Reviewed by Dr. A M Thirugnanam, MD, MSICP, FSCAI, Ph.D. — Senior Interventional Cardiologist
Heart disease is the leading cause of death in Indian women, ahead of every cancer combined — including breast cancer. Yet in survey after survey, women name breast cancer as the thing they fear most. That gap between perception and reality costs lives, because a woman who does not believe heart disease is her problem will not recognise it when it arrives.
Why women are diagnosed later
Three things work against women. First, symptoms are more often atypical — breathlessness, unusual fatigue, nausea, jaw or upper back discomfort rather than crushing central chest pain. Second, women delay seeking help, frequently attributing symptoms to acidity, anxiety or exhaustion. Third, when they do present, they are less likely to be investigated with the same urgency as a man describing identical symptoms.
Women are also more likely to be discharged from an emergency department without a cardiac diagnosis. If you have risk factors and something feels wrong, ask the question explicitly: “Could this be my heart?” Documented questions get investigated.
Risk factors that behave differently in women
The standard risk factors — blood pressure, cholesterol, tobacco, diabetes, obesity, inactivity — all apply. But several carry disproportionate weight in women.
Diabetes raises heart disease risk more in women than in men. A woman with diabetes loses much of the natural protection she would otherwise have before menopause.
Smoking is more damaging to women, and considerably more so in combination with the combined oral contraceptive pill, particularly over the age of thirty-five.
Autoimmune conditions — rheumatoid arthritis, lupus, psoriasis — accelerate atherosclerosis through chronic inflammation, and these conditions are far more common in women.
Pregnancy is a cardiovascular stress test
This is the most overlooked area in the whole of women’s cardiology. Certain pregnancy complications predict cardiovascular disease decades later:
- Pre-eclampsia or pregnancy-induced hypertension — roughly doubles later cardiovascular risk
- Gestational diabetes — greatly increases the likelihood of type 2 diabetes, and with it heart disease
- Pre-term delivery or a low birth-weight baby — both associated with higher later risk
- Recurrent miscarriage — associated with increased cardiovascular risk
These are not merely obstetric history. They are cardiovascular risk factors, and they belong in your medical record permanently. If you had pre-eclampsia twenty years ago, tell your physician. Most women never mention it, and most doctors never ask.
Menopause
Oestrogen has a favourable effect on the arterial lining and on the lipid profile. After menopause, LDL cholesterol rises, HDL falls, blood pressure tends to rise and fat redistributes to the abdomen. Risk climbs steadily rather than suddenly.
Early menopause — before the age of forty-five — is associated with higher cardiovascular risk and warrants earlier and more attentive screening. A sensible plan is a full cardiovascular assessment around the time of menopause: blood pressure, a full lipid profile including Lp(a) at least once, HbA1c and waist circumference.
Hormone replacement therapy is a decision to make with your gynaecologist and physician together. It is not a treatment for heart disease prevention, though for many women started near the time of menopause the cardiovascular concerns are smaller than was once believed.
Conditions largely specific to women
Coronary microvascular disease. The small vessels of the heart fail to dilate properly, causing genuine angina despite an angiogram showing clear major arteries. Women are often told the problem is anxiety. It is not. It is a real condition with real treatment.
Spontaneous coronary artery dissection (SCAD). A tear in a coronary artery wall, occurring predominantly in younger women, sometimes around pregnancy, and often in women with few conventional risk factors. Management differs from an ordinary heart attack, so recognising it matters.
Takotsubo syndrome. Sudden weakening of the heart muscle triggered by severe emotional or physical stress, occurring overwhelmingly in women after menopause. It mimics a heart attack closely and usually recovers, but requires proper assessment.
The Indian context
Many Indian women carry additional burdens: household air pollution from biomass cooking fuel, low levels of structured physical activity, the habit of eating last and least in the household, and a cultural tendency to treat their own symptoms as an inconvenience to the family. Exposure to second-hand smoke is common even among women who have never smoked.
A practical point that matters more than it should: a woman who takes the whole family for check-ups frequently does not book one for herself.
What to ask your doctor
- Given my age and history, what is my cardiovascular risk?
- I had pre-eclampsia / gestational diabetes / a pre-term delivery — how should that change my screening?
- Should my Lp(a) be measured, particularly with our family history?
- I have angina but a normal angiogram — should microvascular disease be considered?
- Is my autoimmune condition being counted as a cardiac risk factor?
Emergency: call 108 or go to the nearest hospital. Do not use this website.
This guide is educational and does not replace a consultation with your own doctor.
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