While heart disease remains the leading cause of death for both men and women in the United States, the signs and symptoms of this life threatening condition can be very different based on gender and often far more subtle in women.
A review published in the American Heart Association (AHA) journal Circulation, found that while both men and women are likely to experience chest pain in association with cardiovascular disease, women will often have other symptoms, such as nausea and upper back pain. And the author of the review said understanding these differences in symptoms is important.
“Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy, but also directly to patients’ lives,” Corrine Jurgens, PhD, RN, an author of the review and an associate professor at Connell School of Nursing at Boston College, told Health. “Symptoms drive healthcare utilization and are a major contributor to quality of life.”
The review also points out that because women may have other underlying conditions that can make identifying symptoms of the disease much more difficult, they tend to be diagnosed with heart disease later in life compared to men.
"Women are generally older than men when diagnosed. As a result, many have a higher comorbid illness burden," Jurgens added. "For example, potential co-morbid illnesses that increase with age include osteoarthritis, atrial fibrillation, chronic lung disease, peripheral vascular disease, and heart failure."
Here's a closer look at the new review and the differences between men and women when it comes to cardiovascular disease.
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Cardiovascular Conditions and Their Symptoms
The newly published review looked specifically at symptoms associated with six cardiovascular conditions and how they differ for men and women.
Chest pain—which can feel like tightness, heaviness, pressure, burning, or general discomfort —is the most common symptom of a heart attack among both men and women.
"Women are similar to men in terms of chest pain when having a heart attack," Jurgens explained.
However, some of the additional classic symptoms such as cold sweat and unexplained pain in the jaw, neck or torso–that men present with are not always present in women, Smadar Kort, MD, co-director of the Valve Center at the Stony Brook Heart Institute in Stony Brook, NY, told Health.
“Women have what we refer to as atypical symptoms, which make it more challenging to diagnose them,” Dr. Kort said. “Some of these symptoms could be mistaken for muscular pain, inflammation of the ribs, or respiratory problems like asthma.”
Women are also more likely to experience nausea and upper back pain than men, said Jurgens. And younger women in particular with heart attack symptoms are more likely to have a cluster of three symptoms, compared to men, Jurgens added.
Sometimes referred to as a brain attack, according to the Centers for Disease Control and Prevention (CDC), a stroke takes place when something is blocking the blood supply to parts of the brain. A stroke may also occur when a blood vessel in the brain bursts.
Common signs of a stroke include arm weakness, challenges speaking, facial drooping, and also confusion or dizziness.
Women however, may also experience some additional symptoms. These include headaches, and a more significant alteration of mental state, the review states.
Heart failure occurs in cases when the heart cannot pump enough blood and oxygen to support other organs in one’s body, according to the CDC.
Most commonly, heart failure will present itself through shortness of breath. This takes place when the heart fails to pump blood as it should. This can also happen after a heart attack has taken place.
Symptoms in this case would range from an upset stomach, to appetite loss, mood changes, memory challenges and fatigue. ,
In the case of women, there may even be more symptoms. Additional signs include sweating, heartburn, unusual swelling and also heart palpitations. The review also said women may also experience depression or anxiety in conjunction with the other symptoms already outlined.
Heart Valve Disease
Heart valve disease is a condition in which a valve in the heart has damage or is diseased, according to the CDC. There are several causes of valve disease.
Shortness of breath is the common indication of this condition. Men will likely experience chest pain when impacted by heart valve disease. Women, on the other hand, could have trouble catching their breath. They may also experience challenges during physical activity and exercising.
Atrial fibrillation, or an irregular heartbeat, occurs when the heart beats too slowly or alternatively, too quickly. It can also occur when a heart beats irregularly, according to the CDC.
Indications of this condition can include fluttering in the chest for women, while men often don't have symptoms.
Additional signs can sometimes include fatigue, chest pain and dizziness.
Peripheral vascular disease
Yet another serious complication of heart disease, peripheral arterial disease in the legs or lower extremities involves narrowing or blockage of blood vessels that carry blood from the heart to the legs, according to the CDC. This condition is generally caused by fatty plaque clogging arteries.
The most common symptom of this condition is pain in the legs associated with activities like walking, that gets better after rest. Though 4 in 10 people may not experience such pain.
Women may also have other conditions—such as osteoarthritis—that have similar symptoms and thus result in the peripheral artery disease not being noticed.
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Underlying Conditions Can Disguise Symptoms
When it comes to women in particular, the review paper found that they may often have underlying conditions and symptoms that make it more challenging to identify signs of cardiovascular disease.
For example, some of the symptoms—including shoulder, arm and upper back pain, shortness of breath and chest pain— could be mistaken for things like muscular pain and weakness or respiratory problems like asthma, said Dr. Kort.
And while some symptoms of cardiovascular disease are common and well-recognized, other symptoms can be uncommon and rare, added Jurgens. Furthermore, people may not consider underlying conditions like fatigue, sleep disturbances, depression or weight gain to be related to cardiovascular diseases.
"Fatigue is common in many cardiovascular diseases; however, fatigue is easily dismissed as due to aging, increased activity or sleep disturbance," Jurgens said. "Depression, common in cardiovascular disease, may also increase the difficulty in symptom awareness and attribution."
Differing Risk Factors And Late Stage Diagnosis
Even though cardiovascular disease risk among women has some commonalities with men—including high blood pressure, smoking and diabetes—differences also exist.
For example, women are at “increased risk due to premature menopause, preeclampsia, or gestational diabetes,” Jurgens said.
In addition, Dr. Kort explained. premenopausal women have enough estrogen hormones that can protect them against heart disease; however when estrogen levels decrease after menopause, the risk for heart disease increases. Estrogen can help protect against heart attacks by preventing inflammation that contributes to the buildup of plaque in the coronary arteries.
"Women are protected by estrogen as long as they are premenopausal. Once reaching menopause they are no longer protected and they have the same risk as men," Kort said.
Health experts say another potential reason women are diagnosed later in life is lack of awareness—despite national efforts to bring attention to the disease. Specifically, a special report from the AHA found a 10-year decline in awareness among women that heart disease is their biggest health threat.
While awareness of risk factors like diabetes, high blood pressure and obesity has increased among women younger than 55 years old, awareness of heart disease as the leading cause of death among women has decreased from 65% in 2009 to 44% in 2019, particularly among younger women 25 to 64 years old, Jurgens said.
"Cardiovascular disease is the leading cause of death among women. Despite decades of trying to raise awareness of this risk by organizations like the AHA, many mistakenly believe that cancer is the most common cause of death," Jurgens said.
Even though education and awareness efforts have not declined, there simply continues to be less awareness of the possible presence of heart disease, resulting in delayed presentation.
"Women tend to think of others and care for others before they care for themselves," Dr. Kort said. "So they will seek attention at a later point in their presentation."
In general, the medical community is also less aware of heart disease in women, which will typically lead to more time being taken before the correct diagnosis is made.
"Not all providers feel adequately prepared to assess cardiovascular disease risk in women," Jurgens said.
With the findings of the scientific review in mind, health experts encourage women— and others for that matter—to know their risk of developing heart disease and to familiarize themselves with subtle symptoms of the condition.
“It’s not too early or too late to have that discussion if it never took place,” Dr. Kort said. “Many of the risk factors are modifiable and a plan should be put in place to reduce these risk factors and develop healthy habits to further reduce the risk.”
"Readers should learn to listen to their body and get attention for any symptom which is new. Better to be evaluated and told that there is no heart problem than to miss one," Dr. Kort said. "Women should also have the same compassion and care for themselves as they do for everyone around them."
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