Women's Cardiology

Cardiovascular diseases in women under 65 often remain undetected, are diagnosed late, or are misdiagnosed. Additionally, if a heart attack or stroke occurs, mortality is higher than in men, and recovery chances are significantly lower. This is primarily because risk factors specific to women are often overlooked. Our team is dedicated to prevention, comprehensive diagnostics, and the application of modern treatment protocols.

Understanding Differences in Women’s Cardiology

Anatomical differences between genders also relate to the heart’s structure; women’s hearts have smaller volume, thinner heart muscle walls, and smaller and narrower blood vessels, along with a lower number of red blood cells that carry oxygen.

In women, cholesterol tends to accumulate in small blood vessels, making them more prone to microvascular disease, where small blood vessels or coronary arteries do not form plaque but have damaged inner walls, which can lead to spasms and reduced blood flow through the heart muscle. In men, cholesterol mainly accumulates in the large arteries leading to the heart, requiring different diagnostic approaches.

Women can have heart attack symptoms that are not typical and rarely occur in men, such as pain and pressure in the upper back or abdomen, neck, throat, or jaw pain, nausea, and cold sweat.

Women may also experience conditions resembling a heart attack, such as vasospastic angina or spasms of the heart arteries, coronary dissection or tearing of the chest aorta, broken heart syndrome or chemical heart attack where blood enzymes affect part of the heart muscle, causing it to temporarily stop pumping blood, resulting in chest pain and shortness of breath, even though there is no artery blockage.

Pregnancy complications like preeclampsia or gestational diabetes and endometriosis are also risk factors exclusive to women. There is also a sudden drop in estrogen during menopause, significantly increasing the number of cardiovascular diseases in postmenopausal women.


The Importance of Specialized Examinations and Treatments

Because of all these factors, women require specialized cardiological diagnostics and treatments tailored to the unique characteristics of the female body.

The Framingham Risk Score, for instance, is a formula that considers the patient’s gender to assess the risk of developing cardiovascular diseases in the next ten years. This algorithm takes into account age, gender, blood pressure, cholesterol levels, smoking status, diabetes, and family history of diseases.

Different approaches are needed for female diagnostics because existing methods are more suited to men. For example, the level of troponin, which measures the extent of heart damage when a heart attack is suspected, is lower in women. Therefore, the threshold values for female patients need adjustment.

Coronary angiography detects blockages in large coronary arteries, which is typical in men. However, women more often have narrowed and blocked smaller blood vessels, so magnetic resonance imaging is recommended to detect inflammatory processes in the heart and examine the inner walls of the heart’s blood vessels.

Due to anatomical, biochemical, and metabolic differences, the absorption, distribution, and metabolism of cardiovascular drugs in women are different, requiring dose adjustments.

Common Cardiovascular Diseases in Women

According to statistics, one in three women in developed countries dies from heart and blood vessel diseases. Despite this, women do not pay enough attention to heart and blood vessel health. Therefore, much greater attention should be paid to cardiovascular diseases in women, among which the most common are:

Coronary Artery Disease (Atherosclerosis)

Atherosclerosis is the most common type of heart disease and the leading cause of heart attacks. It occurs when the artery walls thicken, lose elasticity, and develop narrowings or blockages due to deposits of fats, calcium, and cholesterol (plaques), increasing the risk of heart attack, stroke, and heart failure. The risk in women increases after menopause due to insufficient estrogen to maintain blood vessel elasticity and reduce oxidative stress linked to atherosclerosis.

Heart Attack (Myocardial Infarction)

Among all individuals who have had a heart attack, about one-third are women, and two-thirds are men. Heart attack symptoms in women can be different. Many describe a heart attack as a tightening in the upper back, as if their chest is tied with a rope. This feeling lasts a few minutes, goes away, and then returns. Women also experience jaw pain, nausea, cold sweat, fatigue, and shortness of breath, although it is not always accompanied by chest discomfort.


Strokes are more common in men, but mortality is higher in women, with lower recovery chances and higher disability. Risk factors in women include high blood pressure during pregnancy (preeclampsia), carotid stenosis (narrowing of neck blood vessels), migraines, smoking, contraceptive pills (which increase the risk of blood clots), and obesity. Preventive measures include quitting smoking, a Mediterranean diet with healthy body weight maintenance, and regular physical activity.

Heart Failure

Heart failure can be systolic or diastolic. Diastolic heart failure with preserved ejection fraction is much more common in women. The most common causes of heart failure in women are hypertension and valvular heart disease, whereas in men, it is coronary disease. Women with heart failure report lower quality of life and higher depression rates than men.


Conditions such as atrial fibrillation or atrial flutter most often occur in women over 65. The main risk factors in women are high blood pressure (hypertension) and valvular heart disease, unlike men, where it is atherosclerosis and previous heart attacks. Typical symptoms include palpitations, “skipped” heartbeats, shortness of breath, and chest pain. However, women also experience fatigue and malaise, as well as longer and more frequent episodes of irregular heart rhythm.

Valvular Heart Disease

Common valvular diseases include mitral prolapse, mitral regurgitation, and aortic stenosis. Mitral prolapse is a deformity of the heart valve when it bends backward toward the left atrium, allowing small amounts of blood to return to the chamber (mitral regurgitation). In women, it most often occurs at a younger age, whereas in men, it can occur at any age. If the disease was asymptomatic in its early stages, pregnancy usually triggers its manifestation or worsens the condition.

Aortic stenosis (narrowing of the aorta) in women is characterized by a smaller percentage of calcification but in a more severe form than in men. Compared to men, it occurs later in life with atypical symptoms such as shortness of breath and fainting. Due to a higher number of comorbidities and smaller body surface area, mortality is higher in women.

Microvascular Disease (Small Vessel Disease)

Since women have smaller and narrower blood vessels, microvascular disease is more common. The cause is plaque in the small blood vessels supplying the heart muscle. Typical symptoms include chest pain and tightness (microvascular angina), shortness of breath, and fatigue.

Congestive Heart Failure

Congestive heart failure (heart failure) has two forms: diastolic and systolic. Diastolic heart failure with preserved ejection fraction is much more common in women, while systolic is more common in men. It typically occurs in women over 65. The most common causes of heart failure in women are hypertension and valvular heart disease, while in men, it is coronary disease. Women with heart failure report lower quality of life and higher depression rates than men. Atypical symptoms in women include facial pallor, cold hands, and evening drowsiness.

Congenital Heart Defects

Babies of both genders are born with congenital heart defects, but female children more often have defects such as atrial septal defect (a hole in the heart), mitral valve prolapse (prolapse of the mitral valve leaflets into the left atrium), and patent ductus arteriosus (a permanently open blood vessel connecting the left pulmonary artery to the aorta).

Aneurysm Rupture

Aneurysms are enlargements of the heart, abdominal aorta, or brain blood vessels. Rupture, or their bursting, is more common in women, as is mortality after surgery.

Broken Heart Syndrome (Stress Cardiomyopathy)

Broken heart syndrome, stress-induced cardiomyopathy, or takotsubo cardiomyopathy is a common cause of heart failure in women. It is believed to occur more frequently in women due to their greater emotionality. Postmenopausal women (over 55 years) are at ten times higher risk compared to men.


Risk Factors for Cardiovascular Diseases Specific to Women

Some risk factors are the same for both genders but do not manifest in the same way. Moreover, women, due to pregnancy, significantly higher levels of estrogen and progesterone, and low levels of testosterone, have specific risks for cardiovascular diseases.

High Cholesterol

High cholesterol is a risk factor for both genders, but in women after menopause, total cholesterol rises because there is no longer enough estrogen to regulate fat metabolism in the liver. However, low HDL (“good” cholesterol) can be more dangerous for women, especially those over 65, as it increases the risk of heart disease, heart attack, or stroke.

Diabetes Mellitus

Diabetes mellitus increases the risk of coronary disease in women 3 to 7 times, whereas in men, it is 2 to 3 times. Mortality from coronary disease resulting from diabetes is 50% higher in women.

High Blood Pressure (Hypertension)

Hypertension (high blood pressure) is more common in women over 60. In women, hypertension is less often well-regulated by medications than in men. This occurs because women may have adverse reactions to the drug, making it harder to determine the appropriate therapy and control blood pressure. After menopause, the body becomes more sensitive to salt, so salt intake should be reduced to regulate blood pressure and prevent sudden spikes.


Menopause before the age of 40, natural menopause, and surgical removal of the ovaries are additional risk factors. During menopause, estrogen levels drop sharply, increasing the risk of blood clots (which can lead to heart and stroke) and atherosclerosis. Estrogen decline is directly linked to heart palpitations (rapid and irregular heartbeat) or arrhythmias. Hot flashes and night sweats during menopause are associated with hypertension and other cardiovascular disease risk factors.


Obese women are at higher risk for coronary disease than men. Menopause, due to decreased estrogen levels, carries an increased risk of obesity. Heart attacks are three times more common in obese women, as are other cardiovascular diseases. The heart requires more strength to pump blood, blood vessels are more narrowed due to cholesterol, leading to easier development of hypertension and heart failure.

Lack of Physical Activity

Exercise reduces the risk of heart disease in women, but many do not exercise enough. Lack of physical activity and obesity are more common among women, increasing the risk of cardiovascular diseases.


Smoking in women is 50% more likely to lead to cardiovascular diseases, and it is three times more likely to cause the first acute heart attack than in men. It is believed that smoking reduces estrogen levels, negatively affecting the elasticity and regulation of blood vessel dilation under the influence of this hormone.

Autoimmune Diseases

Systemic and autoimmune diseases (rheumatoid arthritis, lupus) are much more common in women. They lead to faster plaque buildup in arteries, making heart attacks and strokes more severe in women.

Preeclampsia, Pregnancy-Induced Hypertension, Peripartal, and Postpartum Myopathy

Some women experience conditions during pregnancy such as hypertension, preeclampsia or eclampsia, peripartal or postpartum cardiomyopathy (heart failure occurring during or after pregnancy). These conditions can immediately threaten the pregnant woman’s life or increase the risk of cardiovascular diseases (hypertension, stroke) later in life.

Gestational Diabetes

Women who had gestational diabetes during pregnancy are more likely to develop type 2 diabetes and cardiovascular diseases later in life.

Polycystic Ovary Syndrome (PCOS) and Ovarian Insufficiency

Increase the risk of cardiovascular diseases due to associated risk factors. Polycystic ovary syndrome and primary ovarian insufficiency (reduced quality and reserve of egg cells) can lead to diseases such as coronary disease and type 2 diabetes, which itself is an additional cardiovascular risk factor.

Oral Contraceptive Therapy

Oral contraceptives, or estrogen taken through them, increase the risk of blood clots, and thus the risk of stroke and heart attack. There is also an increased risk of high blood pressure, arrhythmias, and tachycardia.

Preventive Measures

All diseases are more effectively treated, and their complications are prevented if prevention is practiced and regular preventive check-ups are conducted. Recommendations include:

– Visit a cardiologist during annual check-ups.

– Work with your doctor to control blood pressure, cholesterol, and blood sugar levels, which may include taking medications.

– Create an exercise plan that suits you. Gradually aim for 150 minutes of moderate-intensity exercise (like walking) per week.

– Avoid tobacco products and limit alcohol intake.

– Follow a heart-healthy diet plan.


How are Cardiovascular Diseases Diagnosed in Women?

Diagnostic procedures for cardiovascular diseases in women are the same as those for men, but their results must be treated according to women’s anatomy, biochemistry, and metabolism.

Electrocardiogram (EKG) – records the heart rhythm to detect heart disease or damage.

Stress Test – monitors heart function while the patient rides a stationary bike, with increasing speed and resistance. EKG, blood pressure, pulse, breathing, and subjective patient complaints are monitored. For those who cannot perform this test due to knee damage or other reasons, a pharmacological stress test with drugs (dobutamine) is applied, called a dobutamine stress echo test. Blood pressure is measured, EKG is performed, and an ultrasound of the heart is taken simultaneously.

Echocardiography (Heart Ultrasound) – uses sound waves to create a video recording of the heart, showing size, shape, and damage.

CT Coronary Angiogram – the patient is injected with contrast into a vein, and the coronary arteries are scanned to detect narrowings and blockages.

Cardiac MRI – detailed imaging of the heart structure using magnetic resonance to detect inflammatory processes.

Coronary Angiography (Catheterization) – a catheter is threaded through a blood vessel in the arm or groin to image the coronary arteries and detect narrowings and blockages.


Puls Cardiology Team for Women

Ladies, be aware that it is a misconception that only men suffer from cardiovascular diseases before the age of 50. Undergo preventive cardiological examinations because we have a team, led by Dr. Sci. Med. Tamara Urošević, specialized in recognizing symptoms typical for women and timely making accurate diagnoses. If you already know you have cardiovascular disease, our team will provide all forms of modern therapy suitable for the specificities of the female body.

Our team also closely collaborates with doctors of other specialties (endocrinologists, radiologists) to consider each case comprehensively and treat all underlying and associated diseases.