Cardiovascular Disease in Women – The Disease of “Unders”

Cardiovascular disease (CVD) is the leading cause of death in women world-wide and the leading cause of premature death for women in Canada1. Yet there are sizeable knowledge gaps in understanding how best to prevent, monitor, diagnose and treat cardiovascular disease in women.

“The stunning lack of research specifically oriented to women and the under-representation of women in CVD research studies are significant contributing factors to the under-recognition, under-diagnosis, under-treatment, and under-support of women with CVD in Canada.”

~“State of the Science in Women’s Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender”, Journal of the American Heart Association, Feb 2020

The knowledge gap is a global issue. There are few Canadian, American or International cardiovascular disease guidelines that are women-specific.

What is cardiovascular disease?

Cardiovascular disease refers to diseases and conditions that affect the heart and circulation, usually resulting from the buildup of fats and cholesterol on the artery walls. You may have heard it described as “hardening of the arteries” or arteriosclerosis.

This plaque causes arteries to narrow, blocking blood flow. The plaque can burst, leading to a blood clot anywhere in the body.

When blood flow is restricted to the heart, angina or chest pain can occur. This is a form of heart disease. When blood flow stops abruptly to a part of the heart it causes a heart attack. Compared with men, women are more likely to experience chest pain (angina) as their first symptom of cardiovascular disease and less likely to present with an acute heart attack2.

Blockages in the brain cause strokes or transient ischemic attacks (TIA). Symptoms can include one-sided weakness or numbness in the face, arm or leg, problems with vision, walking, talking or thinking. Although the overall incidence of stroke is higher in men, stroke incidence in women increases sharply after the age of 853.  When older women have strokes, they’re more severe and with higher rates of institutionalization compared with male stroke survivors

Blockages in the legs leads to peripheral artery disease or intermittent claudication causing muscle pain that happens when women are active and improves at rest.

The global progression of studying CVD in women

Up until the 1990’s, men were primarily recruited for clinical trials of medications, yet it’s well recognized that some drugs act differently in women and men and that there are female-specific risk factors. In 2004 the first women-specific cardiovascular disease prevention guidelines were published in the United States, then updated in 2007 and 2011. In 2016 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice provided some recommendations tailored specifically to women. Between 2010-2017, participation of women in eligible cardiovascular clinical trials was 38%- better, yet remaining under-represented2.

Most women in Canada are unaware of cardiovascular disease symptoms, risk factors, and their own risk status. A recent (2017) national survey of 2000 women in Canada found low rates of cardiovascular risk awareness that varied by age, race and ethnicity, and place of residence4

Empower yourself  

Know your risks

These 9 factors are thought to account for 96% of modifiable risk of heart disease in men and women:

  • Smoking
  • Hypertension
  • Diabetes
  • Obesity
  • Unhealthy dietary patterns
  • Sedentary behavior
  • Excess alcohol consumption
  • Unfavourable cholesterol profile (low HDL cholesterol and/or high LDL cholesterol)
  • Psychosocial/stress factors

Additional female-specific risk factors5:

Puberty:   Women who started menstruating before the age of 12 have a greater risk of cardiovascular disease in later life.

Pregnancy: Pregnancy creates a natural stress on the cardiovascular system and this can be amplified by high blood pressure in pregnancy, gestational diabetes and preterm births.  Infertility and polycystic ovary syndrome have also been associated with a higher risk.

Menopause: Women are at lower risk of cardiovascular disease than men during their reproductive years, but this advantage disappears after menopause. The loss of estrogen is associated with undesirable changes in cholesterol, metabolic health and blood pressure.

  • Premature menopause (before 40) or early onset menopause (40-45) further increases risk, by up to 50%.
  • Women with intense and frequent vasomotor symptoms (hot flashes and night sweats) are at higher risk of heart disease
  • Sleep apnea strains the heart and contributes to hypertension. Incidence of sleep apnea increases in midlife.

Autoimmune disease: The prevalence of autoimmune disease is estimated to be 2-10x higher in women and the associated inflammation can predispose to heart disease.

Depression: Depression is 2x higher in women than men, and is believed to increase risk of cardiac events by 50-75%

Know the symptoms of cardiovascular disease

When in doubt, check it out. Don’t ignore your symptoms.

Symptoms of heart attack6:

  • Chest discomfort. It may be described as pressure, squeezing, fullness or pain, burning or heaviness. However women can experience a heart attack WITHOUT chest pain.
  • Sweating
  • Upper body discomfort: Neck, jaw, shoulder, arm, upper back
  • Nausea
  • Shortness of breath
  • Lightheadedness
  • Extreme fatigue

 Symptoms of stroke – Think FAST7  

Face – is it drooping?

Arms – can you raise both?

Speech – is it slurred or jumbled?

Time to call 9-1-1 right away.

Know your numbers

-Blood pressure, blood sugar, cholesterol, especially if you have a family history of cardiovascular disease or diabetes, and for women approaching or beyond menopause. Your risk increases as you age and the further you advance into post-menopause.

Understand your options to reduce your risk

-Consult with your health care team

-Refer to established, credible organizations when accessing information online – Canadian Heart and Stroke Foundation,  The Mayo Clinic , The Cleveland Clinic, American Heart Association , Canadian Women’s Heart Health Centre

Keep cardiovascular health top of mind and close to your heart.




  1. Causes of Death Collaborators. Global, regional, and national age, sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Lond Engl.2017;390:1151–1210
  2. Norris CM et al. State of the Science in Women’s Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender. J Am Heart Assoc. 2020 Feb 18;9(4):e015634. doi: 10.1161/JAHA.119.015634. Epub 2020 Feb 17. PMID: 32063119; PMCID: PMC7070224.
  3. Persky RW, Turtzo LC, McCullough LD. Stroke in women: disparities and outcomes. Curr Cardiol Rep. 2010 Jan;12(1):6-13. doi: 10.1007/s11886-009-0080-2. PMID: 20425178; PMCID: PMC2861793.
  4. Heart and Stroke Foundation of Canada. 2018 Heart report: Misunderstood. 2018.
  5. Canadian Heart Health Women’s Centre, U of Ottawa Heart Institute. Heart Disease Across Her Lifespan
  6. Canadian Heart and Stroke Foundation (
  7. Canadian Heart and Stroke Foundation (