Ask Dr. Pat

Dr. Pat Consults: Heart Disease in Women: Recognizing the Symptoms

While bias and biology may contribute to a lack of proper risk assessment, bias is certainly apparent in the healthcare system once a woman has been diagnosed with a complication of CAD such as a MI.  Studies indicate that women less commonly receive therapies endorsed by treatment guidelines; this accounts, in part, for their worse prognoses. Invasive procedures like angiograms—the gold standard for demonstrating blockage of the coronary arteries, and a prelude to opening such arteries by stenting or bypass surgery—are performed less commonly in women than in men. This shortcoming is occurring in spite of the demonstration that coronary artery stenting is as effective or more effective in improving prognosis and quality of life in women than in men.

Similarly, women are more commonly discharged from the hospital on less guideline-endorsed medication—which has been proven to improve prognosis following an acute cardiac event— than their male counterparts. These medications include beta-blockers, aspirin, statin therapy to lower cholesterol, and ACE inhibitors.

As the healthcare system and the patients it serves overcome this bias and more women are diagnosed and managed with CAD, some biological differences are coming to light that may require the development of unique treatment paradigms for certain women.

  • The mechanism for heart attack in men involves a ruptured cholesterol plaque, exposing the flowing blood to its cholesterol-rich core and causing the overlying blood to clot and obstruct the artery. But the mechanism in women is often different. In women, a plaque may simply crack or fissure at times, producing heart damage by discharging debris into the small vessels downstream.
  • Furthermore, for any type of presentation of CAD, women tend to have less arterial blockage then men. They even may manifest angina without obvious blockage at all on an angiogram. The latter situation was previously considered to have a good prognosis, but it is becoming recognized that in woman a non-obstructive amount of early plaque may produce substances that signal the muscular coat of the coronary artery to contract. This enhanced reactivity of the vessel wall further narrows the non-obstructed artery to a degree at times sufficient to deprive the heart of blood flow, resulting in angina. Recent studies indicate that, far from experiencing a benign condition, such women with enhanced blood vessel reactivity actually have a high future risk of MI and death; this warrants, at the very least, aggressive control of risk factors.

Physicians and the general public need to recognize that coronary artery disease is the No. 1 killer of women. The symptoms, test results, and treatments of coronary artery disease in women are more similar to those of men than they are different. Removing our general complacency in this area, recognizing the disease and its risk factors at an earlier stage, and following treatment guidelines faithfully should significantly improve outcome among women with this disease.

There are, however some biologic differences in the disease process in women, and more research and effective therapies will be needed to identify and treat differences in risk factors, as well as the greater role of arterial reactivity among those women with CAD, some of whom have less coronary artery blockage than their male counterparts.

Dr. James Blake



Circulation: “Special Report: Woman and Coronary Artery Disease: Understudied, Underdiagnosed, and Undertreated,” Nanette K. Wenger.

UpToDate:  “Coronary Heart Disease: The Basics.”

National Institute of Health:  “How Does Heart Disease Affect Women?”

May Clinic Proceedings: “Heart Disease in Women: Understand Symptoms and Risk Factors”  


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  • Delores Lyon May 14, 2015 at 3:16 pm

    Thanks for sharing this advice on detecting heart disease in women. I had no idea that some women aren’t diagnosed with heart disease because of bias from the doctor. It sounds like it is really important to have a doctor that knows all of the symptoms of heart disease, and who is not willing to rule a high triglyceride count out as part of the woman’s biology. Heart conditions are really serious, and should be treated very seriously if there is any chance you could have one!

  • Margret Avery February 23, 2015 at 11:53 am

    This is a great article Dr. Pat – thanks for posting!