Do We Really Understand Women’s Heart Disease?

Women are far less likely than men to fit the textbook model of heart disease—but they are also more likely to die of a cardiac event. In fact, according to a study published in the Journal of the American Heart Association, they are up to three times more likely to die after a serious heart attack than men.2 That is a staggering statistic—especially when you consider that the common perception is still that heart attacks are a “men’s disease.”
What’s more, the Centers for Disease Control and Prevention reports that 64 percent of women who die suddenly of a heart attack (or heart attack–like event) exhibited no previous symptoms.3 I don’t disagree with the statistic, but “exhibited no previous symptoms” doesn’t mean there were no red flags. It simply means that no symptoms that fit with the male model of heart disease were reported.
In general, we know that women are less likely to have “traditional” heart attacks—meaning, the myocardial infarctions, or “widow makers,” that create the classic symptoms of acute chest and left arm pain. In fact, women are more likely to describe “chest discomfort” when having a heart attack; this may be a diffuse ache, pressure, or “just a funny feeling” rather than the stereotypical “elephant on my chest.” They are also more likely than men to present with a cluster of symptoms such as shortness of breath, unusual fatigue (sometimes for days or weeks before the actual cardiac event), nausea, digestive issues, or even “brain fog.” Alone or in combination, none of these things scream “heart attack” to women because they, too, are expecting themselves to exhibit because they, too, are expecting themselves to exhibit the standard male patterns of heart disease!
Often, when women finally do call 911 or drive themselves to the ED, they don’t receive the proper interventions. There is often a delay between ambulance pickup and arrival at the hospital, perhaps because the EMTs don’t recognize the symptoms or urgency, or perhaps because the women themselves downplay what’s happening—we don’t know for sure. When women get to the hospital, there’s a delay in first medical contact, because they aren’t seen as priority cases. Diagnostic tests like angiograms, angioplasty, cardiac catheterization, and stress tests/electrocardiograms (EKGs)—all of which are designed to look for male-pattern disease—often come back with negative or inconclusive results. They may be told that the tightness in their chest is musculoskeletal or that they are just having a really strong panic attack and should go home and relax because nothing is wrong with their hearts. Regardless of what causes the delay, however, the longer the time lapse between the first sign of a heart attack and the application of appropriate interventions, the less likely a woman is to have a positive outcome.

In order to help women get the treatment they need and deserve, we need to learn to recognize the symptoms of female-pattern disease.
The first thing we need to understand is that women’s hearts don’t “break” the same way as men’s. Instead of presenting with the textbook-pattern blocked big blood vessels, which can be resolved through the implantation of stents or through surgery, women’s heart disease tends to be more diffuse. While men have plaque that builds up in their blood vessels and eventually ruptures (causing myocardial infarction or similar events), women’s plaque erodes into the blood vessels, making them stiffer and less flexible. When dye is injected during an angiogram, we may not see the typical types of clot formations in women because the plaque is in the lining of the vessels themselves. Then, when no areas of clotting show up in the images, the threat of vascular disease is minimized or ruled out entirely, when in fact it’s simply manifesting in a different, woman-specific way. Women then experience yet another level of misdiagnosis and delay in treatment.
Coronary microvascular dysfunction—also referred to as “microvascular disease” or “small vessel disease”—is a condition in which the small blood vessels around the heart become damaged or weakened; this restricts blood flow to and from the heart, resulting in spasms of and stress to the heart muscle. Microvascular disease is far more common among women than men, potentially because our blood vessels tend to be smaller and therefore more susceptible to damage. This condition is also extremely hard to diagnose because our standard tests (angiogram and EKG) aren’t designed to detect it. Nor has there been extensive research about how to treat it; the only pharmaceuticals available are the typical antihypertensives and cholesterol-lowering drugs, so we are forced to treat the condition with what we have available and simply wait to see what happens.
The result of this lack of knowledge is that many women with this dangerous condition never even learn that they have it until they have a full-blown heart attack—and, as we’ve seen in this discussion, sometimes not even then. Sharonne Hayes, MD, professor of cardiovascular medicine at the Mayo Clinic, observed in an interview with Randy Young that “some women with microvascular disease who complain of angina feel they must be crazy and should see a psychiatrist because their doctor says there is nothing wrong with them. It reaches a point where they’re not just undertreated but under-believed.”4
There is hope on this front, however. C. Noel Bairey Merz, MD, director of the Barbra Streisand Women’s Heart Center, is leading the charge to change women’s heart health care and research. Her research is focused on creating in-clinic solutions for patients who have chest pain but no visible arterial blockage, examining the relationship between estrogen levels and heart disease, and encouraging more women to participate in clinical trials. Her clinical trials have already revealed that a magnetic resonance imaging (MRI) stress test is superior to standard angiogram or EKG testing to reveal coronary microvascular dysfunction; we hope that this will soon be integrated into protocol nationwide as a lifesaving strategy for diagnosing women’s heart disease.

Basmah Safdar, MD, is an emergency medicine physician who is also working to serve the women who come into her ED repeatedly for chest pain but exhibit normal stress tests and angiograms. She is researching the physiology of coronary microvascular dysfunction using cardiac positron emission tomography, which can show important metabolic changes in an organ or blood vessel right down to the cellular level. Examining the relationship between patients who have recurrent chest pain and coronary microvascular dysfunction can reveal other vascular-related conditions that are more common in women, such as kidney failure, obesity, sleep disorders, dementia, and diabetes. Dr. Safdar hopes to make it possible for women to get the treatment they need before they have a life-threatening cardiac event. Dr. Safdar told me,
Having talked to many women with long-standing chest pains, I now believe that identifying small vessel disease of the heart is critical. It not only validates the symptoms of patients who have been suffering for a long time and helps us start correct treatment in these patients by making the right diagnosis, but importantly it allows us to recognize patients at risk for failure of multiple organ systems, as small vessel disease is often not limited to the heart only. It is only a matter of time before other organs such as the brain or the kidneys start showing signs of the disease as well. We must take steps to recognize early and take steps to slow the progression of this debilitating disease.


  • Oras A. Alabas et al., “Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry,” Journal of the American Heart Association 6, no. 12 (2017). doi: 10.1161/JAHA.117.007123.
  • “Women and Heart Disease,” Centers for Disease Control and Prevention, page last reviewed May 2019,


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