U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

Subtle and Dangerous: 

Symptoms of Heart Disease 

in Women 

RESULTS FROM STUDIES SUPPORTED BY THE NATIONAL INSTITUTE OF NURSING RESEARCH 
Subtle and Dangerous: 

Symptoms of Heart 

Disease in Women 

HEART DISEASE is the number one cause of death in the United States, 

for women as well as men. The various forms of heart disease, which 

include coronary artery disease (CAD), high blood pressure, atherosclerosis, heart failure and heart attacks, are responsible for over 

250,000 deaths a year among women. Research-based strategies to promote 

heart health – emphasizing lifestyle changes to improve diet, decrease 

cholesterol levels, increase exercise, maintain a healthy body weight, and 

avoid cigarette smoking – have contributed to the steady decrease in rate 

of death from heart disease for men since 1980. Unfortunately, the rate 

for women has remained largely unchanged.1 

The National Institute of Nursing Research (NINR), 

one of the Institutes of the National Institutes of 

Health, supports research by nurse scientists that helps 

to improve the health and health care of individuals 

across the life span – from the management of patients 

during illness and recovery to the reduction of risks for 

disease and disability and the promotion of healthy 

lifestyles. Since its inception, NINR has placed a large 

focus on disease prevention, with particular attention 

devoted to the aspects of heart disease that relate 

specifically to women. Scientists funded by the NINR 

have investigated gender-related factors associated with 

heart disease risk assessment, heart attack symptoms, 

management, and recovery, and the effects of related 

cardiovascular conditions. The results of this research 

have shed new light on differences in how men and 

women experience and respond to heart and other 

cardiovascular diseases. 

Subtle and Dangerous: Symptoms of Heart Disease in Women 1 
Prior to menopause, the female hormone estrogen seems to 

have a protective effect in maintaining adequate levels of 

“good” high-density lipoprotein (HDL) cholesterol, which 

serves to protect the body’s overall cardiovascular health. 

Estrogen also works to relax the smooth muscle of arteries, 

helping to maintain a normal blood pressure and prevent 

some forms of blood vessel damage. However, the beneficial 

cardiovascular effects of estrogen are lost after menopause, 

when the rate of heart disease-related death for women 

steadily increases.2 

One in three American women dies of heart disease, 

making it the #1 killer. 

There are many factors that have been shown to elevate the 

risk of heart disease for post-menopausal women, including 

the “deadly quartet” of chronic conditions that includes 

diabetes, obesity, high blood pressure and high cholesterol.2 

Tobacco use also significantly increases the incidence of heart 

disease, which puts smokers – currently 20% of women in 

the United States – at additional risk.3 

Cardiovascular risk is commonly assessed with the use 

of the Framingham Risk Estimation (FRE), a survey that can 

be used with asymptomatic adults to classify their risk for 

future heart disease. However, the FRE does not take into 

account a family history of premature cardiovascular disease, 

which can be an independent risk factor for the development 

of atherosclerosis – a leading cause of CAD that results from 

the buildup of plaque in the coronary arteries. 

han 

om of 

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Heart Disease Risks for Women 

In a review of several studies on women’s health, 

Elizabeth Sparks, RN, and Dr. Lorraine Frazier 

described the risk factors of heart disease among 

women. Even though cardiovascular disease 

accounts for 43% of all female deaths, few women 

view it as a significant health risk. The diagnosis of

CAD often occurs at a much older age in women t

in men, and angina (chest pain), a frequent sympt

CAD, may receive inadequate attention from healt

providers. 

2 National Institute of Nursing Research 
To help determine the role of family history in the risk 

of atherosclerosis for women, a research team at the 

Johns Hopkins Hospital, including NINR-funded 

researcher Dr. Diane Becker, studied 102 women who 

reported no current cardiac symptoms but had recently 

had a sibling hospitalized with premature CAD. The 

research team first determined the FRE scores for the 

women in the study. Although one-fifth of the women 

were current smokers, almost half were obese, and many 

had high blood pressure or were taking blood pressure 

medications, only two were considered high risk by the 

FRE. The women then underwent a special x-ray scan 

to determine the presence and extent of calcified atherosclerotic plaques within their coronary arteries. Forty 

of the women were found to have detectable coronary 

plaques, with 32 having elevated levels for their age and 

six showing severe and extensive coronary blockage.4 

Each year, about 88,000 women ages 45-64, and about 372,000 

women aged 65 and older, have a heart attack. 

These findings show that women need to be more 

aware of their risks for heart disease, especially after 

menopause or in combination with other conditions or 

lifestyle factors. Also, adding an assessment of family 

history to the current screening procedures for women 

may help to identify those at risk for CAD at an early 

stage, when they would be able to benefit most from 

preventive measures such as dietary changes, weight loss, 

low-dose aspirin, or lipid-lowering medications. 

Subtle Symptoms of Heart Attack 

Most of the early research studies on the symptoms of 

heart attacks underrepresented women and focused 

primarily on older men, who generally reported feeling 

pain and pressure in their chest prior to an attack. Once 

a woman does seek treatment, health care professionals 

commonly misinterpret or underestimate the severity of 

her symptoms. This trend is also apparent when dealing 

with CAD, a frequent precursor to a heart attack. 

Subtle and Dangerous: Symptoms of Heart Disease in Women 3 
In a series of preliminary studies, Dr. Jean McSweeney 

and her research team interviewed women who had 

recently suffered a heart attack about the symptoms 

they experienced both prior to and around the 

time they sought treatment. From these interviews, 

Dr. McSweeney developed the McSweeney Acute and 

Prodromal Myocardial Infarction Symptoms Survey 

(MAPMISS), a questionnaire to help women identify 

and describe their heart attack (also called myocardial 

infarction) symptoms.5 

The research team later administered the MAPMISS 

questionnaire to over 500 female cardiac patients who 

had suffered a heart attack within the last 4-6 months. 

Virtually all the women recalled having early (prodromal) 

symptoms within the weeks prior to their attack. 

The most frequent symptoms were unusual fatigue and 

sleep disturbance. Other symptoms included shortness 

of breath, indigestion and anxiety. Less than a third of 

the women in the survey reported any early warning 

signs involving chest pain or discomfort. Acute symptoms experienced during the attack included shortness 

of breath, weakness, fatigue, cold sweats and dizziness. 

In contrast to most men, fewer than half of these 

women reported some degree of pressure, pain or 

tightness of the chest during the critical time of 

attack onset.6 

In a separate study, Dr. Anne Rosenfeld interviewed 

52 women who had been hospitalized after a recent 

heart attack about their experiences prior to seeking 

treatment. Common symptoms found in this group 

of women were pain of the jaw, arm, back, or chest, 

shortness of breath, fatigue, nausea, and sweating. 

However, most reported that they delayed seeking 

treatment for anywhere from 15 minutes to 2 weeks 

after their symptoms began.7 

Further analysis of the interviews revealed two main 

groups of decision trajectories: knowing and managing. 

Women in the knowing group understood that their 

symptoms were serious and knew they would need help, 

even if they did not recognize that they were experiencing 

4 National Institute of Nursing Research 
 

a heart attack. Some of these women sought treatment 

immediately, but others waited for a convenient time 

to go to the hospital, or delayed seeking treatment 

until a family member or co-worker insisted on calling 

for help. Many women in the managing group believed 

they were suffering from indigestion and tried to 

manage their pain with common analgesics, antacids, 

and other stomach remedies, or simply ignored their 

symptoms until the pain intensified and they were 

forced to seek treatment.8 

During mid-life, a woman’s risk for heart disease starts to rise 

dramatically. In part, this is because a woman’s body stops 

producing estrogen. 

A research team led by Dr. René Martin interviewed 

both men and women recovering from heart attacks to 

determine gender differences in early and acute symptoms. When initially seeking treatment, over half of the 

study participants understood that their symptoms and 

pain indicated a possible heart attack. Women were 

more likely than men to attribute their symptoms to 

gastrointestinal distress, stress, or anxiety, and to be 

surprised to receive a heart-related diagnosis. Those 

who recognized the cardiac nature of their symptoms 

sought treatment earlier than those who associated 

their symptoms with some other cause. While most of 

the participants reported that they had discussed their 

symptoms with a spouse or other support person, 

women were less likely than men to have their symptoms recognized as cardiac in nature, or to be advised 

to seek medical attention.9 

These research results have helped to establish that both 

the early and the acute symptoms women experience 

related to a heart attack vary significantly from the 

classic chest pressure or pain described for men. The 

symptoms for women are more subtle and difficult 

to recognize, often appearing more like stomach 

problems or indigestion. Failure to recognize the 

meaning and severity of these symptoms could lead 

a woman suffering a heart attack to attribute her 

symptoms to other causes and delay seeking treatment. 

Subtle and Dangerous: Symptoms of Heart Disease in Women 5 
Women in Recovery and 

Rehabilitation after a Heart Attack 

The first year following a heart attack, women tend to 

have a higher rate of disability and death, and show 

poorer psychological adaptation, than men. In another 

study led by Dr. Martin, patients recovering from a 

heart attack were interviewed shortly after they were 

discharged from the hospital regarding their beliefs as 

to the causes of their illness. There were no differences 

noted between men and women in their medical histories prior to their hospitalization. Over one-third of 

those interviewed attributed their heart attacks to 

stress; other widely believed causes were diet, smoking, 

heredity and lack of exercise. Men tended to identify 

more causes than women, and were more likely to 

include poor diet, smoking or lack of exercise. 

These same patients were contacted for a three-month 

follow-up, at which time fewer than 20% of all participants reported efforts to lower their stress levels and 

women were less likely than men to report changes in 

diet or exercise.10 

Dr. Sally Rankin recently led a study that followed 30 

female heart attack survivors for a year following their 

attacks, in order to understand the factors that affect 

recovery and improve quality of life. Study participants 

completed questionnaires regarding quality of life at 

preset intervals – the first prior to leaving the hospital, 

then at one month, six months, and one year after 

hospital discharge. The quality of life scores, which 

included overall health, psychosocial and family functioning, mood, and social support, all improved by the 

end of the year. The greatest improvement, however, 

occurred in the area labeled “satisfaction with family 

life,” an area often viewed differently by women and 

men. Social support and mood were the best predictors 

of overall quality of life at one year for women; cardiac 

capacity, which indicates the ability to tolerate activity, 

was not found to have a significant impact.11 

After a heart attack or coronary artery bypass graft 

(CABG) surgery to address CAD, a cardiac rehabilitation 

program consisting of regular exercise can significantly 

6 National Institute of Nursing Research 
reduce mortality during recovery. Dr. Shirley Moore 

followed both recent female heart attack survivors and 

those who had undergone a CABG, to measure the frequency, quantity, persistence and intensity with which 

they followed their rehabilitation programs. She found 

that almost a quarter of the participants did not exercise at all, and only about half were still exercising at 

3 months. Those who reported having fewer associated 

health conditions exercised with greater frequency 

and intensity. Those with more social support tended 

to have a higher rate of persistency, while a belief in 

the positive health benefits of exercise increased the 

amount of exercise undertaken by the participant.12 

Taken together, these results indicate that women and 

men cardiac patients tend to differ in how they attribute 

the causes of their illness, which may influence their 

motivation to change their behavior and reduce the 

risks of reoccurrence after surviving a heart attack. 

Understanding the different dimensions of motivation, 

quality of life, activity levels, and exercise compliance 

could help clinicians improve rehabilitation programs 

for women after a cardiac event. 

Women with Chronic Angina 

Chronic angina is a long-term condition that often 

results from CAD, and two-thirds of the estimated 6 

million Americans who suffer from this condition are 

women. In a survey of elderly CAD patients, Dr. Laura 

Kimble explored how chronic angina limits activity and 

diminishes quality of life. The research found that men 

and women experienced different forms of pain due 

to chronic angina. A significant percentage of both 

men and women described their pain as aching, heavy, 

exhausting or sharp; however, men reported a greater 

number of recent angina episodes, while women 

reported a greater intensity of pain which caused 

more limitation of activity. Also, a large proportion 

of women characterized their pain as hot/burning and 

tender, which was not seen in men. Although small, 

these variations could affect how health care personnel 

interpret the effects of chronic angina, possibly leading 

to different treatments for men and women.13, 14 

Subtle and Dangerous: Symptoms of Heart Disease in Women 7 
Women and Peripheral Artery Disease (PAD) 

Dr. Roberta Oka examined peripheral artery disease, 

a form of atherosclerosis which impairs circulation to 

the legs, for gender-related differences. PAD often 

causes intermittent claudication (leg pain associated 

with exertion) which limits activity and significantly 

decreases the quality of life for its sufferers. Severe 

cases of PAD could lead to leg ulcers and gangrene. 

Dr. Oka and her research team assessed lower leg 

circulation and measured the walking distance, activity 

tolerance, and quality of life in a group of elderly men 

and women suffering from mild to moderate PAD. 

By taking action, older women and especially those who already 

have heart disease can reduce their risk of developing heart-related 

problems. 

Over three-quarters of those polled reported engaging 

in regular exercise and fewer than 10% were smokers. 

However, many reported common related medical 

conditions including high blood pressure, high cholesterol, diabetes, chronic angina, and CAD. As part of 

the study, the participants underwent a graded exercise 

treadmill test. The walking distance before the onset of 

claudication was not significantly different between 

men and women, although the men achieved a greater 

total distance. In a quality of life questionnaire, the 

women reported worse physical functioning, more 

body pain and a poorer mood state.15 Even though 

PAD is more common in men, the results of this study 

indicated that women with PAD might suffer a greater 

decrease in their activity tolerance and quality of life. 

8 National Institute of Nursing Research 
Conclusion 

Research supported by the NINR has contributed to 

the growing body of evidence indicating that women’s 

risks for, symptoms of, and responses to heart and 

cardiovascular disease vary widely from those of men. 

Women’s symptoms tend to be more subtle and less 

predictable, leading to potentially detrimental outcomes. 

Women often underestimate the danger of cardiovascular disease, and may fail to take preventive measures, 

heed warning signs, or seek treatment for symptoms. 

Even after a heart attack or cardiac surgery, their compliance with rehabilitation efforts may be insufficient. 

About 6 million American women have coronary heart disease. 

Understanding the complexity of a woman’s symptoms 

of heart and cardiovascular disease could greatly assist 

nurses and other health care professionals in designing 

interventions both to promote cardiac health awareness 

and to decrease treatment delay – key components in 

survival and recovery. Nursing care also needs to focus 

more on teaching heart-protective lifestyle habits, 

cardiac symptom recognition and response, and 

cardiac recovery and rehabilitation, in order to 

improve the future of women at risk for or suffering 

from heart disease. 

Subtle and Dangerous: Symptoms of Heart Disease in Women 9 
Glossary of Abbreviations 

Atherosclerosis a build-up of plaque in the arteries that can block 

blood flow, also called hardening of the arteries 

CABG Coronary artery bypass graft 

CAD Coronary artery disease 

FRE Framingham risk estimation 

HBP High blood pressure 

HDL High-density lipoprotein, a beneficial form of 

cholesterol 

MAPMISS The McSweeney Acute and Prodromal Myocardial 

Infarction Symptom Survey 

Myocardial 

infarction Another name for heart attack 

NINR National Institute of Nursing Research 

PAD Peripheral artery disease 

10 National Institute of Nursing Research 
References 

1. American Heart Association, 2004. Retrieved January 25, 2006, from 

http://www.americanheart.org/presenter.jhtml?identifier=3000941 

2.	 Sparks EA, Frazier LQ. Heritable cardiovascular disease in women. Journal of 

Obstetric, Gynecologic, and Neonatal Nursing. 2002; 31: 217-228. 

3.	 Tobacco Information and Prevention Source (TIPS). 2004. Adult Cigarette 

Smoking in the United States: Current Estimates. National Center for 

Chronic Disease Prevention and Health Promotion. Retrieved January 25, 

2006, from: 

http://www.cdc.gov/tobacco/factsheets/AdultCigaretteSmoking_FactSheet.htm 

4.	 Michos ED, Vasamreddy CR, Becker DM, Yanek LR, Moy TF, Fishman EK, 

Becker LC, Blumenthal RS. Women with a low Framingham risk score and a 

family history of premature coronary heart disease have a high prevalence of subclinical coronary atherosclerosis. American Heart Journal. 2005; 150(6): 1276-1281. 

5.	 McSweeney JC, O’Sullivan P, Cody M, Crane PB. Development of the 

McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey. 

Journal of Cardiovascular Nursing. 2004; 19: 58-67. 

6.	 McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin BJ. 

Women’s early warning symptoms of acute myocardial infarction. Circulation. 

2003; 108: 2619-2623. 

7.	 Rosenfeld AG. Treatment-seeking delay among women with acute myocardial 

infarction: decision trajectories and their predictors. Nursing Research. 2004; 

53: 225-236. 

8.	 Rosenfeld AG, Lindauer A, Darney BG. Understanding treatment-seeking 

delay in women with acute myocardial infarction: descriptions of decisionmaking patterns. American Journal of Critical Care. 2005; 14 (4): 285-293. 

9.	 Martin R, Lemos K, Rothrock N, Bellman SB, Russell D, Tripp-Reimer T, 

Lounsbury P, and Gordon E. Gender disparities in common sense models of 

illness among myocardial infarction victims. Health Psychology. 2004; 23 (4): 

345-353. 

10. Martin R, Johnsen EL, Bunde J, Bellmen SB, Rothrock NE, Weinrib A, 

Lemos K. Gender differences in patients’ attributions for myocardial infarction: implications for adaptive health behaviors. International Journal of Behavioral 

Medicine. 2005; 12 (1): 39-45. 

11. Rankin SH, Fukuoka Y. Predictors of quality of life in women 1 year after 

myocardial infarction. Progress in Cardiovascular Nursing. 2003; 18: 6-12, 62. 

12. Moore SM, Dolansky MA, Ruland CM, Pashkow FJ, Blackburn GG. 

Predictors of women’s exercise maintenance after cardiac rehabilitation. 

Journal of Cardiopulmonary Rehabilitation. 2003; 23: 40-49. 

13. Kimble LP, Dunbar SB, Weintraub WS, McGuire DB, Fazio S, De AK, 

Strickland O. The Seattle Angina Questionnaire: reliability and validity in 

women with chronic stable angina. Heart Disease. 2002; 4: 206-211. 

14. Kimble LP, McGuire DB, Dunbar SB, Fazio S, De A, Weintraub WS, 

Strickland OS. Gender differences in pain characteristics of chronic stable 

angina and perceived physical limitation in patients with coronary artery 

disease. Pain. 2003; 101: 45-53. 

15. Oka RK, Szuba A, Giacomini JC, Cooke JP. Gender difference in perception 

of PAD: a pilot study. Vascular Medicine. 2003; 8: 89-94. 

Subtle and Dangerous: Symptoms of Heart Disease in Women 11 
Factors That Increase Women’s 

Heart Disease Risk 

Those beyond your control: 

Family history of early heart disease 

Being 55 or older 

Those you can take action against: 

Smoking – about 21.2 million women smoke. 


High blood pressure – 33 percent of women have
 

hypertension, the condition’s medical name; uncontrolled high blood pressure can lead to heart failure,
 

which affects about 2.5 million women. 


High blood cholesterol – about 56.5 million women
 

have high total cholesterol. 


Overweight/obesity – 62 percent of women are overweight, including about 33 percent who are obese. 


Physical inactivity – more women than men are 


physically inactive, with 41 percent of women engaging
 

in no leisure-time physical activity and more than 60
 

percent of women do not meet the recommended
 

amount of at least 30 minutes a day of moderately
 

intense physical activity, such as brisk walking. 


Diabetes – nearly 7 million women have been 


diagnosed with diabetes and another 3 million are
 

undiagnosed. 


12 National Institute of Nursing Research 
These research findings from the NINR show that 

women experience a wide range of symptoms that 

may indicate a heart attack, and often delay seeking 

treatment for a variety of reasons. If you are a 

woman and you begin to feel fatigue, shortness of 

breath, anxiety, weakness, dizziness, or a cold sweat, 

even in the absence of chest pain or pressure, you 

may be having a heart attack. You should contact 

your health care provider or call 911 immediately. 

The NINR is part of the National Institutes of 

Health (NIH), the biomedical research arm of the 

federal government. NIH is an agency of the U.S. 

Department of Health and Human Services. To 

learn more about the NINR and nursing research, 

please visit the NINR website: 

http://ninr.nih.gov/ninr/ 

Other sources of information about women and heart disease: 

National Heart, Lung, and Blood Institute 

www.hearttruth.gov, 301-592-8573, TTY: 

240-629-3255 

Office on Women’s Health, DHHS 

National Women’s Health Information Center 

www.WomensHealth.gov, 1-800-994-WOMAN, 

TDD: 1-888-220-5446 

American Heart Association 

www.americanheart.org, 1-888-MY HEART 

WomenHeart: the National Coalition for Women with 

Heart Disease 

www.womenheart.org, 202-728-7199 
NIH PUBLICATION NUMBER: 06-6079