Understanding Heart Disease in Women

Symptoms, Risks, and Prevention

Heart disease remains a leading cause of death for women globally, yet awareness about its impact on women’s health is often overshadowed by other health concerns. Despite the rise in health awareness campaigns, there are still significant misconceptions about how heart disease manifests in women, how the risks differ from men, and the steps that can be taken to prevent its onset. In this article, we will explore heart disease in women symptoms, risk factors, prevention strategies, and describe the unique physiological factors that affect women’s heart health. The objective of this article is to empower women with knowledge and encourage proactive measures to mitigate heart disease risks.

Heart Disease in Women: An Overview

Heart disease, in medical jargon known as cardiovascular disease (CVD), encompasses various conditions, including Coronary Artery Disease (CAD), Heart Failure, Arrhythmias, and Hypertension. Although in the UK female patients have around half the number of myocardial infarctions (heart attacks) as male patients, it still remains a major health concern for women. While traditionally seen as a male-dominated disease, coronary artery disease in women is responsible for twice as many deaths as breast cancer in the UK every year. And heart attacks were the most common cause of death in women worldwide in 2019. Over 800 000 women in the UK have Coronary Heart Disease and around 50% had a heart attack at some point in the past. Each year, there are 30 000 female patients admitted to British hospital with a diagnosis of a heart attack. 

To summarise the above (https://www.bhf.org.uk/informationsupport/conditions/heart-attack/signs-and-symptoms-of-heart-attacks-in-women):

• In 2019 heart attacks were the leading cause of death in Women Worldwide
• 800 000 female patients in the UK have Coronary Artery Disease
• Around 50% of the above had a heart attack at some point in the past
• Every year, 30 000 women are admitted to hospitals with a heart attack in the UK 

The misconceptions around heart disease awareness for women often stem from the fact that heart disease in women symptoms can vary from men, and this difference can lead to delayed diagnoses or misinterpretations. There were two research articles, published recently in this area, describing women-specific heart disease symptoms in terms of diagnosis of a heart attack. Both these studies are described in details below.  

Risk Factors for Heart Disease in Women

Understanding the risk factors for heart disease in women is crucial to preventing and managing this condition. Several factors increase a woman’s likelihood of developing heart disease, and these can be broadly categorized into modifiable and non-modifiable risks. The modifiable risks mean that we can have impact on them, by changing our lifestyle or by using medication. The non-modifiable risks mean that we cannot change them, i.e. our family history. 

1. Non-Modifiable Risk Factors

• Age: As female patients, particularly after menopause, their risk for heart disease increases. This is due in part to the hormonal impact on heart disease in women, as the body produces less estrogen, which has a protective effect on the cardiovascular system. (https://pubmed.ncbi.nlm.nih.gov/17364594/) More details can be also found in this article entitled: `Sex differences in cardiovascular aging`, which was published in 2016 in a British, medical journal called Heart. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993677/)
• Family history: If a woman has a family history of heart disease, particularly if immediate family members have experienced heart attacks or other cardiovascular events, her risk is significantly elevated. Generally speaking, this is formally considered a positive risk factor, if an immediate blood relative had been diagnosed with coronary artery disease or stroke before the age of 60. 
• Ethnicity: Some ethnic groups are at higher risk of heart disease. This is often related to higher prevalence rates of conditions like hypertension and diabetes within these populations. Hypertension and diabetes are modifiable risk factors. 

2. Modifiable Risk Factors, preventing heart disease in women: 

• High blood pressure: Hypertension is a significant contributor to heart disease. The ideal blood pressure readings that we should be aiming for are on average <135/85 mmHg. 
• High cholesterol: Elevated levels of LDL (“bad”) cholesterol increase the risk of heart disease. European Society of Cardiology guidelines published in 2020, described the levels and estimation of the risk in details. (2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk – PubMed (nih.gov)) 
• Diabetes: Women with diabetes have a higher risk of developing heart disease than men with diabetes, largely due to differences in the way diabetes affects female physiology according to a meta-analysis published in 2014, which included over 800 000 individuals. (https://pubmed.ncbi.nlm.nih.gov/24859435/) This publication concluded that females who have diabetes have more than a 40% higher risk of incident Coronary Heart Disease compared with men, who have diabetes.
• Smoking cigarettes: According to data published in a British medical journal, called Lancet in 2011, smoking confers a 25% greater relative risk of coronary heart disease in women than in men. (https://pubmed.ncbi.nlm.nih.gov/21839503/) 
• High Body Mass Index: Obesity, particularly around the abdomen, increases the risk of developing conditions like hypertension and diabetes, which, in turn, increase the likelihood of heart disease.
• Sedentary lifestyle: Lack of physical activity is a major contributor to heart diseases. Women are encouraged to adopt lifestyle changes for women’s heart health by engaging in regular exercise.
• Excessive alcohol consumption: Drinking too much alcohol contributes to high blood pressure, elevated body mass index, and high cholesterol levels, all of which increase the risk of heart disease.

Early Signs of Heart Attack in Women

Recognizing the early signs of heart attack in women is critical for timely intervention, long term wellbeing and improving survival rates. While chest pain or discomfort is still the most common symptom of a heart attack in women, there is some research evidence that it may not present in the same way as it does in men. 

A study published in 2019 in the Journal of American Heart Association concluded that, in 92% of women presenting with a heart attack, the initial symptom was chest pain. Similarly, in men, chest pain was the presenting symptom in 91%. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755854/) 

On the other hand a meta-analysis published in 2022 in Journal of Clinical Medicine demonstrated that women’s symptoms are often more subtle then in men. According to this study, women with a suspected heart attack more often present with lack of breath, arm pain, nausea and vomiting, fatigue and pain at the shoulder in comparison to male patients with a suspected heart attack. Therefore, it`s important to be aware of these symptoms, which can be mistaken for less severe conditions. Women, according to the same study, also present at a slightly older age, 4.15 years older compared to men. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8910933/pdf/jcm-11-01319.pdf) 

To summarise, Common Early Symptoms in Women are listed below:

• Chest pain: By far the most common symptom of a heart attack both in women and men.
• Unexplained fatigue: Fatigue, especially if it’s extreme or unrelenting, can be an early sign of heart trouble. Women may feel unusually tired, even after a period of rest and recovery.
• Shortness of breath: Difficulty breathing or feeling out of breath, especially without exertion, may be a signal of an impending heart attack.
• Pain in the arm or shoulder: This symptom is more often present in female patients according to the above study.
• Nausea or vomiting: Women may experience digestive discomfort, such as nausea or indigestion, in the early stages of a heart attack.
• Dizziness or lightheadedness: These symptoms can also be a sign of a heart attack, especially if there are episodes of arrythmias as well. 
• Cold sweats: Unexpected sweating, especially if accompanied by other symptoms, may be indicative of a heart attack.

These symptoms can appear gradually or suddenly, and they are often misattributed to stress, aging, or other health conditions. That’s why increasing heart disease awareness for women is key to encouraging timely medical intervention. It`s important to add, that all of the above symptoms can also be present in men, who suffer from myocardial ischaemia or a heart attack. 

Hormonal Impact on Heart Disease in Women

One of the most significant distinctions between men and women when it comes to heart disease risk is the role of hormones, particularly estrogen. The past several years have been marked by some controversy concerning if estrogens are truly cardioprotective. However the latest evidence would suggest that estrogen has a protective effect on the cardiovascular system, helping to keep the inner lining of blood vessels flexible and supporting blood flow. Especially in postmenopausal women estrogen deficiency causes inflammation, and atherosclerosis. (https://www.sciencedirect.com/science/article/pii/S2090123220301983)  

Hormone replacement therapy (HRT) was once considered a way to reduce heart disease risk, but more recent research has cast doubt on its effectiveness. Thus, women should consult their healthcare providers to weigh the risks and benefits of HRT on an individual basis. More details can be found in this review article, published in Heart in 2021. (https://heart.bmj.com/content/heartjnl/107/14/1115.full.pdf) 

Prevention Strategies for Heart Disease in Women

While heart disease is a serious condition, it is largely preventable with the right approach. Implementing heart disease prevention strategies for women can significantly reduce the risk of developing cardiovascular disease. The below strategies apply to both genders and are well known to the public. 

1. Healthy Diet

Adopting a heart-healthy diet is one of the most effective ways to protect against heart disease. A diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats (such as those found in nuts, seeds, and olive oil) helps lower cholesterol levels and blood pressure, reducing the strain on the heart.

A Mediterranean-style diet, in particular, has been shown to improve heart health, as it emphasizes foods rich in omega-3 fatty acids, antioxidants, and fiber. A study, which was published in the New England Journal of Medicine in 2018, concluded that in people with high cardiovascular risk Mediterranean diet supplemented with nuts or extra-virgin olive was associated with a lower incidence of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes) as compared to those using reduced-fat diet. (https://pubmed.ncbi.nlm.nih.gov/29897866/) 

2. Regular Physical Activity

Engaging in regular exercise is essential for maintaining a healthy heart. According to the NHS website adults between 19 and 64 years old should perform at least 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity a week with a spread of exercise evenly over 4 to 5 days a week, or every day. (https://www.nhs.uk/live-well/exercise) 

Exercise helps lower blood pressure, maintain healthy weight, and improve overall heart function, making it a very important element of women’s heart health tips.

3. Weight Management

Maintaining a healthy weight is important for preventing heart disease. Excess weight, particularly in the abdominal area, can increase the risk of developing heart disease by contributing to conditions like diabetes, hypertension, and high cholesterol. According to a study published in 2001, even a modest weight reduction can help to reduce the blood pressure levels. However the greatest benefit was found in individuals, who lost 4.5kgs at 6 months, and maintained it for next 30 months. (https://pubmed.ncbi.nlm.nih.gov/11187414/) 

4. Smoking Cessation

Quitting smoking is one of the most important lifestyle changes women can make to protect their hearts. Smoking damages the blood vessels, increases blood pressure, and reduces the amount of oxygen that reaches the heart. 

5. Stress Management

Chronic stress can contribute to heart disease by increasing blood pressure and causing inflammation in the body. Women, in particular, are prone to experiencing stress from balancing work, family, and personal life demands. Practicing relaxation techniques such as yoga, meditation, and deep breathing can help lower stress levels and protect the heart. A study published in 2022 showed that, transcendental meditation significantly reduced chronic stress and burnout in health care workers. (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796494) 

6. Regular Health Screenings

If there is any doubt or questions, it`s always best to consult your doctor. Regular health check-ups are essential for early detection of heart disease and modification of risk factors. Blood pressure, cholesterol levels, and blood sugar levels should be monitored regularly, especially as women age. These screenings allow for early intervention and treatment, reducing the likelihood of heart disease developing or progressing.

Research Evidence Supporting Women’s Heart Health

Several key studies have highlighted the importance of recognizing and addressing heart disease in women:

1. The Women’s Health Initiative (WHI) study found that heart disease is the leading cause of death in postmenopausal women and that lifestyle interventions, such as diet and exercise, significantly reduced the risk of heart disease. The key messages from this trial including: Hormone therapy, Calcium and vitamin D supplementation and Low-fat diet can be found here https://www.medscape.com/viewarticle/womens-health-initiative-trials-clinical-messages-2024a10008aa. 
2. A 2021 study in the Journal of the American College of Cardiology found that women who experience early menopause, either natural or due to surgery (before the age of 40) are at small but statistically significant increased risk for a composite of cardiovascular diseases among postmenopausal women. The composite end point consisted of incident coronary artery disease, heart failure, aortic stenosis, mitral regurgitation, atrial fibrillation, ischemic stroke, peripheral artery disease, and venous thromboembolism. (https://pubmed.ncbi.nlm.nih.gov/31738818/) 
3. The INTERHEART study, conducted across 52 countries, the following risk factors as crucial in preventing heart attacks in both genders: Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity. (https://pubmed.ncbi.nlm.nih.gov/15364185/) 
4. Research data published in the New England Journal of Medicine (NEJM) found that women with a history of breast cancer, who have undergone ionizing radiation during radiotherapy are  are at higher risk of ischaemic heart disease. (https://www.nejm.org/doi/full/10.1056/NEJMoa1209825) 
5. A study published in 2001 in NEJM, which followed over 80 000 female nurses between 1980 to 1996, concluded that, majority of type 2 diabetes occurrence can be prevented by adopting healthy lifestyle measures. (https://pubmed.ncbi.nlm.nih.gov/11556298/) 

Conclusion

Heart disease in women symptoms can sometimes be subtle and differ from male presentation, leading to delays in diagnosis and treatment. Awareness is the first step in combating this global health challenge. Women must be educated about the unique risks they face, including the hormonal impact on heart disease in women and the importance of recognizing early signs of heart attack in women.

By adopting heart disease prevention strategies for women, such as maintaining a healthy diet, engaging in regular physical activity, quitting smoking, managing stress, and undergoing regular health screenings, women can significantly reduce their risk of heart disease. In addition to this, healthcare providers must continue to advocate for gender-specific research to improve prevention, diagnosis, and treatment for women suffering from heart disease.

Increased heart disease awareness for women can empower individuals to take proactive steps, leading to better health outcomes and ultimately saving lives.

Dr Bart Olechowski is a Consultant Interventional Cardiologist, located in Hampshire, UK. His expertise is coronary artery disease, heart attacks, angina and stenting procedures. Amy Rossiter, who is his very friendly and helpful medical secretary can be contacted on 07984 245 550 or via an email pa@drbart.co.uk. Additional blog posts can also be found on our Winchester & Basingstoke Cardiology website, https://www.winchesterandbasingstokecardiology.co.uk/heart-health-advice. 

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