Heart disease has long been perceived as a “man’s disease,” yet it remains the leading cause of death in women, claiming more lives than breast cancer.1 Despite advancements in cardiovascular care, progress in reducing the incidence and mortality of coronary heart disease has stagnated, particularly among younger women under 55.2

Women experiencing myocardial infarction are less likely to receive timely and evidence-based interventions upon symptom onset. Cardiac rehabilitation is also underutilized, with women being 55% less likely to participate than men. This disparity arises from multiple factors, including lower referral rates by physicians, despite clear evidence that rehabilitation improves long-term outcomes.3

One of the key challenges in women’s heart health is that their heart attack symptoms often differ from men’s, leading to missed diagnoses and higher mortality rates. Diagnosing acute coronary syndromes in women, especially younger women, is particularly challenging, making it essential to recognize gender-specific differences in symptoms to improve patient management and outcomes.4

How Women’s Heart Disease Symptoms Differ from Men’s

The Framingham Heart Study was among the first to highlight sex-based differences in heart disease presentation. It demonstrated that women are more likely to develop angina as their initial symptom of ischemic heart disease and are less likely to present with an acute myocardial infarction compared to men.5

In cases of acute coronary syndrome, women more commonly present with unstable angina rather than ST-segment elevation myocardial infarction (STEMI). Yet, most heart attack research has historically been based on male symptoms, contributing to frequent misdiagnoses in women.

While classic symptoms of STEMI and non-STEMI, such as chest pain radiating to the arm or jaw, are common in both sexes, women more frequently report atypical symptoms, including nausea and vomiting, shortness of breath, unexplained fatigue, and dizziness or lightheadedness.6

A large-scale study involving over 10,000 patients found that older women (over 65) exhibited symptoms similar to men and had a higher frequency of typical angina, whereas younger women were significantly more likely to experience atypical presentations.7 These differences contribute to delays in diagnosis and treatment, increasing the risk of worse clinical outcomes.

Why Do Women Experience Different Symptoms?

The physiological differences between men and women contribute to distinct symptom patterns in heart disease.

Women are more likely to experience heart attacks without severe arterial blockages, a condition known as non-obstructive coronary artery disease (CAD). This occurs when blockages form in smaller blood vessels, making symptoms less localized and harder to detect through standard diagnostic tools. Instead of the crushing chest pain typically seen in men, women with non-obstructive CAD may experience breathlessness, nausea, or profound fatigue due to reduced blood flow to the heart muscle.8

Women’s blood vessels are also smaller and more susceptible to microvascular dysfunction, which can result in diffuse rather than focal damage to the heart. This often leads to subtle symptoms that are mistaken for anxiety, indigestion, or stress-related conditions.

Women-Specific Factors That Increase Heart Disease Risk9

Pregnancy complications serve as early warning signs of future heart disease. Hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, are associated with an increased risk of hypertension, heart disease, and stroke later in life. These complications cause vascular and metabolic changes that accelerate the development of atherosclerosis.10

Polycystic ovary syndrome (PCOS) also raises cardiovascular risk due to its strong association with insulin resistance, dyslipidemia, and hypertension. Women with PCOS are more likely to develop metabolic syndrome, a cluster of conditions that significantly increases the likelihood of heart attacks and strokes. Despite this, cardiovascular screening for women with PCOS remains inadequate, often focusing only on reproductive concerns rather than long-term heart health.11

Autoimmune diseases, which disproportionately affect women, are another overlooked cardiovascular risk factor. Chronic systemic inflammation in conditions like lupus and rheumatoid arthritis accelerates vascular damage and increases the likelihood of plaque buildup and blood clots. Women with lupus, for example, are at a significantly higher risk of early-onset cardiovascular disease and myocardial infarction compared to the general population.12

References:

  1. Garcia, M., Mulvagh, S. L., Merz, C. N., Buring, J. E., & Manson, J. E. (2016). Cardiovascular Disease in Women: Clinical Perspectives. Circulation research, 118(8), 1273–1293. https://doi.org/10.1161/CIRCRESAHA.116.307547

  2. Wilmot KA, O’Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the united states from 1979 through 2011: Evidence for stagnation in young adults, especially women. Circulation. 2015;132:997–1002. doi: 10.1161/CIRCULATIONAHA.115.015293.

  3. Witt BJ, Jacobsen SJ, Weston SA, Killian JM, Meverden RA, Allison TG, Reeder GS, Roger VL. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004; 44:988–996. [PubMed: 15337208]

  4. Garcia M, Mulvagh SL, Merz CN, Buring JE, Manson JE. Cardiovascular Disease in Women: Clinical Perspectives. Circ Res. 2016 Apr 15;118(8):1273-93. doi: 10.1161/CIRCRESAHA.116.307547. PMID: 27081110; PMCID: PMC4834856.

  5. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: A 26-year follow-up of the Framingham population. Am Heart J 1986;111 :383–90.

  6. Schulte KJ, Mayrovitz HN. Myocardial Infarction Signs and Symptoms: Females vs. Males. Cureus. 2023 Apr 13;15(4):e37522. doi: 10.7759/cureus.37522. PMID: 37193476; PMCID: PMC10182740.

  7. Rosengren A, Wallentin L, K Gitt A, et al. Sex, age, and clinical presentation of acute coronary syndromes. Eur Hear J 2004;25:663–70.

  8. UCI Health. (2025). How heart attacks differ in women

  9. Tay, C. T., Mousa, A., Vyas, A., Pattuwage, L., Tehrani, F. R., & Teede, H. (2024). 2023 International Evidence-Based Polycystic Ovary Syndrome Guideline Update: Insights From a Systematic Review and Meta-Analysis on Elevated Clinical Cardiovascular Disease in Polycystic Ovary Syndrome. Journal of the American Heart Association, 13(16), e033572. https://doi.org/10.1161/JAHA.123.033572

  10. Rabadia, S. V., Heimberger, S., Cameron, N. A., & Shahandeh, N. (2025). Pregnancy Complications and Long-Term Atherosclerotic Cardiovascular Disease Risk. Current atherosclerosis reports, 27(1), 27. https://doi.org/10.1007/s11883-024-01273-9

  11. Tay, C. T., Mousa, A., Vyas, A., Pattuwage, L., Tehrani, F. R., & Teede, H. (2024). 2023 International Evidence-Based Polycystic Ovary Syndrome Guideline Update: Insights From a Systematic Review and Meta-Analysis on Elevated Clinical Cardiovascular Disease in Polycystic Ovary Syndrome. Journal of the American Heart Association, 13(16), e033572. https://doi.org/10.1161/JAHA.123.033572

  12. Mehta PK, Levit RD, Wood MJ, Aggarwal N, O'Donoghue ML, Lim SS, Lindley K, Gaignard S, Quesada O, Vatsa N, Leon A, Volgman AS, Malas W, Pepine CJ; American College of Cardiology Cardiovascular Disease in Women Committee. Chronic rheumatologic disorders and cardiovascular disease risk in women. Am Heart J Plus. 2023 Feb 9;27:100267. doi: 10.1016/j.ahjo.2023.100267. PMID: 38511090; PMCID: PMC10945906.