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Center for Women's Heart & Vascular Health
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Women and Heart Disease
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Heart disease is no longer considered a disease that affects just men. In the past, women usually received less aggressive treatment for heart disease and were not referred for diagnostic tests as often. As a result, when many women were finally diagnosed with heart disease, they usually had more advanced disease and their prognosis was poorer. We now know that cardiovascular diseases affect more women than men and are responsible for more than 40% of all deaths in American women.

Women and Heart Attacks

Heart attack symptoms in women may be different from those experienced by men. Many women who have a heart attack do not know it. Women tend to feel a burning sensation in their upper abdomen and may experience lightheadedness, an upset stomach, and sweating. Because they may not feel the typical pain in the left half of their chest, many women may ignore symptoms that indicate they are having a heart attack.

Heart attacks are generally more severe in women than in men. In the first year after a heart attack, women are more than 50% more likely to die than men are. In the first 6 years after a heart attack, women are almost twice as likely to have a second heart attack.

See also on this site: Straight Talk about Heart Attacks

Estrogen and Heart Disease

Studies have shown that after menopause, women experience an increased risk of heart disease. Researchers have connected this pattern to decreasing levels of the female hormone estrogen during menopause—a process that begins around age 50. Estrogen is associated with higher levels of high-density lipoprotein (HDL or "good cholesterol") and lower levels of low-density lipoprotein (LDL or "bad cholesterol"). Withdrawal of the natural estrogen that occurs in menopause leads to lower "good cholesterol" and higher "bad cholesterol" thus increasing the risk of heart disease. Because the life expectancy for women in the United States is 79 years, women can expect to live a large part of their lives with an increased risk of heart disease. In fact, 1 out of 4 women older than 65 has some form of identified heart disease.

Researchers have looked at how hormone replacement therapy (HRT) may affect women who already have heart disease. In the Heart and Estrogen/progestin Replacement Study (HERS), doctors found that postmenopausal women with heart disease who were given estrogen and progestin actually had more heart attacks and heart disease deaths during the first year of the study than women not on HRT did. However, after 4 years of study, there were no differences between the groups in heart attacks or heart disease deaths. After HERS and other trials, the American Heart Association (AHA) recommended against the use of HRT in women with known heart disease.

In 2002, one phase of the Women's Health Initiative (WHI) trial showed that healthy postmenopausal women with a uterus who were taking the combination hormone treatment of estrogen plus progestin were not protected from heart disease. The AHA was awaiting the results of this trial before making their recommendation about HRT for these women. But the trial was stopped early, because the combined estrogen and progestin treatment was shown to increase the risk of breast cancer, stroke, and heart disease. So, the study's researchers recommend that combined estrogen and progestin therapy should not be started or continued solely for the prevention of heart disease in these women.

The National Institutes of Health has since stopped the estrogen-only phase of the WHI trial after finding an increased risk of stroke and no reduction in the risk of heart disease in postmenopausal women without a uterus. Because of the results from this phase of the WHI trial, researchers recommend that estrogen-only therapy not be used for the prevention of heart disease. 

In 2008, results of a Danish study—the largest since the WHI study—showed that how and when women take HRT may affect their risk of heart attack. During a 6-year period, researchers looked at almost 700,000 healthy Danish women aged 51 to 69. There was no information on whether the women were postmenopausal, but given the womens’ age range, the researchers stated that most of even the younger women in the study were probably postmenopausal.

Results of the Danish study showed that there was no increased risk of a heart attack in women who were currently taking HRT compared with women who had never taken HRT. But there was a 24% increased risk in younger women (aged 51 to 54) and a heightened risk in younger women who had been taking HRT for a long time. Women who took a combination of estrogen and progesterone administered continuously had a 35% increased risk of heart attack compared with women who had never used HRT. But estrogen taken alone, followed by estrogen plus progesterone (a cyclical regimen) actually resulted in a reduced risk of heart attack compared to women who had never taken HRT.

The AHA still does not advise women to take HRT to reduce the risk of coronary heart disease or stroke. Women should weigh the risks of HRT and discuss them with their doctor. For the symptoms of menopause, including bone loss, effective non-hormonal treatments are available.

Click the following link for more information from the AHA:

American Heart Association
Postmenopausal Hormone Therapy and Cardiovascular Disease in Women 

Modifiable Risk Factors for Women

Updated Guidelines Focus on
"Real-World" Recommendations

(February 2011)—The American Heart Association (AHA) has updated heart disease prevention guidelines for women. Highlights include:    

  • Focusing on what works best in the "real world" vs. clinical research settings and considering personal and socioeconomic factors that can keep women from following medical advice and treatment.   
  • Incorporating illnesses that increase heart disease risk in women, such as lupus, rheumatoid arthritis and pregnancy complications.   
  • Helping women—and their doctors—to understand risks and to take practical steps that can be most effective in preventing heart disease and stroke.

For the full AHA news release and additional resources, go to  

Also from the AHA, read 

Women need to be aware of the risk factors for cardiovascular disease and the importance of making lifestyle changes that may reduce those risks. Factors such as race, increasing age, and a family history of heart disease cannot be changed. Other risk factors, however, can be changed or eliminated by making informed decisions about cardiovascular health.

Smoking is a major risk factor for cardiovascular disease. Although the overall number of adult smokers has decreased in this country during the last 20 years, the number of teenaged girls who smoke has increased. Studies show that smoking lowers levels of good cholesterol, increasing the risk of heart disease. Cigarette smoking combined with the use of birth control pills has also been shown to increase the risk of heart attack or stroke. The good news is that no matter how long or how much someone has smoked, smokers can immediately reduce their risk of heart attack by quitting. After 1 year of not smoking, the excess risk of heart disease created by smoking is reduced 80%; after 7 years of not smoking, all the risk from smoking is gone. It is never too late to stop smoking.

High blood pressure, or hypertension is a silent disease. If left untreated, it makes the heart work harder, speeds up hardening of the arteries (atherosclerosis), and increases the risk of heart attack, stroke, and kidney failure. Women who have a history of high blood pressure, black women with high blood pressure, and overweight women with high blood pressure are also at greater risk. Although high blood pressure cannot be cured, it can be controlled with diet, exercise, and, if necessary, medicines. High blood pressure is a lifelong risk and requires effective long-term management, including regular blood pressure checks and the appropriate medicines.

Pregnancy may trigger high blood pressure, especially during the third trimester, but high blood pressure caused by pregnancy usually goes away after childbirth. This is called pregnancy-induced hypertension. Another form of high blood pressure that can occur during pregnancy is called preeclampsia, and it is usually accompanied by swelling and increased protein in the urine. Women with a history of preeclampsia face double the risk of stroke, heart disease and dangerous clotting in their veins during the 5 to 15 years after pregnancy.

Cholesterol levels are also related to a person's risk of heart disease. Doctors look at how your levels of LDL, HDL, and fats called triglycerides relate to each other and to your total cholesterol level. Before menopause, women in general have higher cholesterol levels than men because estrogen increases HDL levels in the blood. A study reported in the American Journal of Cardiology found that HDL levels were the most important predictor of cardiovascular health. That is, the higher a woman's HDL level, the less likely she is to have a cardiovascular event such as heart attack or stroke. But after menopause, HDL levels tend to drop, increasing the risk of heart disease. HDL and LDL cholesterol levels can be improved by diet, exercise, and, in serious cases, statins or other cholesterol-lowering medicines.

Obesity is a strong predictor for heart disease, especially among women. A person is considered obese if body weight exceeds the "desirable" weight for height and gender by 20 percent or more. Where fat settles on the body is also an important predictor. Women who have a lot of fat around the waist are at greater risk than those who have fat around the hips. In the United States, about one third of women are classified as obese. A plan of diet and exercise approved by your doctor is the best way to safely lose weight.

Diabetes is more common in overweight, less active women and poses a greater risk because it cancels the protective effects of estrogen in premenopausal women. Results of one study showed that women with diabetes have a higher risk of death from cardiovascular disease than men with diabetes have. The increased risk may also be explained by the fact that most diabetic patients tend to be overweight and physically inactive, have high cholesterol levels, and are more likely to have high blood pressure. Proper management of diabetes is important for cardiovascular health. If you think you have diabetes, see your doctor.

Other diseases and conditions, such as lupus and rheumatoid arthritis, can also increase a woman's risk of heart disease. According to new guidelines released by the AHA, illnesses linked to a higher risk of cardiovascular disease should now be incorporated into a woman's overall risk factor evaluation.

Cardiovascular disease is the leading cause of death for American women.

Source: National Heart, Lung and Blood Institute, NIH, 

Physical inactivity is a significant risk factor for heart disease, yet millions of Americans still don't exercise at all. Many studies have shown that exercise reduces the risk of heart attack and stroke, increases HDL cholesterol levels, regulates glucose, lowers blood pressure, and increases the flexibility of arteries. Exercise has also been shown to reduce mental stress as well. Many people can benefit from exercising for 30 minutes a day, at least three times a week.

Oral contraceptives (birth control pills) may pose an increased cardiovascular risk for women, especially those with other risk factors such as smoking. Researchers believe that birth control pills raise blood pressure and blood sugar levels in some women, as well as increase the risk of blood clots. The risks associated with birth control pills increase as women get older. Women should tell their doctors about any other cardiovascular risk factors they have before they begin taking birth control pills.

Excessive alcohol intake can contribute to obesity, raise triglyceride and blood pressure levels, cause heart failure, and lead to stroke. Although studies have shown that the risk of heart disease in people who drink moderate amounts of alcohol is lower than in nondrinkers, this does not mean that nondrinkers should start drinking alcohol or that those who do drink should increase the amount they drink. For women, a moderate amount of alcohol is an average of one drink per day.

Stress is considered a contributing risk factor for both sexes, although researchers are still unclear about its relationship to heart disease. Stress, however, can lead to other risk factors such as smoking and overeating.

Depression treatment has not been shown to directly improve cardiovascular health, but depression might affect whether women follow their doctor's advice. According to new guidelines from the AHA, depression screening should now be part of an overall evaluation of women for cardiovascular risk.

Many risk factors that contribute to heart disease can be controlled. Quitting smoking, losing weight, exercising, lowering cholesterol and blood pressure, controlling diabetes, and reducing stress are within every woman's grasp.

See also on this site:

Center for Women's Heart & Vascular Health

Ask a Texas Heart Institute Doctor


See on other sites:

Heart Disease in Women 

American Heart Association   
Updated guidelines (February 2011) for preventing heart disease and stroke in women focus on "real-world" recommendations. Heart Disease FAQ
A site devoted to heart health for women from the National Women’s Health Information Center (NWHIC), a service of US Department of Health & Human Services.

U.S. Food and Drug Administration

Heart Health for Women

Updated December 2013
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