When it comes to heart disease, men and women are not created equal. In whatever way you look at heart disease – the way it is best diagnosed, the symptoms, the risk factors that contribute to its progression, as well as treatments or their application – clear differences emerge based on whether you are born a woman or a man.

While efforts are underway to better understand these sex-specific differences in heart disease, today’s research is just a start.

So, if you are a woman or care for one, listen up. Arming yourself with knowledge about your risk is important. Coronary heart disease is not just a “man’s disease,” and its effect on women tends to be riddled with misunderstandings. While deaths related to coronary artery disease – known as CAD for short – are declining overall, rates are increasing in young women.

To put it into context, more women have died from heart disease than all cancers combined. All told, heart disease claims the lives of 1 out of 3 women in the UK each year.

What is Coronary artery disease

Coronary artery disease is the most common type of heart disease. It develops when your coronary arteries, which act like fuel lines to supply blood and oxygen to the heart, become damaged or diseased. This often results when plaque or atherosclerosis builds up in the walls of the arteries.

When your coronary arteries become narrowed or blocked, it limits blood flow to the heart. In some cases, the plaque can rupture, and blood flow is abruptly reduced and completely blocked. CAD can lead to:

• Chest pain (angina)
• Heart attack
• Heart failure
• Heart rhythm problems

CAD in Women

In women more often than men, these things can occur even without evidence of any obstructive coronary artery disease. This may be because the small vessels of the arteries are not responding normally. This makes the diagnosis and treatment in women challenging.

Women are just as likely as men to develop CAD. Diabetes is the strongest risk factor in women. In fact, studies suggest diabetes more than triples the chance of CAD in women, compared with doubling the chance for men.

In women, CAD usually develops seven to 10 years later in life compared with men. Menopause seems to trigger a host of risk factors including:

• Weight gain, especially carrying excess fat around your waist or midsection
• Higher blood pressure
• Unfavorable changes in cholesterol levels (rise in LDL and triglycerides, fall in HDL)

Heart Attack in Women

When women experience symptoms of a heart attack, women tend to:

• Experience many other symptoms in addition to chest pain or chest pressure
• Have no overt signs of blockages in the three major coronary arteries on tests, although blood flow to the heart muscle is reduced
• Have diffuse blockages or vascular dysfunction in smaller arteries (men are more likely to have plaque buildup in the large arteries around the heart)
• Be treated less aggressively with guideline-recommended therapies than men
• Be less likely to dial 911 when they experience symptoms of a heart attack

Most women – 9 out of 10 – have at least one risk factor for heart disease or stroke. The good news is 80% of heart disease and strokes can be prevented through lifestyle change.

Cardiologists say one of the most important things you can do for your heart health is to understand your personal risk of developing heart disease. That means you should know:

• What makes it more likely you will have heart disease
• What you can do to lower your chance of developing heart disease

Traditional risk factors

For women, it’s especially important to talk with your health care provider about traditional risk factors linked to heart disease, as well as those that are specific to being a female.

The better-known indicators for heart disease include:

• Smoking
• Having high blood pressure, high cholesterol, or diabetes
• Not exercising routinely or sitting for long periods of time
• Eating a diet high in processed foods, salt, saturated fats, cholesterol and added sugars
• Being overweight or obese
• Family history of early heart disease
• Older age

Race, such as being Black or South Asian, also is linked with a higher risk.

Diabetes, mental stress/depression, obesity and smoking tend to play a bigger role in the development of CAD in women compared with men.

Female-specific concerns

Also, be certain to discuss risk factors that are unique to women. These conditions are known to up the likelihood of heart disease. For example:

• Menopause – Heart disease can happen at any age, but it tends to increase in women around or after menopause.
• Having started menstruating before 10 or after 17 years of age.
• Health problems during pregnancy
  • Hypertensive disorders of pregnancy – including gestational high blood pressure, preeclampsia, eclampsia, or chronic high blood pressure – or any elevation in blood pressure increases the chance of heart disease in women.
  • Gestational diabetes during any pregnancy.
  • Preterm delivery (delivering before 37 weeks of pregnancy).
  • Having a small-for-gestational age baby (in the lowest 10^th percentile)
• Polycystic ovarian syndrome (many ovarian cysts).

Oral birth control, if you smoke, is also a concern.

Less common conditions

Women are also more likely to have the less common conditions linked to coronary artery disease. These include:

• Heart disease that affects the smaller arteries supplying the heart (microvascular): These are typically due to dysfunction of the arteries and not complete blockages. Standard tests aren’t designed to diagnose microvascular endothelial dysfunction.
• Spontaneous coronary artery dissection (SCAD).
• Autoimmune diseases, such as lupus (SLE) or rheumatoid arthritis (RA).
• Broken heart syndrome, also called Takotsubo Syndrome or stress cardiomyopathy. Despite the name, it can occur with overwhelming good or bad emotional excitement.
• Breast cancer: Although not exclusive to women, it certainly occurs more often in women. The chemotherapy and radiation for breast cancer can damage the heart, both acutely and in the future. Knowing your risk for heart disease and controlling risk factors is important after breast cancer. It is now more likely you will die from heart disease than breast cancer because the treatment for breast cancer has been so successful. Having a history of breast cancer should be considered as a risk factor for heart disease.

Heart disease symptoms can look and feel very different in men and women.

Although many women will have the classic crushing central chest pain, which is often thought of as the hallmark sign of a heart attack, women often experience three or more additional symptoms when they have a heart attack. Tragically, heart attack or sudden cardiac death can be the first symptom of coronary artery disease in women, especially younger women.

This underscores the importance of always knowing your risk factors for heart disease – you won’t know if you don’t get checked. High blood pressure, for example, is often called a “silent killer” because it has no symptoms. In other words, the only way to know if your blood pressure is high – or becoming too high – is to check your blood pressure readings over time. Uncontrolled high blood pressure is a leading cause of heart attack and stroke.

What a Heart Attack Feels Like

Chest pain or discomfort is the most common symptom of a heart attack for both men and women. But women are more likely than men to have additional symptoms as well, such as nausea and shortness of breath.

Chest Pain Can Feel Like	Other Symptoms Include
Chest pressure, tightness, squeezing or burning Discomfort in your chest, shoulders, arms, back, neck, or jaw Pain that travels down one or both arms Shortness of breath	Unusual or extreme tiredness Feeling dizzy or lightheaded Nausea or vomiting Cold sweat Anxiety

There are many ways CAD can be diagnosed. Visit the Exams and Tests section of our Coronary Artery Disease resource.

The choices you make every day can play a large role in determining your risk for coronary artery disease and how quickly it might progress. Positive lifestyle changes are very important and can help to prevent CAD and delay its progression.

Listen to your body

Every 90 seconds in the United States a woman suffers a heart attack, according to the Centers of Disease Control and Prevention. Keep in mind that that sudden, crushing chest pain, or pressure or tightness aren’t the only signs of a heart attack.

If you have a worrisome feeling something is wrong, play it safe and call 911 right away. Let the health experts decide if you are having a heart attack or on the verge of a heart attack. Treatment is most effective if it’s given within one hour of a heart attack starting.

There are several treatment options for coronary artery disease, including lifestyle changes, medications, surgery and/or medical procedures.

Lifestyle changes are the mainstay of therapy. Commit to putting your health first:

• Make healthy food choices to eat more whole plant-based and less processed foods.
• Lose weight if needed.
• Quit smoking or don’t start.
• Reduce stress.
• Get enough sleep.
• Limit alcohol intake to one drink a day or less.
• Know your blood pressure, cholesterol levels and find out if you have elevated blood sugar or are at risk for diabetes.

Women often are the ones juggling tasks and taking care of everyone else first. By making these heart-healthy choices every day, you can help protect your heart and help those around you live healthier, too.

In addition to lifestyle changes, you may need:

• Medication. People who have or are at high risk for coronary artery disease are often advised to take one or more medications. Medicine can help the heart work better, lower blood pressure and cholesterol, manage symptoms including chest pain (angina) and/or prevent blood clots.
• Coronary angioplasty and stenting (also called percutaneous coronary intervention). This procedure opens the narrowed or blocked blood vessels that supply blood to the heart. A stent is a small, metal mesh tube that is expanded inside a coronary artery to keep it propped open. Angioplasty is a balloon procedure to open blocked arteries. Your doctor will decide which procedure is right for you based on your test results.
• Heart surgery or coronary artery bypass grafting (CABG). Surgeons will open the chest to place artery or vein grafts that reroute blood flow around the blocked or damaged arteries that supply the heart.  This will restore blood flow to the heart muscle.
• Cardiac rehabilitation. Cardiac Rehab is a 12-week program that includes a mix of supervised exercise in addition to nutrition counseling, stress management, help to quit smoking, and education about the disease process, including how you can better take control of your health and improve outcomes. Studies show that people who complete cardiac rehab have fewer returns to the hospital and better quality of life.  Unfortunately, more women opt out of Cardiac Rehab or do not complete the full program.

Historically, treatments have been based on clinical studies that included mostly men. In fact, less than 25% of participants in heart-related studies have been women. The good news is that as research continues to evolve and include more women of all races and ethnicities, researchers are beginning to find diagnostic approaches and therapies that are better matched to women with coronary artery disease.

Make sure you are getting the best possible treatment. If you have coronary artery disease or have a high likelihood for developing it, take the time to talk with your doctor about whether you are getting the guideline-recommended therapies. Women are less likely to get them. This includes aspirin and referrals to cardiologists, as well as cardiac rehab.

Women are natural caretakers – whether it’s as a mother, sister, daughter and/or partner. Often, women are so busy caring for everyone else that their own health and well-being slips to the bottom of the list. Sound familiar? If so, for your loved ones and your heart, commit to making you and your health a priority.

Take time to understand how likely you are to develop heart disease and what you can do to prevent it. This way, you’ll be taking steps to be here and healthy for the people who mean the most to you.

Talk with your health care team beyond the traditional cardiovascular risk factors. For example, if you developed diabetes or preeclampsia during any pregnancy, if you have an autoimmune disease or poor sleep patterns. You should take stock of your risk of heart disease at every age, and especially around the time of menopause.

Here are some other questions you can ask to learn more about CAD and what you can do.

• What is my risk for heart disease? (Your provider can use a formula to assess your chance of developing heart disease.)
• What are my blood pressure and cholesterol numbers? Have they changed over time? What do they mean for my heart health?
• Do I need to lose weight?
• Am I at risk for diabetes?
• What tests are best for detecting blockages in women? To what extent are my arteries blocked or narrowed?
• What treatments would you recommend for me?
• Will I need a procedure or surgery to address my coronary artery blockages?
• How often should I have an assessment of my risk of CAD or related issues?
• How will we know if my condition is getting worse or progressing?
• How much exercise should I get each week to protect my heart?
• What is a heart-healthy eating plan for me?
• What symptoms should I pay attention to and report?
• How can I tell if I’m having a heart attack or chest pain (angina)?
• What are the best medications for reducing my risk of heart disease?
• Are there any supplements I should be taking to reduce my risk of heart disease?
• Should I take an aspirin to lower my risk for heart disease or stroke?
• Was I given the recommended medications that prevent another heart attack after my first heart attack?
• Will I need to take all the medicine I was given after my heart attack for the rest of my life?

If you’re a woman diagnosed with coronary artery disease, there are several key questions that you should ask your cardiologist during your next visit. These questions will ensure that you and your doctor have discussed your major risk factors so that you can become or stay as healthy as possible.

• How common is coronary artery disease in women?
• What are the risk factors for coronary artery disease in women?
• How can I distinguish cardiac chest pain from chest pain of a different source?
• When should I seek medical attention if I think I have chest pain?
• How can women be screened for coronary artery disease?
• Are there support groups and resources specifically for women?
• How do I find a cardiologist who specializes in women’s cardiovascular health?
• What can I do to stop or reverse coronary artery disease?