Heart disease in women: the risk many still underestimate

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When people think about major health risks for women, cancer, particularly breast cancer, is often the first condition that comes to mind. Public awareness campaigns have done important work highlighting those risks, but the epidemiological data tells a different story about what actually kills women most.

Cardiovascular disease remains the primary health threat for women. In the United States, heart disease accounts for roughly 1 in 3 deaths each year, more than all cancers combined. (1) (2) Yet awareness has declined. In 2009, approximately 65% of women correctly identified heart disease as their leading cause of death. By 2019, that number had dropped to 44%, with the steepest declines observed among Hispanic and Black women, populations that already face elevated cardiovascular risk. (3) When that risk goes unrecognized, symptoms get misinterpreted and care gets delayed at the moments it matters most.

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The data gap in cardiovascular research

Many clinical guidelines, diagnostic thresholds, and risk models used in cardiovascular medicine were developed from datasets in which women were underrepresented. For decades, women were routinely excluded from clinical trials, partly out of concern for those of childbearing age, leaving an evidence base derived primarily from male participants.

That imbalance is still around. A systematic review of cardiovascular trials conducted between 2017 and 2023 found little meaningful improvement in female participation, (4) with especially low enrollment in studies focused on arrhythmia and coronary heart disease. A 2024 analysis published in the Journal of the American Heart Association, covering nearly 124,000 trial participants, documented persistent underrepresentation of women alongside Black and Hispanic patients. (5)

The gap extends beyond who participates. Women are also underrepresented among study authors and trial leadership, and this matters, because research led by women tends to recruit more female participants. Leadership diversity, it turns out, shapes the science, too.

The clinical consequences are real. Physiology differs between sexes in ways that affect how treatments work. In heart failure research, for example, women have been shown to achieve optimal clinical benefit at lower medication doses than those recommended based on male-dominated trial data. Guidelines built on incomplete datasets may simply not reflect optimal care for everyone.

Medical education compounds the problem. Surveys of physician trainees suggest that many receive limited instruction on sex-specific differences in cardiovascular disease. In one study, 70% reported insufficient education on gender-based medical differences, (6) and only 22% of primary care physicians felt well prepared to assess cardiovascular risk specifically in women. (7) The science is advancing; translating it into clinical practice remains the harder task.

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“Atypical” symptoms are typical for women

Cardiovascular symptoms in women don't always follow the pattern most people associate with a heart attack. Chest pain remains the most common symptom across sexes, but women are more likely to also experience nausea, jaw or upper back pain, shortness of breath, dizziness, unusual fatigue, or discomfort that resembles indigestion.

These presentations are often described in clinical literature as "atypical" - a label that reflects the male-centered research from which diagnostic norms were derived. When male physiology sets the baseline, symptom patterns more common in women read as outliers, even when they are well documented.

Studies of acute coronary syndrome patients show that women frequently present differently than men. Symptoms like nausea, vomiting, shortness of breath, or upper abdominal discomfort can delay recognition during early clinical evaluation, (8) making cardiovascular events in women more likely to be misinterpreted at the outset.

The consequences are measurable. Women are significantly more likely than men to have heart attacks initially missed or misclassified. Those missed diagnoses mean delayed treatment and substantially higher short-term mortality. Research also shows that women receive fewer diagnostic tests on average and are referred for further cardiac evaluation less often than men presenting with comparable symptoms. (9) When they do receive care, disease progression may already be more advanced.

These patterns reflect systemic challenges more than individual clinical errors. Diagnostic frameworks built from incomplete data shape how symptoms get interpreted. As cardiovascular research grows more inclusive, improving recognition of sex-specific presentations is one of the clearest paths toward earlier and more accurate care.

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Cardiovascular risk factors unique to women

Women face several cardiovascular risk factors tied to reproductive health, hormonal shifts, and specific life events - factors that traditional risk models were not built to capture.

Pregnancy is a clear example. Complications including hypertensive disorders, gestational diabetes, and preterm delivery are now recognized as meaningful signals of long-term cardiovascular risk. Women who experience preeclampsia or gestational diabetes face a significantly elevated lifetime risk of cardiovascular disease and stroke. (10)

Hypertensive disorders of pregnancy alone affect roughly 10% of women who have given birth. Compared with women who maintain normal blood pressure during pregnancy, those who develop these conditions carry approximately twice the risk of cardiovascular disease and premature cardiovascular death later in life. (11) Yet pregnancy-related complications are still not consistently incorporated into long-term cardiovascular risk assessment.

Other reproductive health factors carry similar weight. Polycystic ovary syndrome, variations in the age of menarche, infertility, and breastfeeding patterns have all been linked to changes in cardiovascular risk later in life. These are common experiences, not rare edge cases, with real implications for long-term health.

Menopause represents another inflection point. Hormonal changes during this transition affect metabolism, vascular health, and cardiovascular risk in ways that are still being mapped. The timing of menopause (particularly when it occurs early) and how symptoms are managed can both influence long-term outcomes.

Together, these factors paint a picture of cardiovascular risk that extends well beyond the variables most clinical risk models were designed to measure. Integrating them into routine preventive care is one of the central challenges facing women's cardiovascular health today.

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Toward a more complete picture of women’s heart health

Research on women's cardiovascular health is expanding rapidly, with studies increasingly capturing how heart disease develops across the full female lifespan, from pregnancy-related risk signals to the physiological transitions of menopause.

But a significant gap persists between what research now shows, what happens in clinical practice, and what the public understands. Many women still underestimate their cardiovascular risk, and health systems are only beginning to incorporate sex-specific evidence into standard prevention and risk assessment.

Closing that gap starts with awareness. As research becomes more inclusive and the picture of women's cardiovascular health grows clearer, heart disease needs to be understood for what it already is: one of the central health challenges women face across their lives. Greater visibility of these risks supports earlier recognition, more informed conversations, and, ultimately, more effective prevention.

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Sources:

(1) D. Vervoort et al., “Addressing the Global Burden of Cardiovascular Disease in Women: JACC State-of-the-Art Review”

(2) CDC, “Leading causes of death in females”

(3) M. Cushman et al., “Ten-Year Differences in Women's Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey: A Special Report From the American Heart Association”

(4) F. B. Rivera et al., “Participation of Women in Cardiovascular Trials From 2017 to 2023. A Systematic Review”

(5) R. Kohn et al., “Who Are We Missing? Reporting of Ethnicity, Race, and Sex‐Specific Populations in Clinical Trials”

(6) N. K. Wenger et al., “Call to Action for Cardiovascular Disease in Women: Epidemiology, Awareness, Access, and Delivery of Equitable Health Care: A Presidential Advisory From the American Heart Association”

(7) N. Isakadze et al., “Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women”

(8) S. Sivanesan et al., “Sex differences in the presentation and management of acute coronary syndrome patients: Insights from the FORCE-ACS registry”

(9) L.S. Mehta et al., “Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association”

(10) N. I. Parikh et al., “Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association”

(11) K. Melchiorre et al., “Hypertensive Disorders of Pregnancy and Future Cardiovascular Health”