Heart attacks present differently in women

Cardiovascular disease is the leading cause of death in women in most countries — ahead of any single cancer. It is also widely perceived as a men's condition, by patients and, the data suggests, by some clinicians.

That misperception is not harmless. Women having a heart attack are more likely to be initially misdiagnosed, more likely to experience delays to treatment, and less likely to receive guideline-recommended interventions and secondary prevention.

The symptoms

The textbook description — heavy central chest pain radiating to the left arm — derives largely from male presentations. Chest pain is still the most common symptom in women too, and it should never be dismissed. But women are considerably more likely to present with additional or predominant symptoms that do not fit the picture:

• Unusual, extreme fatigue, sometimes for days or weeks beforehand
• Shortness of breath
• Nausea, vomiting, or indigestion-like discomfort
• Pain in the jaw, neck, back or between the shoulder blades
• Light-headedness or fainting
• Cold sweat
• A sense that something is badly wrong

The pattern that gets missed most often is discomfort rather than pain, described as pressure, tightness, aching or burning, accompanied by breathlessness and profound fatigue — and attributed to indigestion, anxiety or a virus.

What to do

If you have chest discomfort or any combination of these symptoms that is new, severe or unexplained: call emergency services. Not a taxi, not a GP appointment tomorrow, not a lie-down.

Time is the single most important variable in heart attack outcomes, and the largest component of delay in women is the time between symptom onset and seeking help. Studies consistently find that women wait longer before calling, most commonly because they do not think it can be a heart attack, or because they do not want to make a fuss.

The right frame is: it is better to be wrong in an emergency department than right at home.

Conditions that disproportionately affect women

Coronary artery disease is not the only mechanism, and several that are more common in women are more easily missed because a standard angiogram can look normal.

Coronary microvascular dysfunction — disease of the small vessels rather than the large ones. Causes angina with unobstructed coronary arteries on imaging, and is more common in women.

Spontaneous coronary artery dissection (SCAD) — a tear in a coronary artery wall. Disproportionately affects younger women, often without conventional risk factors, and is associated with pregnancy and the postpartum period.

Takotsubo syndrome — stress-induced cardiomyopathy, overwhelmingly affecting postmenopausal women, presenting like a heart attack.

The important consequence: "your angiogram was clear" does not always mean your heart is fine, and persistent symptoms warrant further assessment rather than reassurance.

Risk factors that are specific to women

Standard risk factors — smoking, blood pressure, cholesterol, diabetes, family history, inactivity — apply, and diabetes appears to confer a greater relative increase in cardiovascular risk in women than in men.

Beyond those, several sex-specific factors are recognised risk markers and are frequently not asked about:

• Pre-eclampsia or gestational hypertension, which roughly doubles later cardiovascular risk
• Gestational diabetes
• Preterm birth
• PCOS, through its metabolic associations — PCOS beyond the ovaries
• Early menopause or primary ovarian insufficiency, which extends the years without oestrogen's vascular protection
• Autoimmune conditions such as lupus and rheumatoid arthritis, which raise risk substantially

Your obstetric history is cardiovascular history. It is worth volunteering, because it is rarely asked for.

Menopause changes the trajectory

Cardiovascular risk in women rises around and after the menopause transition. Oestrogen has effects on vascular function and lipid profiles, and after menopause LDL cholesterol tends to rise, blood pressure tends to rise, and visceral fat tends to increase.

The practical point is that the years around menopause are a natural moment to have blood pressure, lipids and glucose checked and to address them — a window that is often occupied entirely by discussion of symptoms. The perimenopause symptoms nobody lists and what happens to your bones cover the other things worth attending to in the same window.

Hormone therapy is not prescribed for cardiovascular prevention. Its cardiovascular risk profile depends heavily on age at initiation and route — hormone therapy: what actually changed after the WHI.

What actually reduces risk

Not smoking. Blood pressure control, which is one of the highest-impact interventions available and is under-treated in women. Managing cholesterol and glucose. Regular activity, including resistance training — strength training does more for women than any other exercise. Sleep, which is an independent cardiovascular risk factor and one that is systematically under-weighted.

And knowing your numbers. Blood pressure, lipids and HbA1c, checked periodically from midlife, are the basis of every prevention decision that follows.

Keep the history

The risk factors that matter most in women are historical — a pregnancy complication fifteen years ago, an early menopause, a period of missing cycles in your twenties. They are exactly the things nobody has written down when they are eventually asked.

Naked keeps that long record: cycles, pregnancies, symptoms and the years around them, so the history you need at 55 is one you actually have. It is not the reason most people start tracking, and it may turn out to be the most valuable thing they end up with.