Women make up one-half of the population in the United States and according to the US Department of Labor, play a key role as health care decision makers. Yet, for the longest time, the focus on women’s health has been mainly on reproductive health. Now that the focus is expanding and the women’s health sector is gaining more attention, it is paramount to expand the definition of women’s health to include the most common conditions affecting women.
Despite being largely preventable, heart disease remains the leading cause of death for women, accounting for one in five female deaths in the United States.
However, according to a survey of more than 1,500 women over the age of 25 on heart disease awareness trends over 10 years, in 2019 only 44% of women recognized that heart disease is their number one killer, down from 65% in 2009.1 The largest declines in awareness, after adjusting for factors such as income and education level, were among younger women ages 25-34 years old, Hispanic women, and non-Hispanic Black women.
The survey also found a decline in awareness of nearly all warning signs and symptoms of a heart attack. Even though heart disease kills more women than all cancers combined, many women incorrectly identify cancer as their leading cause of death. This awareness gap is unsettling as it could drive women to delay otherwise life-saving preventive screening and interventions until it is too late. Therefore, raising awareness of heart disease among women from all walks of life should continue to be a priority.
Understanding heart disease in women cannot be an afterthought. Not only because it is the leading cause of death for women, but also because risk factors can differ, and heart disease can present quite differently between men and women.
Heart attack symptoms that women experience can be different from those experienced by men. While the most common symptom for both genders is chest pain, women may also experience other non-typical, less-known symptoms such as:
Upper back pain
Fainting
Indigestion
Extreme fatigue
In a 2018 study of 2,009 women and 976 men aged 18 to 55 years, researchers found that about 62% of women reported at least three non-chest pain-related symptoms compared to about 55% of men.2 Under-recognition of less obvious, non-chest pain-related symptoms can mean that women may have trouble recognizing that they are having a life-threatening heart attack and, as a result, delay seeking timely care.
While the risk for heart disease does increase with age for both men and women, biological differences also play a role. Conditions specific to women and their reproductive histories, such as endometriosis, preeclampsia, and gestational diabetes that develop during pregnancy, and menopause can increase a woman’s future risk of heart disease.3,4,5
In a study of more than 116,000 women, researchers found that women with endometriosis were 62% more likely than those without to have a heart attack, chest pain, or require intervention for blocked arteries.³ Our understanding of how these conditions affect risk is relatively recent, considering that until the late 1990s, research studies and clinical trials predominantly consisted of men. Prioritizing the representation of women of different backgrounds in research is critical to informing more personalized and effective diagnostic and preventive interventions.
Addressing the awareness gap and funding studies alone would not be sufficient. It requires clinicians to acknowledge and bridge the care gap that exists. It is not uncommon for clinicians to misread heart attack symptoms in women. In the same 2018 study, 53% of women reported that their clinician did not think that their symptoms were cardiac-related, compared to 37% of men.²
Numerous studies have also shown that women are less likely to receive proper treatment and care for heart disease compared to men.6 Missed diagnosis and under-treatment can lead to fatal consequences and further exacerbate disparities in health outcomes.
Improving heart care for women means knowing the tools and interventions that work well for women. Diagnostic tools for heart disease that work well for men may not always work equally well for women. Commonly used heart disease risk calculators such as the Framingham Risk Score and ASCVD Pooled Cohort Equation do not include women-specific risk factors and often underperform for female patients.7,8,9
A critical limitation of the current imaging standard, including coronary computed tomographic angiography (CCTA), is that it focuses on identifying physical blockages in the arteries. However, heart disease in women often manifests as Ischemia with Non-Obstructive Coronary Arteries (INOCA), a condition far more common in women where clinical symptoms exist despite the absence of obstructive blockages on a scan. Up to 65% of women undergoing angiography for stable angina have no significant obstruction, meaning their disease often goes undetected by traditional tools until it has progressed to a life-threatening event.10
Healthcare decisions are only as good as the tools and data available. Clinicians can address this disparity by moving away from a one-size-fits-all approach to a precision medicine approach, embracing evidence-based, innovative solutions that work well for women.
We can now use integrated genetic-epigenetic testing to assess for three-year risk of having a coronary heart disease event, including a heart attack and identify the current presence of heart disease, including those cases with INOCA. This enables a more sensitive, scalable alternative that captures the complexity of heart disease in women, ensuring they receive personalized and effective care regardless of whether they fit the traditional "male pattern" of obstructive disease.
Written by Meesha Dogan, PhD, CEO Cardio Diagnostics
Clinically reviewed by Dr Rob Philibert, CMO Cardio Diagnostics
References
Cushman, Mary, 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." Circulation 141, no. 9 (2020). https://doi.org/10.1161/CIR.0000000000000907.
Lichtman, Judith H., et al. "Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction." Circulation 137, no. 8 (2018): 781–790. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.031650
Mu, Fan, et al. "Endometriosis and Risk of Coronary Heart Disease." Circulation: Cardiovascular Quality and Outcomes 9, no. 3 (2016): 257–264. https://doi.org/10.1161/CIRCOUTCOMES.115.002224.
Mosca, Lori, et al. "Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women – 2011 Update." Circulation 123, no. 11 (2011): 1243–1262. https://www.ahajournals.org/doi/10.1161/CIR.0b013e31820faaf8.
WebMD. "Menopause and Heart Disease." Accessed February 24, 2026. https://www.webmd.com/menopause/guide/menopause-heart-disease.
Vallahajosyula, Saraschandra, et al. "Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young." Circulation: Heart Failure 13, no. 12 (2020). https://doi.org/10.1161/CIRCHEARTFAILURE.120.007154.
Isiadinso, Ijeoma, et al. "Do We Need a Different Approach to Address Cardiovascular Risk in Women?" US Cardiology Review 11, no. 1 (2017): 5-9. https://doi.org/10.15420/usc.2016:8:2
Dogan, Meesha, et al. "External Validation of Integrated Genetic-Epigenetic Biomarkers for Predicting Incident Coronary Heart Disease." Epigenomics 13 (14): 1095–1112. https://pubmed.ncbi.nlm.nih.gov/34148365/
Park, Kim, et al. "Assessing Cardiovascular Risk in Women: Looking Beyond Traditional Risk Factors." 11, no. 4 (2015): 275–281. .
Philibert, Robert, et al. "Validation of an Integrated Genetic‐Epigenetic Test for the Assessment of Coronary Heart Disease." Journal of the American Heart Association 12, no. 22 (2023). https://doi.org/10.1161/JAHA.123.030934.
