Symptoms of heart disease — the country's No. 1 killer — may be more subtle and varied in women than in men, according to a review published Thursday in the American Heart Association journal Circulation.
Understanding the differences in symptoms is particularly important for women. Corrine Jurgens, an author of the review and an associate professor at the Connell School of Nursing at Boston College, said that women tend to be diagnosed with heart disease later in life than men, when they may have other underlying conditions that could make identifying subtle symptoms of heart disease much more difficult.
What's more, a 2020 report, also published in Circulation, found a 10-year decline in awareness among women that heart disease is indeed their biggest health threat.
"Many women are concerned about their breast cancer risk, and they perceive that as their greatest health threat," said Dr. Deirdre Mattina, a cardiologist at the Cleveland Clinic. But "we know that one in three women are going to die of heart disease" every year.
For both women and men, signs of heart problems rarely occur in isolation.
"Symptoms often occur in clusters," Jurgens said. "Very rarely does someone come in with just one symptom."
And though sudden cardiac events — heart attack or stroke, for example — certainly appear without warning, many symptoms worsen over time.
Mattina said that patients with heart failure, for example, may report no longer being able to walk as far as they used to, or a gradual decline in the ability to take in full breaths.
"We're looking for a pattern," Mattina said.
Here are the most common ways for six different cardiovascular conditions that present in patients.
A heart attack occurs when blood flow to the heart muscle is cut off or drastically reduced.
Chest pain is the classic symptom, but other symptoms associated with heart attacks can be much more subtle, such as a pressure or tightness within the chest that can sometimes radiate to the jaw, arms and back.
Men are about twice as likely as women to have a heart attack.
But women often have more symptoms that accompany a heart attack than men, including nausea, lightheadedness, extreme fatigue and cold sweats.
Younger women, generally considered as younger than 55, tend to experience at least three symptoms during a heart attack. Those can include pain in the jaw, neck, arms or shoulders, chest palpitations or feelings of heartburn.
A stroke occurs when blood flow to the brain is cut off or drastically reduced.
The signs of a stroke are facial drooping, arm weakness, difficulty speaking, confusion and dizziness. Immediate medical care is necessary when a person is having a stroke.
Women tend to experience additional symptoms, such as headache, and a more severe altered mental state, according to the review.
It's critical for patients to follow up with their physicians following a stroke, as it can affect cognitive function. That may make it more difficult for patients to identify any new symptoms.
Shortness of breath is the most common symptom associated with heart failure, which happens when the heart isn’t pumping blood as well as it should be. It can often occur after someone has a heart attack.
Jurgens said that heart failure symptoms may build slowly over the course of up to three weeks before people may realize they are having a problem that requires emergency medical care.
Women with heart failure have a wider variety of symptom, such as sweating, unusual swelling, heart palpitations and feelings of heartburn. Those symptoms, the review found, are often accompanied by depression and anxiety.
Depression tends to be more prevalent in people with heart failure and other cardiovascular conditions. According to the review, 10% of people with heart disease experience depression, compared with 5% of those without heart problems.
That may make it difficult for patients to figure out whether symptoms — fatigue, for example — are due to depression or heart disease or both.
Heart valve disease
Heart valve disease occurs when one or more of valves in the heart doesn't work properly. Like heart failure, shortness of breath is often reported.
It can lead to a complication called aortic stenosis, which occurs when the valve that allows blood to flow from the heart to the rest of the body is narrowed, restricting that blood flow. While men are more likely to experience chest pain with valve disease, women tend to report more trouble catching their breath and exercising.
Abnormal heart rhythm
An arrhythmia, or irregular heartbeat, occurs when the heart's electrical signals misfire, making the heart beat too quickly or too slowly.
The problem is often felt as fluttering in the chest, especially in women.
Men often don't experience symptoms of an irregular heartbeat at all.
But sometimes fatigue, chest pain, shortness of breath and dizziness can also accompany an arrhythmia. Black Americans are most likely to report those symptoms.
Peripheral vascular disease
The legs are not to be ignored when it comes to heart disease risks and their accompanying symptoms.
Peripheral vascular disease can lead to amputation and can increase the risk for heart attack and stroke.
There are two types: peripheral artery disease and peripheral vein disease.
Peripheral vein disease affects blood flow from the legs back to the heart, and can lead to blood clots and deep vein thrombosis.
Peripheral artery disease occurs when cholesterol builds up in the arteries that carry blood to the extremities, usually the legs.
For peripheral artery disease, "one of the primary symptoms is difficulty walking," said Dr. Amy Pollak, a cardiologist at the Mayo Clinic. Though leg and foot pain can occur, she said that many patients report leg fatigue, and sometimes heaviness or discomfort in their legs.
It's "a symptom that many patients chalk up to something else," Pollak said. "They think it's arthritis or neuropathy or aging."
Indeed, women may also have accompanying conditions, such as osteoarthritis, that could mirror or mask symptoms of peripheral artery disease.
Figuring out the cause of such leg pain or discomfort is key, Pollak said, as it "may be a really important clue to that greater arterial tree that runs through our body, connecting our heart, brain and legs."