Heart disease kills more women than all cancers combined. But many women believe they are most likely to die of cancer, or breast cancer alone, according to surveys.
That’s not too surprising. Women’s heart health has long been overlooked and understudied.
As a result, doctors sometimes struggle to diagnose heart problems that are more common in women. Researchers aren’t clear on what causes some conditions, making them harder to prevent. And many patients don’t know that heart attack symptoms can present differently in women, or what to look out for.
But despite the challenges, there’s a lot that women can do to reduce their risk.
Some of the advice is universal: Men and women can benefit from eating healthily, exercising and staying on top of their blood pressure, cholesterol and glucose.
But other information is sex-specific. Here’s what women should know about their hearts.
Women have different risk factors.
Hypertension, high cholesterol, diabetes, smoking, inactivity and family history of heart disease increase risk for both men and women.
But women have to consider a longer list.
Those who have pregnancy complications such as pre-eclampsia or gestational diabetes are likelier to have heart problems later. But patients “don’t necessarily think to tell their doctor that they had a pregnancy 20 years ago that was affected by pre-eclampsia, and a lot of doctors won’t ask,” said Dr. Anais Hausvater, a co-director of the Cardio-Obstetrics Program at NYU Langone Health.
Polycystic ovary syndrome, or PCOS, is also associated with higher risk of heart disease. So are lupus and rheumatoid arthritis, autoimmune diseases that are much more common in women.
And women who go through menopause before age 45 are especially vulnerable.
Menopause is a critical transition for the heart.
Largely because estrogen helps protect the heart and blood vessels, women tend to develop heart disease about 10 years later than men. Menopause is the key transition: As estrogen falls, blood pressure and cholesterol tend to increase, and arteries tend to become less elastic, a surprise to many women.
“They’re like: ‘My cholesterol wasn’t that bad in my 30s. Why is it all of a sudden so bad? I’m still exercising. I’m eating the same things,’” said Dr. Tala Al-Talib, the medical director of Johns Hopkins’s Green Spring Station cardiovascular clinic.
Your doctor can help you find the best strategy for your situation, whether it’s lifestyle changes, medication or a combination of the two.
While premenopausal women’s risk is lower, it’s not zero. And the impact of high blood pressure and cholesterol is cumulative over decades, so what you do in your 20s and 30s can affect you later.
Women’s heart attack symptoms can differ.
Doctors and patients alike frequently dismiss women’s heart attack symptoms because they don’t always present as crushing pain and pressure.
Chest pain is still the most common symptom. But many women describe it differently, as “a pressure or a heaviness, as opposed to men, who will sometimes just say ‘it hurts,’” said Dr. Natalie Bello, an associate professor of cardiology at Cedars-Sinai and director of women’s cardiovascular health and cardiology at Atria Health and Research Institute.
And women are likelier than men to have multiple symptoms, such as shortness of breath, nausea, dizziness, jaw pain, upper back pain, cold sweat or unusual fatigue.
Women may be more inclined to minimize their symptoms: Those managing family obligations often “put their own health on the back burner or find other reasons to explain symptoms,” said Dr. Erica Spatz, the director of the Preventive Cardiovascular Health Program at the Yale School of Medicine. “Some women also have had the experience of coming in for symptoms and being dismissed, and so are reluctant to come in again.”
Women’s heart attacks can have different causes.
Heart attacks in men are typically caused by a blockage in a major artery as a result of obstructive coronary artery disease. Plaque breaks off or a blood clot forms, stopping blood from reaching the heart, which leads to damage to the heart muscle.
Many women experience such blockages, too. But women also have heart attacks unrelated to that disease more frequently than men do, and they can be tricky to diagnose and require different treatment.
For example, women are likelier than men to have coronary microvascular disease, which affects small blood vessels, and they are also prone to coronary artery spasms, in which an artery periodically squeezes, said Dr. Nupoor Narula, the director of the Women’s Heart Program at Weill Cornell Medicine. Both conditions can cause heart attacks.
Women are also disproportionately susceptible to spontaneous coronary artery dissection, a tear in an artery’s wall that is especially common after childbirth. It can lead to a heart attack, and its symptoms are similar. And takotsubo cardiomyopathy, or broken-heart syndrome, is a reversible form of heart failure in response to severe stress that happens mostly in postmenopausal women.
Women may need different tests.
Emergency room doctors sometimes wrongly conclude that a woman’s symptoms are unrelated to the heart because atypical heart attacks don’t always show up on standard tests. For example, an ordinary angiogram, in which a provider injects dye into blood vessels and takes X-rays, may not show artery spasms or a blocked minor blood vessel.
If you go to the E.R. with heart-attack-like symptoms and your angiogram is normal, it’s a good idea to see a cardiologist afterward. The doctor may recommend assessments such as a PET scan, a heart M.R.I. or coronary function testing, Dr. Narula and Dr. Spatz said.
Even one episode of such symptoms is reason to follow up, said Dr. Nisha Parikh, the system director of the Women’s Heart Program at Northwell Health. Many patients with clear angiograms may have had a heart attack without a major artery obstruction, she said, but aren’t diagnosed because the testing technology is only recently becoming more widely available.
There are significant research gaps.
The history of gender bias in medical research still profoundly affects health care, even though women’s health research has increased in recent decades.
Women have historically been underrepresented in studies of drugs, treatments and medical devices, Dr. Narula said. Doctors don’t fully understand the effects of hormones on cardiovascular health or the long-term impacts of certain pregnancy complications.
Standard treatment guidelines for heart disease are based largely on decades-old studies in which few participants were women, said Dr. Sonia Tolani, a co-director of the Columbia Women’s Heart Center.
Even medical devices are designed for men. Many women receive stents optimized for the size of men’s arteries, which can increase complications, said Leslee Shaw, the director of the Blavatnik Family Women’s Health Research Institute at Mount Sinai.
Doctors’ attitudes can delay treatment.
Many women who could benefit from medications for high blood pressure and cholesterol start taking them later than they should. Sometimes, the reason is that their own doctors worry about prescribing medications to women of reproductive age.
“I see this all the time,” Dr. Hausvater said.
Some of these medications are unsafe during pregnancy, but that doesn’t mean no woman of reproductive age should take them. Even for women who want children, it can be safe — with a doctor’s guidance — to stop a medication temporarily during pregnancy, Dr. Spatz said.
Women also sometimes avoid discussing heart health because they fear doctors’ judgment of their weight or lifestyle.
“I turn that back on us as the medical system,” Dr. Bello said. “We need to be more accommodating of our patients and explaining how we can help them, and not blaming people.”
Maggie Astor covers the intersection of health and politics for The Times.
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