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Elsa-Grace V. Giardina, MD, cardiologist and director of the Center for Women’s Health at New York Presbyterian Hospital and a Health editorial advisor

Cardiovascular disease kills one in three American women—480,000 per year.

For two decades, it has killed more women than men, and the gap is actually widening as men’s heart-attack death rates improve faster than women’s. Yet, only a third of American women consider themselves at risk for heart disease, according to a 2006 poll. Most women worry far more about breast cancer than heart disease, according to Giardina. But for every woman who dies from breast cancer, ten die from heart attacks.

Despite the sobering statistics, there are ways to protect your heart.  The conventional wisdom has long been based on the male experience, but doctors are now realizing that heart disease can be very different for women, from symptoms to diagnostic tests to effective treatments.

Two thirds of women who have heart attacks die without ever knowing that they’re having one. In large measure, that’s because the symptoms can differ from men’s and are often misinterpreted by the victim or misdiagnosed by their doctors.  Women commonly experience very different symptoms, such as shortness of breath, fatigue, pressure in the abdomen, and jaw pain.  And those are often misidentified as stomach ailments or anxiety attacks, so the early warning signs go unheeded.

Even when doctors suspect heart disease and order an angiography (a diagnostic X-ray of the heart and its blood vessels) or perform an angiogram (a procedure involving the insertion of a tiny camera into the heart’s blood vessels to look for blockage), they often don’t see problems. Doctors have long been baffled by that. But findings of a 10-year study by the National Institutes of Health—the Women’s Ischemia Syndrome Evaluation (WISE) completed in 2006—appear to unravel the mystery.

WISE researchers discovered that although two-thirds of the study participants with chest pain had “clear” angiograms, half of those women had a condition called coronary microvascular syndrome, in which plaque coats small arteries in the heart rather than building to clumps in larger vessels.  Instead of discrete obstructions, the plaque is evenly distributed throughout the blood vessels, so it’s pretty much invisible on the angiogram. Nonetheless, the vessels become narrowed, rigid, and less permeable, choking off the flow of blood and oxygen to the heart (a condition called ischemia), leading to chest pain and potentially a heart attack. Researchers estimate that as many as three million women have the syndrome, sometimes referred to as small-vessel heart disease.

The medical tests used in the WISE study to identify the syndrome are not yet widely available, but one common procedure can spot it: a nuclear stress test, in which thallium is injected into the bloodstream. Using a special camera, physicians then observe how well the radioactive material moves through the blood vessels supplying the heart.  For years cardiologists thought that stress tests didn’t work well for women because after they turned up problems, the angiogram would come up clear.  But now experts know that the angiogram is sometimes inaccurate for women.

That’s why, no matter what the angiogram shows, a poor result on the nuclear stress test calls for treatment. But standard procedures, such as angioplasty (which uses an inflatable balloon to open clogged arteries and a mesh tube called a stent to keep them open) and bypass surgery (during which blood vessels from other parts of the body, such as the arms and legs, are grafted onto the heart to bypass clogs) aren’t necessarily the answer. After all, with small-vessel heart disease, there are no discrete clogs to clear or bypass; the problem lies in smaller blood vessels coated with plaque. A better solution—and, happily, a much less invasive one—is drug therapy to reduce blood cholesterol (and therefore plaque), to thin the blood (improving flow) and, in some cases, to limit the pace of the heart (easing its burden). Reducing other heart-disease risk factors, such as poor diet and lack of exercise, is also effective.

Still, not everything about women’s heart attacks is so different from men’s: Risk factors, for instance, are nearly identical.  Until about 15 years ago, women were told by their gynecologists that they didn’t need to worry about heart disease until menopause because their hormones would protect them, and afterwards that hormone therapy would protect them.  But studies during the last decade have shown that hormones provide little or no protection, and we’re back to basics with traditional male risk factors, such as obesity, high cholesterol, smoking, stress, a sedentary lifestyle, and family history of heart disease.


Although anyone can feel any of the following symptoms, women and men typically have very different experiences during heart attacks:

Chest pain and pressure
Left arm numbness

Abdominal pressure
Back pain
Shortness of breath
Jaw pain