Heart disease is a significant global health concern. Biological sex plays a substantial role in how heart disease presents, progresses, and responds to medical interventions. Understanding these differences can aid in more effective prevention, diagnosis, and treatment strategies.
Biological and Hormonal Influences
Fundamental biological and physiological distinctions exist between male and female bodies that influence heart health. Hormones, particularly estrogen, contribute to these differences. Estrogen has protective effects on the cardiovascular system in pre-menopausal women by helping to keep blood vessels flexible, regulating cholesterol, and managing blood pressure. It also helps prevent inflammation that can lead to plaque buildup in coronary arteries.
The female heart is, on average, about one-fourth smaller than the male heart. Women also tend to have smaller ventricular chambers and narrower blood vessels compared to men. While the female heart typically beats faster and has a larger ejection fraction, its cardiac output is generally smaller than a male heart’s. Testosterone, the primary male sex hormone, has also been linked to cardiovascular health; some research suggests an association between testosterone and the hardening of blood vessels due to calcification.
Distinct Risk Factor Profiles
Common heart disease risk factors can affect men and women differently, and certain risk factors are specific to biological sex. High blood pressure may develop later in women but can become more severe after menopause due to hormonal shifts that stiffen blood vessels and alter cholesterol balance. Diabetes also poses a higher relative risk for heart disease in women.
Women have unique risk factors tied to their reproductive health. Polycystic ovary syndrome (PCOS) is a condition that significantly increases the risk of cardiovascular events, including heart attack and stroke. Women with PCOS often exhibit metabolic dysfunction, insulin resistance, dyslipidemia, and inflammation, which contribute to heart disease risk.
Pregnancy complications such as preeclampsia and gestational diabetes are also associated with an elevated risk of future heart disease. Women who experience preeclampsia have a two to four times higher risk of high blood pressure and double the risk for heart disease and stroke, with these risks emerging years after pregnancy. Early menopause, occurring before age 45, is another factor that increases the risk of coronary heart disease due to the earlier cessation of estrogen’s protective effects.
Varied Symptom Presentation and Diagnostic Pathways
Heart disease symptoms can vary between men and women, impacting diagnosis. Men often experience classic symptoms such as crushing chest pain that may radiate to the left arm, neck, or jaw. This discomfort can also manifest as pressure or squeezing in the chest.
Women frequently experience more atypical or subtle symptoms. These can include shortness of breath, unusual fatigue, nausea, indigestion, or pain in the back, jaw, or upper abdomen. Sleep disturbances can also be a symptom. These differences in symptom presentation can lead to misdiagnosis or delayed diagnosis in women, as healthcare providers and patients may not immediately associate these less typical signs with a heart attack.
Treatment Responses and Outcomes
The effectiveness of heart disease treatments and long-term outcomes can differ between men and women. While statin therapy has shown benefits in reducing cardiovascular events and mortality in both men and women, women are less likely to be prescribed these medications. This disparity occurs despite guidelines recommending their use for both genders.
Women often experience worse outcomes after coronary artery bypass grafting (CABG) compared to men, including higher mortality rates and major adverse postoperative events. This is partly attributed to women generally being older, having smaller coronary arteries, and presenting with more comorbidities at the time of surgery. After percutaneous coronary intervention (PCI), women may experience higher rates of adverse cardiac events and bleeding complications. Despite advances in care, women experience higher all-cause mortality after PCI compared to men.