Quick: picture someone having a heart attack. Chances are you imagined a man clutching his chest. But the heart-health truth is that women have an equal risk for heart attack as men. “Heart disease is the number-one killer of women as well,” says Tapati Stalam, MD, a cardiologist at Inspira Health. “But people do associate it more with men than women.”

In fact, heart disease caused 1 in every 5 female deaths of women in 2021, and women face a 20% higher risk of heart failure or death within 5 years after an initial severe heart attack compared to men. Here’s a look at why heart health should be on every woman’s radar.

Tapati Stalam, MD

1. Subtle signs, unequal care

While chest pain is typically the hallmark of coronary disease for both sexes, women often experience more subtle and diverse symptoms. “With men, we always think about the elephant on the chest, chest tightness, they can’t breathe,” says Stalam. “Women can have more arm pain, nausea, vomiting, fatigue, pain in between their shoulder blades. We used to call them atypical symptoms but we’re moving away from that term.”

Studies also show women are less likely to receive attention from cardiovascular specialists in hospitals. Only about 73% of women are seen by heart specialists, compared to 84% of men, according to the American Heart Association. When it comes to treatment after a heart attack, women are generally prescribed fewer medications than men, and they undergo fewer procedures like surgical angioplasty, which is a procedure to restore blood flow. 

Mark Zucker, MD, a cardiologist with Jefferson Health in New Jersey, points out how doctors, conditioned to respond urgently to chest pain complaints from middle-aged men, may overlook similar (or subtly different) symptoms in women, especially younger ones. He recalls a pivotal moment from his early career when he was called to evaluate a 19-year-old woman with chest pain during emergency room rounds. He initially dismissed it as non-life threatening, sending his partner instead. He was surprised to learn the teenager was taken to the cardiac catheterization lab for tests. “Guess what? They found a 90 percent blockage,” Zucker says. “Anything can affect anybody at any age. And we have to be vigilant about our own preconceived biases.”

Mark Zucker, MD

2. Menstrual history matters

The timing of a girl’s first menstrual period could have implications for her future heart health, says Zucker. 

“The risk of cardiovascular disease is higher if your period comes much earlier or much later than usual,” he says. 

“In the rush to take care of patients relatively effectively and quickly, we sometimes ignore family history or fail to ask important questions, like the age when a patient first got her period,” Zucker says. “It’s important because we now have a better understanding of how much disease can be genetically driven.”

3. Stress or heart trouble?

A fast, fluttering or pounding heart could be an indication of serious heart problems, but sometimes doctors and their female patients tend to downplay the seriousness of the symptom. That could be a mistake, says Stalam.

“Palpitations are probably the number-one reason young women present to a doctor,” she says. “They often come in thinking it must be anxiety and most of the time it is benign, but we won’t know until we evaluate.” 

Stalam notes that palpitations in younger women may be a sign of congenital valvular heart disease (a heart valve condition present from birth) or heart murmurs that they are not aware of. These conditions need to be closely monitored, particularly during pregnancy, as they can affect the health of both the mother and the fetus.

However, stress-induced palpitations also pose a risk to heart health.

Stress can increase inflammation in your body, which in turn is linked to factors that can harm your heart, such as high blood pressure and lower “good” HDL cholesterol, Stalam says. Moreover, chronic stress indirectly threatens heart health by disrupting sleep, reducing exercise and influencing poor dietary choices, all of which heighten heart disease risk. This, she adds, is all the more reason to prioritize staying active, working out and checking in regularly with doctors.

4. Aging differences

Women generally have better heart health than men during their younger years, largely attributed to the female hormone estrogen. “Estrogen has a protective effect against heart disease,” Stalam says. “However, as estrogen levels fluctuate and decline during and after menopause, we start to see impacts on blood pressure and cholesterol.”

Because of these changes, women on average have heart attacks later in life than men – around 72 years old compared to 61 for men. By the time they have a heart attack, many women have other health problems like high blood pressure, diabetes, heart rhythm issues and lung diseases, which can all make heart failure more likely, says Zucker.

“It’s great that we now have technologies so that women in their early 40s can get pregnant,” he adds, “but all those hormones do lead to increased risks down the line.”