His and hers heart disease - Harvard Health Publishing

His and hers heart disease

Published: September, 2005

It's often been said that matters of the heart affect men and women differently. However, medical research isn't focusing on who hails from Mars and who from Venus, but on gender distinctions in earthly anatomy and physiology and their influence on heart disease.

So, after years of gender-based research, it's becoming increasingly clear that gender differences should guide many aspects of heart disease prevention, diagnosis, and treatment.

Differences in risk

Men and women share a lot of the same risk factors, but there are also some important differences:

  • Smoking. A cigarette habit tops the list of lifestyle risk factors for men and women alike. But for women who take birth control pills, smoking increases the risk of heart attack and stroke even more.
  • Cholesterol. Levels of "bad" LDL cholesterol above 130 mg/dL are thought to signal even greater risk for men, while levels of "good" HDL cholesterol below 50 mg/dL are seen as greater warnings for women. High triglyceride levels (over 150 mg/dL) are also a more significant risk factor for women.
  • High blood pressure. Until age 45, a higher percentage of men than women have high blood pressure. During midlife women start gaining on men. By age 70, women, on average, have higher blood pressure than men do.
  • Diabetes. For both men and women, having diabetes more than doubles the risk of developing heart disease, but diabetes more than doubles the risk of a cardiac death in women, while raising it 60% in men.
  • Metabolic syndrome. Metabolic syndrome has five features— abdominal obesity, high blood pressure, high triglycerides, low HDL cholesterol, and high blood sugar or insulin resistance. Having any three of the five features of is riskier for women than for men: it triples the risk of a fatal heart attack in a woman, and increases her chance of developing diabetes 10-fold. The combination of a large waist and high triglycerides is especially toxic to women.
  • Inflammation. Chronic inflammation inside an atherosclerotic plaque makes it more likely to rupture, causing a heart attack or stroke. Women more often have conditions that lead to persistent, low-grade inflammation. For example, the inflammatory disease, lupus, is much more common in women than in men, and more than doubles the risk of heart attack and stroke for women.

Heart disease differences



Most important risk factors

  • Diabetes
  • Low HDL
  • High triglycerides
  • Waist measurement of 35 inches or more
  • Inflammatory disorders
  • High LDL
  • High blood pressure in young men


  • "Unconventional" symptoms — fatigue, malaise, shortness of breath, nausea, depression
  • First heart attack at average age 70 with higher fatality rate than men
  • More likely to have microvascular disease
  • Unstable angina warrants immediate attention
  • First heart attack at average age 65

Diagnostic procedures

  • ECG stress test less informative than nuclear test
  • When angiography shows no discrete lesions, IVUS and pressure flow studies also should be performed.
  • Stress tests more reliable than in women
  • Angiography more likely to be informative


  • Less likely to have bypass or angioplasty for coronary lesions
  • Longer hospital stays, higher complication rate
  • More likely to receive bypass surgery, angioplasty for coronary lesions
  • Shorter hospital stays
  • More likely to enter cardiac rehabilitation

Differences in risk reduction

Men and women who want to live a heart-healthy life together can devise a single diet and exercise program that will suit them both. But their paths diverge at pill time and cocktail hour.

Aspirin. Men at risk for heart attack are advised to take a low-dose aspirin daily starting at age 45, but women are told to hold off until they're 55, and then to take it for the purpose of preventing strokes.

Alcohol. While two drinks a day may keep a man's cardiologist away, they may hasten a woman's journey to the ER. Women are limited to a single drink because their bodies hang on to alcohol longer. As a result, alcohol abuse has more serious effects on women's hearts than on men's.

Differences in the disease process

Molecular biology and high-tech imaging have revealed some differences in how heart disease develops in men and women. In men, plaque tends to be deposited unevenly, creating discrete lesions that bulge from vessel walls to form blockages inside the arteries. In women, plaque is put down more uniformly throughout the vessel walls. Heart attacks in men are likely to be caused by plaque rupture. In women, they're more likely to be the result of plaque erosion.

Women are also more likely than men to have microvascular disease—a narrowing or stiffening of the microscopic tributaries of the coronary arteries, which nourish the heart muscle.

Differences in symptoms

Both men and women may experience angina, the classic sign of coronary artery disease. Angina is characterized by a squeezing pain in the middle of the chest, often accompanied by breathlessness, and sometimes accompanied by a cold sweat or nausea. But women often have less dramatic symptoms than men, such as general fatigue and a flulike malaise, and may not have chest pain at all.

Differences in diagnosis

ECG stress tests are more likely to miss cardiovascular disease in women than in men. Nuclear stress tests, in which an image indicating blood flow to the heart is made before and immediately after exercise, cost more, but they're more reliable than ECGs in women.

Coronary angiography — an X-ray that outlines blockages in coronary arteries — is considered the gold standard for identifying the location of blockages in people with positive stress tests. But all that glitters isn't gold for women. Because they're less likely than men to have discrete, bulging lesions and more likely to experience microvascular disease, their angiograms may show no obstructions. Women may need two additional tests, which can be performed during angiography:

  • Intravascular ultrasound (IVUS) and
  • Coronary flow reserve studies.

Differences in treatment

For women who have uniformly narrowed coronary arteries or microvascular disease, lifestyle changes and medications are the only treatment options. For women and men with obstructive coronary lesions, angioplasty with stenting and coronary bypass surgery are equally likely to succeed in opening their arteries, but women are less likely than men to be offered these procedures.

When women do have bypass surgery or get angioplasty, they tend to be a decade older than men undergoing similar procedures. Perhaps as a result, they require longer hospital stays, have higher death rates in the weeks following the procedure, and are less likely to be referred to coronary rehabilitation centers.

October 2009 update

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