Cardiovascular diseases, especially heart disease, are common in the United States and around the world. Heart disease was traditionally viewed as a male problem; however, it is also the leading cause of death in women.1-3 Women often display different symptoms, receive less aggressive treatment, experience worse complications and outcomes, and are under-studied or not included in research trials investigating heart disease.2-5 Women are also less likely to receive preventive treatments, and when medications are given, they are less likely to achieve the desired results.5 Understanding these differences can help women advocate for their own needs and determine their best path for optimizing heart health.
Understanding Heart Health in Women
For women in their early adult to mid-life period, heart disease is not a commonly talked about topic nor are screenings regularly conducted.1 Most of the heart issues that occur in younger women are related to smoking.2 However, after menopause the story changes. Markers of heart health decline, risk factors increase, and even the composition of plaque in arteries changes to be more inflammatory and vulnerable.1-3 This ultimately results in a spike in the number of heart issues for women, eventually catching up to the rate seen in men.1-3
This distinct switch that occurs at menopause led researchers to investigate the role estrogen may play in protecting the heart, or at least delaying the development of heart disease.1 Estrogen, a hormone that controls the female reproductive system, regulates several metabolic factors that influence heart health, including lipids, inflammatory molecules, and compounds involved in blood coagulation.2 It also directly promotes vasodilatory effects in blood vessels.2 Additional studies have confirmed that young women with an estrogen deficiency have a more than sevenfold increase in risk of heart disease.6 While estrogen appears to be protective, it cannot fully prevent heart disease.2
Most heart issues develop seven to 10 years later in women than in men, eventually becoming the leading cause of death for women over 65.2 More than 60 million women (44 percent) in the U.S. have some form of heart disease, and it is responsible for one in every five female deaths. Heart disease also looks different in women, including:1,2,4,7
- more diffuse, or spread out, heart disease compared to the obstructive kind found in men
- plaque formation in blood vessels that is more stable and undergoes erosion rather than a rupture
- experiencing a heart attack as a result of emotional distress rather than physical exercise
While more recent studies are beginning to detail these important differences, much of what is known about heart health stems from studies that did not include women. This means many healthcare practitioners as well as patients do not know their own risk, best treatment options, and ways to support their heart health.
Unique Risk Factors for Women
While men and women share many of the classic risk factors for heart disease – smoking, hypertension, dyslipidemia, diabetes – others are more relevant to women and may be more harmful.2,4,5 For younger women, smoking is much more harmful as compared to men, and this risk is even greater for younger women who smoke and take oral contraceptive pills.2-4 Together, this results in a ten-fold increase in their risk of having a heart attack.8 Presence of type 2 diabetes is also more risky for women.1
Complications during pregnancy, including gestational diabetes (high blood glucose) and preeclampsia (high blood pressure) increase the risk of heart disease later in life.2-4 Other hormonal factors that contribute to heart disease risk including early menarche, early menopause, earlier age at first birth, pre-term delivery (before 32 weeks’ gestation), and history of miscarriage, stillbirth, or hysterectomy.4,5 Polycystic ovarian syndrome (PCOS) may also be an independent risk factor for heart disease.9 Unfortunately, these female-specific independent risk factors are not always included in cardiovascular assessments.4
Many of the classic risk factors for cardiovascular disease, including unhealthy body weight, blood pressure, and blood lipids, change significantly for women after menopause.2 Body composition changes to include more fat in the abdomen (central obesity), which often coincides with development of type 2 diabetes and blood pressure, can rise steeply in aging women, and blood lipids are worse upon menopause.2 Together, this creates a heightened risk for women that, just several years prior, had a much different risk profile.
Beyond hormonal and reproductive factors, genetics contribute to some of the differences in risk for heart disease. Women possess two X chromosomes and gene expression on these can affect the cardiovascular system.5 They are also modified by female hormones, which further contributes to differences between men and women.5 There are also sex differences in epigenetic regulation of genes, specifically DNA methylation patterns which affect genes involved in cardiometabolic health.7 Unfortunately, methods used in many genetic studies have trouble deciphering the genetic code when two X chromosomes are involved, further exacerbating the gap between what is known about heart health in men and women.7
The presence of certain autoimmune diseases, including rheumatoid arthritis and lupus, are more common in women and may also increase the risk of death from a heart issue later in life.4 The underlying cellular mechanisms that contribute to autoimmune diseases including inflammation, endothelial dysfunction, and oxidative stress, may also contribute to poor heart health.4 The treatments for rheumatoid arthritis and lupus have also been linked to increased heart disease risk.4
Symptoms of Heart Disease in Women
The most common symptom of a heart attack for both men and women tends to be pain or pressure in their chest with pain radiating to the neck, shoulders, and back.3 Other common symptoms for women include sudden onset of weakness, shortness of breath, fatigue, and feeling unwell.3 Women tend to not go to the hospital in response to chest pain which can also make diagnosing heart issues more challenging.3 For women who do experience chest pain, it may be harder to identify the cause as women are much more likely to experience non-heart disease chest pain, including spontaneous tears in the coronary artery wall (spontaneous coronary artery dissection) and stress-induced cardiomyopathy.4,5
Many of the non-invasive diagnostic tests for heart health are less reliable in women, especially for those under 55 years of age.2 Many of these tests struggle to work reliably in women because of inherent differences, including lower exercise tolerance and smaller blood vessel size.2,3 Until researchers are able to close the gap on what is known about symptoms in men versus women, it is important that women seek care for any suspected heart issue and that health care providers adopt a treatment plan that is specific to a woman’s symptoms, even the less common ones.
Preventing Heart Disease in Women
Most advice for reducing the risk of heart disease remains the same between men and women.3 Women can decrease their risk of cardiovascular disease in general by more than 80 percent by adhering to certain lifestyle factors: not smoking, maintaining a healthy body weight, consuming a healthy diet, participating in moderate to vigorous exercise for 30 minutes a day, and consuming a moderate amount of alcohol (or none).5
Because smoking is so much more harmful in women than men, smoking cessation or abstaining altogether is critical for women.4 Depression and stress also contribute to the development of heart disease in women to a greater extent than men, and as such, prevention efforts in women should focus on stress management techniques as well.4 Attending regular medical check-ups and screenings is also critical for women. This provides more opportunities to catch an issue before it becomes even bigger.
Consuming a heart-healthy diet can lead to significant benefits for the heart and entire body. Heart-healthy diets tend to be higher in fruits and vegetables, whole grains, and legumes, and lower in trans fats, sodium, refined carbohydrates, sugar-sweetened beverages, and red meat.10 It also includes moderate consumption of nuts, lean meats, low fat dairy and oils.10 Dietary patterns that align with this recommendation including the Mediterranean diet and the DASH (Dietary Approach to Stop Hypertension) diet.10
These dietary patterns can significantly improve heart health by reducing inflammation in blood vessels, positively altering the gut microbiome, providing important antioxidants, and improving blood lipid levels.11 They can also impact gene expression and reduce blood pressure.10,11 To further improve blood pressure, avoid the “salty 6,” which are the foods with the most sodium (cold cuts/cured meats, pre-seasoned poultry, sandwiches, bread, canned soup, and pizza).10
The components of a heart-healthy diet provide many benefits to the heart and body. Complex whole grains provide important micronutrients and phytonutrients, increase satiety or fullness upon consumption which can help limit caloric intake and maintain a healthy weight, and help keep blood glucose levels stable.10 The higher fiber content also helps promote weight loss and healthy body composition.10 Consumption of many and diverse fruits and vegetables is critical to any heart-healthy diet. They provide fiber, vitamins, minerals, and phytonutrients only found in plants.10 Extra virgin olive oil, a staple of many Mediterranean style diets, is a rich source of polyunsaturated fatty acids (PUFAs), vitamins, and phytonutrients, and is a highly anti-inflammatory food.11 Polyunsaturated fatty acids protect against heart disease by reducing cholesterol and triglyceride levels.12
Engaging in regular physical activity is an important aspect of maintaining heart health. Exercise burns calories which can help with healthy body weight maintenance and body composition. Endurance exercise can also cause the heart to adapt and undergo remodeling, making it stronger and more efficient.13 Engaging in regular physical activity that works different muscles is also important in keeping muscles strong and functioning well, which in turn increases heart health. Exercise can also improve risk factors for heart disease including lowering blood pressure, improving blood glucose levels, reducing inflammation, and reducing stress hormones that can burden the heart.
Exercise is so critical to heart health that not engaging in enough activity is a major risk factor for heart disease in both men and women. Physical inactivity is higher among women than men and increases with age, which likely contributes to the increased risk of heart disease seen in older women.5 Fortunately, engaging in regular resistance and endurance exercise can decrease the risk of heart issues in women.14 Even a daily walk can help prevent cardiovascular events in women.15 Exercise can also help reduce the risk of other chronic diseases and improve overall health.5
Women face unique challenges when it comes to heart health. They tend to be under-represented in important clinical trials, experience different symptoms than men, and also have unique risks due to pregnancy and other hormonal changes in the body. Women should be proactive about maintaining and improving their heart health, especially throughout and after menopause. The protective effects of estrogen may subside, but most of the risk for heart disease comes from modifiable lifestyle factors. Heart disease is preventable and manageable with the right approach: stop smoking, consume a heart healthy diet, and be physically active.