Heart disease is the leading cause of death for women in the U.S, and in 2019 was responsible for about 1 in every 5 female deaths. Surprisingly to many, heart disease kills more women than all forms of cancer combined — including breast cancer. And heart disease is the number one killer of new mothers, accounting for over a third of all maternal deaths. 

Yet despite the prevalence and severity of heart disease, a survey conducted by the American Heart Association found that just 13 percent of women see it as their greatest personal health risk. What might explain this gap between perception and reality? It could be that many younger women feel that heart disease (and its potential consequences such as heart attack and stroke) do not need to be a top concern until much later in life, when they enter their “golden years.” However, this belief is not supported by the facts. 

Studies on Heart Disease in Younger Women   

Multiple studies show that heart disease in younger women is on the rise:  

•  An observational study published in the American Heart Association’s journal Circulation reviewed more than 28,000 hospitalizations for heart attacks over a 20-year period, and found that the proportion of hospitalizations for heart attack has increased among those aged 35-54, especially in women. Commented the study’s lead author Dr. Sameer Arora, a cardiology fellow at the University of North Carolina School of Medicine: "Cardiac disease is sometimes considered an old man's disease, but the trajectory of heart attacks among young people is going the wrong way…It's actually going up for young women. This is concerning…it tells us we need to focus more attention on this population."
• A nationwide US study published in the European Heart Journal - Quality of Care and Clinical Outcomes found increasing death rates from heart disease in women under 65. Commented the study’s senior author Dr. Erin Michos of Johns Hopkins University School of Medicine: “Young women in the U.S. are becoming less healthy, which is now reversing prior improvements in heart disease deaths…there is a misconception that women are not at risk for heart disease before the menopause, yet one-third of their cardiovascular problems occur before 65…just because a woman is before the menopause does not mean she is not at risk.”
•  A study published in the European Heart Journal found that women aged 50 or younger who suffer a heart attack are more likely than men to die over the following 11 years.

Going Behind the Numbers

What could be driving this alarming uptick in the number of younger women with heart disease and heart attacks? It could be a combination of reasons:   

Different Risk Factors for Women 

A study of adults younger than 55 who had heart attacks published in JAMA Network Open found that seven risk factors for heart disease — including diabetes, depression, hypertension or high blood pressure, current smoking, family history of premature heart attack, low household income, and high cholesterol — accounted for the majority of the risk for heart attack in both men and women. However, there were important differences in these risk factors between men vs. women. For example, while high blood pressure, depression, diabetes, current smoking, and family history of diabetes had stronger associations in young women, high cholesterol had a stronger association in young men. Given the results, the authors concluded that we may need sex-specific strategies in cardiovascular risk factor modification.

Different Symptoms for Women 

Guidance from the American Heart Association emphasizes that symptoms of heart disease may be more subtle and varied in women than in men, and women are more likely than men to have heart attack symptoms unrelated to chest pain, such as nausea, shoulder pain, and upper back pain. Commented Judith Lichtman, an associate professor of epidemiology at the Yale School of Public Health: “Women may experience a combination of things they don't always associate with a heart attack…a lot of them talk about not really experiencing the Hollywood heart attack.”  A heart attack doesn't necessarily feel like a sudden painful episode that ends in collapse, she notes. 

Medical Gaslighting 

A study published in the European Heart Journal — Acute CardioVascular Care found that compared to younger men, younger women hospitalized for a heart attack had higher rates of cardiovascular risk factors and presented with higher clinical risk scores.  They were less likely to have previously had a heart attack or procedure for treatment of coronary artery disease, and less often underwent procedures to open the blocked coronary artery. Other studies have also shown that women with heart attacks less often received stents and medications. 

A separate study published in the Journal of the American Heart Association found that women aged 18 to 55 waited longer to be evaluated for chest pain in the emergency room, and received a less thorough evaluation for a possible heart attack than men in the same age range. Commented clinical psychologist Leigh W. Jerome Ph.D in an article published by Psychology Today: “Medical gaslighting has been well-documented across a variety of clinical conditions. It is extremely commonplace for women…medical gaslighting drastically increases morbidity and mortality, exacerbates symptom distress, and imposes self-doubt, confusion, humiliation, and, ironically, anxiety and depression. Medical gaslighting erodes trust in the doctor-patient relationship and interferes with help-seeking for legitimate medical issues.” 

Tendency to Put Others First 

Due to long-held gender beliefs about household duties and parenting, many women are pressured from an early age to focus on taking care of others, even at the cost of neglecting their own health and wellness. Commented Ewa Gross, MD, PhD, Director of UH Women’s Cardiovascular Center: “We know that women tend to be motivated when it comes to the needs of those they care for. But this same principle does not necessarily apply to their own health needs.” This tendency may also contribute to the fact that on average women wait longer than men to seek help for a heart attack — which can lead to more extensive heart damage or death.

What Women Can Do  

Women of all ages need to realize that heart disease is one of their biggest health risks, and as such it is vital to make informed lifestyle choices that strengthen heart health. The Mayo Clinic recommends the following tips: 

• Quit smoking — and if you don’t smoke, then don’t start. Plus, try to avoid exposure to second-hand smoke, which can damage the heart and blood vessels.
• Eat a healthy diet rich in whole grains, fruits, vegetables, low-fat dairy products, and lean meats. Limit or avoid saturated and trans fats, added sugar, and high amounts of salt.
• Follow a doctor-approved exercise program, and maintain a healthy weight.
• Avoid or limit alcohol. Excessive alcohol intake can lead to high blood pressure, heart failure or stroke. It can also contribute to cardiomyopathy, which is a disorder that affects the heart muscle.
•  Take prescriptions as directed, such as blood thinners, aspirin, and blood pressure medications.
•  Monitor and manage other health conditions that increase the risk of heart disease, such as high blood pressure, diabetes, and high cholesterol. 

At the same time, women need to realize — and be encouraged by their family, friends, and overall support network — that taking care of their heart health (and overall health and wellness) is not selfish. On the contrary, it is strategic. By “putting their own oxygen mask on first,” they are in a much better position to help others.  

What Doctors Can Do 

The medical community as-a-whole needs to do a better job of understanding how women’s bodies work and are configured — and how they aren’t. Shockingly, while females account for 50 percent of the population, most health and physiology research is still conducted in males. Commented Dr. Alyson McGregor, an emergency medicine physician who often treats young women experiencing a heart attack: “It’s the women who keep coming in over and over again without a diagnosis that I see so often that it just makes me feel we have to do better at figuring out women’s specific physiology…medicine is always evolving — I feel this is the next evolution of our understanding of how to care for each other.” 

What Employers Can Do 

Employers also have a critical role to play in helping the women in their workforce understand the importance of heart health across the age continuum. Digital health programs can be part of this overall strategy to span the gap between the traditional health system and self-care. 

For example, Hello Heart’s smartphone-based hypertension self-management program includes women-specific insights and support, demystifying blood pressure, cholesterol, and other heart-related topics. By offering a program like Hello Heart as a benefit to employees, employers can:

• Provide access to content that explains risk factors and outlines the symptoms that women and providers often overlook. This includes born-gender-based explanations of lipids panels (HDL cholesterol ranges), and workflows to check for possible heart attack symptoms that are unique to women.
• Empower women to manage their own health through real-time monitoring and management of blood pressure and cholesterol, anywhere and anytime.
• Enable behavior change with personalized coaching and other resources. This makes it easier to make and stick to changes with support and content based on sex, comorbidities, age, and geography.
• Encourage women to get care sooner with prompts to talk to their doctor, or schedule an appointment at a neighborhood pharmacy.

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Promoting Health Equity 

Furthermore, a recent study, published as an abstract in the American Heart Association’s Hypertension Journal, indicates that Hello Heart’s smartphone-based hypertension self-management program could contribute to health equity. Participants in the study using Hello Heart’s program achieved consistently lower systolic blood pressure (SBP). The data show similar improvements in SBP for a range of populations across age, race, and preferred language, indicating that the digital coaching program could be one tool to contribute to health equity. As noted by the American Health Association:

Achieving health equity is the right thing to do for all organizations. Equity benefits employee health in many ways, and it increases productivity and reduces health care costs for both employees and employers. These benefits can be multiplied far beyond an organization’s offices. Equity also improves the health of employees’ families and their communities. The health of the entire nation will improve if more employers commit to actions that eliminate inequities.

The Bottom Line 

One in 10 women who die from heart disease or a stroke are under age 65, and this age group now accounts for one-third of all heart and stroke-related hospitalizations. Women should be empowered, enabled, and encouraged to view heart health as a priority across the age continuum. If the healthcare community and employers actively and meaningfully support this critical objective with a strategy that includes (but is not limited to) digital health programs that span the gap between the traditional health system and self-care, then the impact for thousands of women from teens to seniors could be life-changing — and in some cases life-saving.