An under-recognised problem

Surveys consistently find that both women and clinicians underestimate women's cardiovascular risk, often ranking breast cancer as the greater threat. In reality, cardiovascular disease causes more deaths in women than all cancers combined in many high-income countries.

The consequences are measurable. Women having a heart attack are on average diagnosed later, receive guideline-recommended treatments less often, and are referred to cardiac rehabilitation less frequently. Younger women in particular are more likely to be sent home from emergency departments without a cardiac diagnosis.

  • Ask explicitly for cardiovascular risk assessment rather than waiting for it to be offered.
  • If chest symptoms are dismissed and persist, seek re-evaluation.
  • Ask about cardiac rehabilitation after any cardiac event — referral rates for women are lower.

Female-specific risk factors

Standard risk calculators use age, blood pressure, lipids, smoking, and diabetes. Several factors specific to women are recognised risk enhancers and are frequently missing from the record.

  • Pre-eclampsia or gestational hypertension — associated with substantially higher later risk of hypertension and cardiovascular disease.
  • Gestational diabetes — raises later risk of type 2 diabetes and cardiovascular disease.
  • Preterm delivery and recurrent pregnancy loss — both associated with higher later risk.
  • Polycystic ovary syndrome — linked to insulin resistance and metabolic risk.
  • Early menopause, before 45, whether natural or surgical.
  • Autoimmune conditions such as rheumatoid arthritis and lupus, which raise risk through chronic inflammation and affect women more often.
  • Migraine with aura — associated with modestly higher stroke risk, particularly alongside smoking.

Bring these up even if the pregnancy was decades ago. They change how risk is estimated.

What changes at menopause

Before menopause, women have on average lower rates of coronary artery disease than men of the same age. After menopause, the gap narrows. LDL cholesterol tends to rise, blood pressure often increases, fat distribution shifts toward the abdomen, and sleep disruption becomes common — each contributing to risk.

This makes perimenopause a practical checkpoint. Rechecking blood pressure, lipids, and glucose at this stage catches changes that previous results no longer reflect.

  • Recheck the core numbers as the transition begins rather than assuming old results hold.
  • Prioritise strength training, which addresses muscle, bone, and metabolic risk together.
  • Address sleep problems; disrupted sleep worsens blood pressure and glucose.
  • Menopausal hormone therapy is not prescribed to prevent heart disease; it is a symptom-focused decision made individually with a prescriber.

How symptoms can differ

Chest discomfort remains the most common heart attack symptom in women, and the idea that women rarely get chest pain is a misconception. What is true is that women more often report additional or alternative symptoms, which can delay recognition.

  • Shortness of breath, sometimes without chest pain.
  • Nausea, vomiting, or indigestion-like discomfort.
  • Pain in the jaw, neck, back, or between the shoulder blades.
  • Unusual fatigue, sometimes for days beforehand.
  • Light-headedness, cold sweat, or a sense that something is seriously wrong.

Women are also more likely to have certain patterns such as coronary microvascular dysfunction and spontaneous coronary artery dissection, which can produce symptoms with less obvious findings on standard tests. If symptoms persist without explanation, ask about further evaluation.

Call emergency services for chest discomfort lasting more than a few minutes, severe breathlessness, or stroke signs — face drooping, arm weakness, speech difficulty.

Prevention that works

The core prevention measures are the same for everyone, and they are effective.

  • Do not smoke — smoking appears to raise cardiovascular risk particularly steeply in women, and it interacts with combined hormonal contraception.
  • Know and manage blood pressure — measure at home and treat to the agreed target.
  • Know your lipids, including non-HDL cholesterol.
  • Screen for and manage diabetes, particularly after gestational diabetes.
  • Meet activity targets — 150 to 300 minutes of moderate aerobic activity plus two strength sessions.
  • Follow a DASH or Mediterranean eating pattern.
  • Limit alcohol — less is better, and no amount is established as beneficial.
  • Address sleep and mental health — depression and poor sleep both affect cardiovascular outcomes.