atrial fibrillation. Treatment for sleep apnea is highly effective at reducing this risk.
Preeclampsia and pregnancy-associated hypertension
Preeclampsia greatly raises a person’s risk of developing hypertension and/or diabetes mellitus later in life. It raises the risk of a stroke. A preeclampsia diagnosis makes a person 75% more likely to die of cardiovascular disease down the road.
This diagnosis doubles a person’s risk of developing diabetes mellitus in the four months after delivery. That risk jumps to 21 times higher if their fasting glucose is at least 121 mg/dL during pregnancy. Gestational diabetes also raises the risk of cardiovascular disease throughout life. People with gestational diabetes are 67% more likely than those without it to develop cardiovascular disease later on.
Peripartum (postpartum or pregnancy-associated) cardiomyopathy
Peripartum cardiomyopathy is a weakening of the heart that can lead to heart failure. It is a global problem that is rare but happening more often as people gain more risk factors like obesity, hypertension and diabetes. Peripartum cardiomyopathy can cause serious complications and death.
Having pre-existing heart disease when pregnant
People who have heart disease before getting pregnant face higher risks of pregnancy complications as well as problems later in life. One study showed these women are 20 times more likely than women without heart disease to have an adverse cardiovascular event within 20 years of pregnancy. They also have a higher risk of developing hypertension or diabetes mellitus in the years after pregnancy.
Polycystic ovary syndrome (PCOS)
PCOS raises a person’s 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 a person’s risk for cardiovascular disease if they have other risk factors such as obesity or smoking.
Estrogen helps reduce a person’s risk of cardiovascular disease. But menopause and surgical menopause cause estrogen levels to drop. As a result, a person faces a higher risk of blood clots, plaque in the arteries, and high cholesterol.
How are testing and treatment for heart disease different for women?
Tests and treatments can have different results for women and people AFAB vs. men and people AMAB. Below are a few examples:
- Sometimes rather than having a big chunk of plaque (obstructive coronary artery disease), an artery contains a smooth layer of plaque. This happens more often in women than men. A coronary angiogram can’t always catch this type of plaque. So even if women have symptoms and get tested, the results may come back fine. In this case, more tests are needed to identify the cause of the symptoms.
- Women are more likely than men to be intolerant of ACE inhibitors.
- Statins reduce cholesterol levels in both women and men. But women may be more likely to develop side effects.
It’s important to talk with your provider about your own 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?
Women have the power to take action and reduce their heart disease risk. Many risk factors are preventable or manageable with treatment. The top seven risk factors women (and everyone) can target for change include:
- High blood pressure.
- High cholesterol.
- High blood sugar.
- Lack of exercise.
- Unhealthy diet.
- Having overweight or obesity.
Ideally, prevention starts in early childhood when habits begin to form. But adults in their 20s and 30s can make a huge difference in their health by paying attention to their heart health and working to reduce their risk. And it’s important to remember that change doesn’t happen overnight. When it comes to eating a heart-healthy diet, remember these simple steps:
- Plan. Write down your dietary goals and get advice from your healthcare provider or dietitian. Write down all the foods you want to eat more and those you want to eat less or eliminate.
- Pick. Choose recipes you like and map out your meals for the week. Make a list to take to the store to avoid impulse buying. If you prefer takeout, make your own personal menu of healthy options and only choose from those.
- Portion. Even healthier foods can become unhealthy in large quantities. Keep an eye on your portions and keep some leftovers for tomorrow’s lunch.
- 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 to treat yourself on weekends and holidays.
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 us the power to make changes. Research shows that 4 out of 5 heart disease cases can be prevented.
It’s not just up to the individual, though. We live as part of neighborhoods and communities that influence what we eat, how we exercise, and our anxiety and stress levels. Individual choices are never the full story. But they can make a huge difference, especially when supported with the right resources. Talk with your healthcare provider today about how you can make changes to reduce your risk one step at a time.
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