What is the leading cause of women’s deaths worldwide? Many would mistakenly say breast cancer.
In fact, it is heart disease which claims more than twice as many lives as breast cancer and is responsible for the deaths of one in four women in Ireland.
Yet, women are less informed than men about the risks and symptoms, often waiting an average of 37 minutes longer to seek medical help during heart attacks.
Research conducted by the local heart and stroke charity, Croí, and the Global Heart Hub (GHH ) last year, revealed alarming gaps in awareness of heart attack symptoms among women in Ireland.
While many believed they would recognise the signs of a heart attack, only three per cent were able to name all the relevant symptoms. And fewer than one per cent could accurately name the symptoms without giving any incorrect ones. Additionally, only half of those surveyed were aware that the critical warning signs in women may differ from those in men.
Dr Sathish Parasuraman, a consultant cardiologist at the Blackrock Health Galway Clinic, said there is a “huge lack of awareness” among patients and doctors.
“Not uncommonly we see women with heart symptoms referred for hormone tests and men with similar symptoms undergoing heart scans. Studies show that young women with heart attacks are more likely than men to be told by their health care provider that their symptoms are not due to their heart.”
Care delivery
An Irish study of more than 10,000 patients who suffered heart attacks between 2013 and 2017 revealed women experienced longer waiting times, compared with men, at all key stages of care delivery, he said.
A 25-minute delay was recorded from the onset of their symptoms to their first medical contact and a further 12-minute delay was reported in getting lifesaving treatments.
“There are clear gaps in patient help-seeking behaviour and gender bias in symptom recognition by health care professionals.
“Also, women suffering heart attacks are less likely to be treated with optimal medications, less likely to receive urgent angiograms, and stents. Consequently, the risk of a second heart attack is two-fold higher in women than men, after an initial large heart attack. The key is to do research on the reasons behind these delays, and then to create national awareness campaigns with key messages to both public and medical professionals.”
The false belief that heart disease is solely a male problem contributes also to low awareness levels about heart attack symptoms in women.
“Male gender is a risk factor for heart attack,” he said. “This is a fact, but this makes us subconsciously believe that women are not at risk! In the 20th century, heart disease was considered a man’s disease. If women had a role to play, it was in taking care of the men in their lives.
“In the 1960s, even the American Heart Association hosted a conference themed: ‘How can I help my husband cope with heart disease?’ and published a nutrition pamphlet titled: ‘The way to a man’s heart””
Dr Parasuraman said, even today, there is a public perception that women’s health checks involve smear tests and mammograms while men’s check-ups focus on their hearts.
Very little research
The fact that men suffer heart attacks about seven years earlier than women and that heart disease studies in the past included very little research on women’s experiences – this has changed in recent years, according to the heart specialist – has also contributed to heart disease being historically associated with men.
“In reality, one in four Irish women are at risk of dying from cardiovascular causes (heart attack or stroke ). In 2021, 686 women died from breast cancer and 4,145 women died of cardiovascular causes, which means that women in Ireland are six times more likely to die from cardiovascular disease than breast cancer.”
And, there are further alarming statistics. Twenty-five per cent of women are at risk of dying within five years of having a heart attack compared to 19 per cent of men, he said.
The common symptoms of heart attack in women, as in men, are chest pain/discomfort, tightness/pressure, or a squeezing sensation across the chest. This pain/discomfort can radiate to the jaws, shoulders, arms, or back and is often associated with nausea, sweating, breathlessness, and sometimes, dizziness.
“In women, these associated symptoms can be more prominent than the chest pain itself. Importantly, women may only present with associated symptoms, and no chest pain at all. Women also present with symptoms at rest or on minimal exertion only, while men tend to have exertional chest pains or breathlessness.
“Shoulder and arm pains may occur alone without chest pains. Other indicators in women are feeling anxious, tired, experiencing flu symptoms, or palpitations. Also, these symptoms can be less abrupt and can fluctuate, recur, or gradually intensify over days, weeks, or even months before a heart attack.”
Studies show that women often wait longer than men to seek medical help when experiencing a heart attack, leading to worse outcomes. This may be because women do not always recognise their symptoms as heart-related or may underestimate their risk of heart attack.
Risk factors
Creating awareness among the public and healthcare providers on the disparity in the intensity and time span in symptoms holds the key for early diagnosis and treatment of heart attack in women, he believes.
What are the main risk factors for heart disease in women? Dr Parasuraman said the “Big Five” risk factors are high blood pressure, high cholesterol, diabetes, smoking, and obesity. Women under the age of 50 who smoke increase their heart attack risk five-fold. For those over 55 years, a family history of heart attacks or stroke before the age of 60 are non-modifiable risk factors. Stress and long-standing inflammatory conditions such as rheumatoid arthritis also increase heart attack risk.
Reproductive and hormonal milestones confer additional risks for women, he explained. High blood pressure or diabetes during pregnancy, polycystic ovarian syndrome, and early menopause increase the chances of future heart attack.
“Elevated levels of a ‘sticky’ bad cholesterol, called Lipoprotein-a, increases heart attack risk more than two-fold in women. It is mostly genetically determined and elevated levels increase heart attack risk independent of other risk factors. Current recommendations are that all adults get this checked once in their lifetime.”
Studies indicate that 80 per cent of heart attacks are due to modifiable risk factors, such as smoking, being physically inactive, having an unhealthy diet, high blood pressure, and being overweight. These factors can be changed or managed to lower your risk of heart attack and stroke.
“Hence the recommendation is that all adults reaching 40 years of age get checked. It is better to know early, so we can start lifestyle changes, and in some situations, medications.”
Women’s menstrual cycles provide a protective effect from heart disease, according to the consultant cardiologist. “It is likely that this is due to the positive effects of the female hormones on cholesterol, blood pressure, and fat distribution. Men suffer heart attack at a younger age, as they lack these protective hormones.
Cholesterol spikes
“Early menopause before the age of 45, has shown to be a strong heart attack risk factor. Blood vessel stiffening, adverse cholesterol spikes (higher bad cholesterol and lower good cholesterol ), altered body fat distribution, insulin resistance, and higher blood pressure, all occur at menopause, increasing heart attack risk.
“Consultations during the perimenopausal and menopausal periods are an ideal opportunity to assess the cardiovascular risk.”
He said that women under 50 years and men under 40 are generally considered at low risk for heart attack. “A common way of understanding the effects of age is with the kitchen pipe: as a kitchen pipe clogs up over time, we all develop thickening of blood vessels with age. People over the age of 70 are at higher risk of heart attack. Periodic check-ups after 40 years of age in both men and women identifies the modifiable risk factors, so preventative action can be taken to reduce future risk.”
Are heart attack rates among women on the increase? Globally, they have declined in recent decades, but this improvement has slowed and, in younger women under 55, rates are now increasing in many countries, according to Dr Parasuraman. This rise appears to be driven by increasing obesity, diabetes, high blood pressure, smoking, and chronic stress, he said.
“National Audit Office records show that women presenting with major heart attacks here in Ireland are on the rise over the past three years. A total of 344 women had major heart attacks in 2022, while it was 360 in 2023, and 407 in 2024. These numbers appear low as they do not include minor heart attacks that do not show up obviously on ECG.
“Improving awareness and early recognition is therefore one of the greatest opportunities to reduce deaths from heart attack in women. Medical practitioners should avail of modern screening methods to risk assess, and initiate preventative treatment in those with modifiable risk factors.”
The consultant cardiologist offers the following advice to help women protect their heart health:-
Looking after your heart
1. At age 40, get your blood pressure, cholesterol profile, and diabetes checked, and, if possible, the additional marker-Lipoprotein (a ) levels. Untreated high blood pressure is the leading modifiable risk factor for mortality globally in women.
2. Quit smoking or vaping. The long term safety of vaping has not been established.
3. Improve your physical activity levels. “The World Health Organisation recommends 30 minutes of fast walking cycling, or swimming five days a week. And two days a week of resistance to improve muscle tone. I would recommend a free YouTube channel called HASFIT, as their exercises are easily doable from your living room, with a pair of light weight dumb-bells.”
4. Watch your diet. Cut down your use of sugary drinks and drink alcohol only in moderation. Reduce saturated fat and additional salt intake (ketchups, pickles, and sauces have high salt content ). Read the content labels when you buy foods. Include unsalted nuts, fruits, fish, and vegetables regularly in your diet.
5. Do not ignore chest or arm pains, palpitations, dizziness, or breathlessness. Seek help early.
