Cardiovascular Disease in Women

What is cardiovascular disease (CVD) in women?

Cardiovascular disease (CVD) affects women 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 females. Yet, research shows it’s a silent killer. One study showed that only 50% of females 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.

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 females experience heart disease compared to males. A few examples include:

• Anatomy. Females have smaller blood vessels and heart chambers. The walls of their ventricles (pumping chambers) are also thinner.
• Blood count. Females 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 females. These changes can lead to sudden drops in blood pressure.
• Hormones. Estrogen and progesterone levels are typically higher in females, while testosterone is higher in males. These hormones can impact many aspects of your heart health and overall health.

How does a woman know she has heart disease?

Females usually develop symptoms of cardiovascular disease about 10 years later than males. Many causes and symptoms are the same regardless of your sex. 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 females 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. Females over age 65 are more likely to die from a silent heart attack than males over age 65.

Women 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)

Women 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 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
• 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 both sexes at similar rates. But causes, symptoms and other aspects of a person’s experience may differ based on their sex. Here’s what researchers know:

• Diastolic heart failure (heart failure with preserved ejection fraction) is more common among females.
• Causes of heart failure in females include high blood pressure (hypertension), heart valve disease, diabetes and coronary artery disease. Hypertension and valve disease cause heart failure more often in females. Coronary artery disease is the most common cause among males.
• Stress cardiomyopathy (broken heart syndrome) as a cause of heart failure is more common among women.
• Females face a higher risk of developing symptomatic heart failure following a heart attack.
• Compared to males, females 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 females have a higher chance of experiencing:

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

Females 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. But research has found that these risk factors have some sex-based differences. Plus, there are some risk factors and diagnoses unique to females.

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 females than for males aged 65 and older.

Diabetes mellitus: Women with diabetes are two to four times more likely to develop cardiovascular disease than men with diabetes.

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

• Responses to treatment: Women 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 somen have obesity. Obesity is more dangerous for females than males (64% vs. 46% increased risk of coronary artery disease). Obesity nearly triples the risk for a heart attack among females.

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

Smoking: Women who smoke are more likely to develop cardiovascular disease than men who smoke. They’re also three times more likely to have a heart attack.

Autoimmune diseases: Women make up about 80% of people diagnosed with autoimmune diseases (like 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 like 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 like 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 females. 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.
• Females are more likely to have ACE inhibitor intolerance.
• Statins reduce cholesterol levels for everyone, but females may be more likely to develop side effects. However, true side effects due to statins remain very rare, including in females.

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.