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Heart disease in women: How to understand symptoms and risk factors?

Tobacco use sharply reduces HDL cholesterol and markedly increases the risk of heart attacks in women, even more than in men, says cardiologist and epidemiologist Prof K. Srinath Reddy

It is important to bust the myth that heart and blood vessel diseases are uncommon in women. (Photo source: Pexels)

Half a century ago, it was a popular misconception that heart disease was mostly a male problem. That was because men more often adopted behaviours which increased the risk of heart and blood vessel disease. Prior to menopause, hormonal influences were protective in women. A male-dominated medical research enterprise designed and tested diagnostic tools in men only and later inappropriately applied them to women, often missing the signs and symptoms of heart disease in women. Health education messages and risk reduction programmes exclusively targetted men. Even clinical trials with medicines had only men as subjects.   As the threshold for suspecting heart disease was inordinately high in women, few women sought care for symptoms. Those who did were often misdiagnosed by doctors who did not expect women to have heart disease.

Cardiovascular disease involves the heart as well as blood vessels all over the body, including those that supply blood to the heart and the brain. Injury to the heart muscle may result not only from blockages in the blood vessels of the heart but also from inflammation of the heart muscle (myocarditis), which is provoked by infections or autoimmune phenomena wherein the body’s own immune mechanisms turn renegade to target the heart. Other forms of heart muscle disease too occur, without a clearly identifiable causal agent (cardiomyopathies). Such a cardiomyopathy may also be associated with pregnancy.


Internal valves which separate the chambers of the heart are also vulnerable to disease. Rheumatic heart disease was till recently a widely prevalent cause of autoimmune valve damage in young persons, with some forms more common in women. This was triggered by the body’s reaction to a bacterial throat infection caused by streptococcus. With widespread use (and misuse) of antibiotics and improved living conditions, this threat has receded. Age-related degeneration of some valves may occur in older decades of life. The covering of the heart can also become inflamed (pericarditis) due to viral or tubercular infection. The arteries supplying blood to the brain, lungs or limbs can manifest disease in many ways. High blood pressure can arise during pregnancy, threatening both mother and child. The veins are not exempt  — the deep veins of the legs and pelvis can develop clots that may travel to the lungs and threaten life (pulmonary embolism).

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While there are many ways by which women can suffer from cardiovascular disease, the leading causes world over are coronary heart disease and cerebrovascular disease. The former manifests as angina or heart attacks. The latter causes brain strokes (temporary or permanent paralysis of some body parts). As societies experience developmental transitions, both of these increase in incidence with some geographical variations where these two disorders are more dominant. As life expectancy increases, these become more common but they can occur at younger ages too as living habits change.  To prevent these disorders through public health programmes, detect their risk factors and signs early, create capacity in health systems for their effective management and facilitate long-term self-care.

For these to happen, it is important to bust the myth that heart and blood vessel diseases are uncommon in women. In many countries, cardiovascular diseases are the leading cause of death among women. The risk factors for coronary and cerebrovascular disorders are common and mostly modifiable.  High blood pressure, smoking, diabetes, obesity, unhealthy food habits resulting in abnormal blood fat patterns and physical inactivity are toxic to blood vessels everywhere in the body, with those supplying the heart and brain being especially vulnerable.


Prior to menopause, female sex hormones tend to protect the blood vessels. The protective HDL fraction of blood cholesterol is higher in women of reproductive age than in men. Tobacco use sharply reduces HDL cholesterol and markedly increases the risk of heart attacks in women, even more than in men. Hence the statement “if women smoke like men, they will die like men,” which countered the tobacco industry’s campaigns to target women as customers. High blood pressure is widely prevalent in women. Diabetes becomes more frequent with increasing body fat (especially when it accumulates in the abdomen). While women normally tend to have more fat around the hips than in the abdomen (pear shaped, men usually show a reverse pattern (apple shaped). This distinction gets abolished when women smoke, become physically inactive, grow obese, are highly stressed, sleep less or develop diabetes. Then, women get heart attacks at a relatively young age.


Polycystic ovary syndrome (PCOS) is associated with a higher risk of vascular disease due to many associated metabolic abnormalities, and may manifest as coronary disease at a young age.


Symptoms of a heart attack are not always the same as those in men. There may be dull discomfort in the chest rather than the crushing central chest pain that men describe. The pain may be in the upper back, neck, lower jaw, arm or upper abdomen rather than in the chest. Severe fatigue, a feeling of utter exhaustion or breathlessness may be the only symptoms. Women may experience chest discomfort from intermittent spasm of the coronary arteries, even when blocks are not obstructing the vessels. Such pains are not associated with exertion.


Women are more likely to have microvascular disease, which is a disease of the small blood vessels that supply the inner layers of the heart muscle.  Since many of these presentations are “atypical”, when matched with the “classic” symptoms in men, the diagnosis may be missed by doctors trained on textbook descriptions gathered from male experience. Till recently, men’s interest in women’s hearts did not stretch beyond the Valentine’s Day emojis!

Coronary angioplasty and stents were shown to confer lower benefit in women than in men in early follow up studies, whether because of late detection of coronary disease, older age at presentation being associated with more comorbidities or due to a smaller calibre of coronary arteries. Recent innovations in medicated stents and newer anti-clotting medications have narrowed these differences. However, the problem of late recognition of disease and delayed care are persistent problems, especially in low and middle income countries.


Cardiovascular disease, manifesting as compromised blood supply to the heart or brain, is becoming a major challenge to the health of women in India. Several recent studies have indicated high prevalence of coronary risk factors (like hypertension and diabetes) in Indian women, especially in urban areas. Low HDL cholesterol and high triglyceride levels (indicative of the ‘metabolic syndrome’) are common in India and pose a high risk of cardiovascular disease.

The recent National Family Health Survey (NFHS-5) reports that 24 per cent of the Indian women aged between 15 and 49 years are overweight or obese, while 56.7 per cent have abdominal obesity. These portend a high risk of future cardiovascular disease and diabetes. Cultural barriers of a patriarchal society reduce opportunities for regular exercise, even as consumption of unhealthy foods is increasing due to malign market mechanics. It is essential that we create social conditions wherein women can promote and protect their health, even as health systems must gear up to assess and correct cardiovascular risk at various stages of their lives.


(The author is President, Public Health Foundation of India [PHFI]. The views expressed are personal)

First published on: 26-09-2022 at 13:00 IST
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