The average age for a first heart attack in women is seven years older than in men.
For both men and women, cardiovascular disease is the leading cause of death. But their risks and symptoms can differ.
Cardiovascular disease is the No. 1 cause of death among adults of both sexes in the United States. But this unadorned statistic does not capture the differences in how the disease unfolds in men and in women. “Most of what we know about diagnosis and treatment of heart disease comes from research done on middle-aged men, so we are extrapolating from that data,” says Dr. Nadita Scott, a cardiologist and co-director of the Corrigan Women’s Heart Health Program at Harvard-affiliated Massachusetts General Hospital. As a result, ways in which the disease is different in women, who tend to be older when they develop coronary artery disease, have been under-recognized and under-investigated, she says.
Distinctive aspects of heart disease in women
In men, a heart attack typically begins with the sudden rupture of a cholesterol-filled plaque in a coronary artery, which then precipitates a blood clot. In younger women in particular, a plaque is more likely to erode into the vessel wall rather than to burst. “Women are also more likely to have smaller, nonfatal heart attacks,” says Dr. Scott.
Women are also more likely than men to develop small vessel disease, a condition where blockages occur in the tiny vessels within the heart muscle rather than in the large, surface arteries. “We see a lot of women who have classic angina [heart-related chest pain], but their major coronary arteries look normal, so they are told it’s not their heart. But you might have a heart attack if the condition is not treated,” says Dr. Scott.
Postmenopausal women are also subject to a sudden and unusual change in the shape of the heart muscle known as Tako-
tsubo cardiomyopathy that occurs in response to severe emotional stress. Also called “broken heart syndrome,” the condition is characterized by chest pain and changes in the heart’s electrical activity that mimic a heart attack. However, the arteries appear clear of plaque. During the initial event, these women are still at risk of heart rhythm problems, shock, or even death.
The myth of atypical symptoms
Some attempts to tease out gender-related differences have led to misconceptions about the nature of angina symptoms in women. Specifically, women were thought to have subtler, “atypical” symptoms that diverged from the classic pattern of chest pain—the tightness and crushing pressure described by men. But a recent analysis published in JAMA Internal Medicine revealed that men and women experience similar forms of discomfort when having a coronary blockage. Women, however, are more likely to have a “silent” heart attack, which has no overt symptoms at all. This variation may be due to women being older when the heart attack occurs, and also may be more likely if they have diabetes.
Stroke risk also differs between the sexes. Each year, about 425,000 women have a stroke—55,000 more than men. This can partly be explained by women’s longer average life span, since advancing age is a key element in stroke risk. However, women face unique stroke threats due to hormones, reproductive health, pregnancy, and childbirth. This understanding prompted the American Heart Association and American Stroke Association to issue Guidelines for Preventing Stroke in Women in 2013.
“Pregnancy is like a stress test for your cardiovascular system,” Dr. Scott explains. A history of eclampsia or pre-eclampsia—a pregnancy complication characterized by high blood pressure, high urine protein levels, and sometimes seizures—doubles a woman’s risk of having a heart attack or stroke within the next five to 15 years.
Because birth control pills are known to raise blood pressure, women should be checked for high blood pressure before starting this medication. Women who experience migraine headaches with aura (visual disturbances) also have a greater likelihood of having a stroke and therefore should avoid both smoking and birth control pills so as not to boost their risk further.
Other stroke risk factors such as atrial fibrillation, diabetes, depression, and emotional stress also tend to be stronger or more common in women than in men. Moreover, women tend to suffer more after a stroke. Three months following the event, female stroke survivors are more likely to struggle with mobility problems, pain, anxiety, and depression than their male counterparts. Women also report a lower quality of life a year after having a stroke.
The well-known culprits
Men and women alike can protect their cardiovascular health by paying attention to their personal heart risks. Lifestyle basics such as getting regular physical activity, eating a healthy diet, and maintaining a normal body weight apply to everyone. In addition, increasing your awareness of how gender differences shape your personal cardiovascular risk profile can give you an added edge in staying healthy.