Six months after giving birth to her second child in May 2019, 35-year-old Marianne Dancy began feeling strangely unwell. It started with general fatigue and swollen ankles, which she chalked up to postpartum mom fatigue from being on her feet all the time. But a few months later, she began experiencing unexpected vision problems, so she decided to see a doctor.
“I went in for a check-up, and they couldn’t find anything,” Dancy says. She tells PS she was simply told to “wait and see.” After seeking a second opinion, Dancy was recommended the same thing. But her symptoms continued to progress, and Dancy became increasingly worried. In November 2019, she went to the emergency room complaining of severe muscle fatigue, shortness of breath, and difficulty lying down without feeling suffocated.
Doctors diagnosed her with pneumonia and sent her home that same day, but despite being treated for what was supposed to be pneumonia, she suffered from the exact same symptoms a few weeks later.
At that point, Dancy scheduled an appointment with another doctor, who gave her a prognosis of heart failure.
Ms Dancy was quickly admitted to hospital where she was diagnosed with peripartum cardiomyopathy, a rare heart condition that can develop during pregnancy or after birth.
Dancy’s story may seem extreme, but sadly, missed heart disease like hers is not uncommon. Heart disease is the number one cause of death among women in the United States. And although women are more likely to experience heart failure, they are less likely to receive life-saving treatment. Additionally, younger women, in particular, are often underdiagnosed for heart disease because symptoms go unrecognized or are misinterpreted.
So the statistics were stacking up against Dancy from the start, but why does heart disease in women get less consistent attention?
Experts featured in this article:
Payal Kohli, MD, is a noninvasive preventive cardiologist, founder and medical director of Cherry Creek Heart in Aurora, Colorado, and an associate adjunct professor in the Department of Cardiology at Duke University.
Nikki Bhatt, MD, is a cardiologist and visiting professor at Brigham and Women’s Hospital and Harvard Medical School.
Harmony Reynolds, MD, is chair of the American Heart Association’s Committee on Cardiovascular Disease and Stroke in Women and Minority Populations and director of the Sarah Ross Souter Women’s Cardiovascular Research Center at NYU Langone.
What is Heart Disease?
To understand why women may not notice the symptoms of heart disease, it’s important to first understand what heart disease exactly is.
There are many different types of heart disease. They can be broken down into three main categories, says noninvasive preventive cardiologist Payal Kohli, MD, founder and medical director of Cherry Creek Heart in Aurora, Colorado, and an associate adjunct professor in the Department of Cardiology at Duke University.
First, there’s the “plumbing problem.” The heart is a muscle that’s constantly working, so it needs a constant flow of blood. You can think of blood vessels as tiny pipes that carry blood to your heart. These pipes can become clogged or blocked in a condition called atherosclerosis. In atherosclerosis, cholesterol deposits develop in these arteries, preventing blood from getting to where it’s needed, leading to a heart attack, says Dr. Kohli. “Imagine your shower pipes suddenly stopping completely and starting to back up,” she explains. “When experts talk about heart disease being the number one cause of death, they’re usually talking about this type of blockage that leads to a heart attack or stroke.”
The next type of heart disease isn’t a plumbing problem, but rather a pumping problem. “Your heart is a muscular pump that pumps blood throughout your body. You can get a condition called congestive heart failure, where the pump stops working because it’s not strong enough, it’s weak, or it’s too stiff and it stops working,” says Dr. Kohli. This type of heart disease is more common in older women and people with diabetes.
The third type of heart disease is electrical problems. “Just like a house, your heart has electricity running through it that keeps it beating regularly,” says Dr. Kohli. Disruptions to the “electrical cables” can be caused by a variety of factors, including age, alcohol, tobacco, marijuana, high blood pressure, diabetes, and weight, which can lead to arrhythmias and heart rhythm problems.
Although women most commonly experience plumbing problems, they can experience all kinds of heart problems, says Dr. Kohli, but diagnosis comes with its own challenges.
Why is heart disease overlooked in women?
It’s no secret that medical stigma plays a big role in whether or not women are diagnosed with certain health conditions, and when it comes to heart disease, that stigma runs deep, especially in how symptoms are assessed.
“What we understand to be the classic symptoms of heart disease… those classic symptoms are actually what men experience: feeling like an elephant is being crushed in their chest, pain in the arms, shortness of breath,” explains cardiologist Nikki Burt, M.D., visiting professor at Brigham and Women’s Hospital and Harvard Medical School. “Women experience a completely different set of symptoms.”
In women, the signs of heart disease are often more subtle, such as fatigue, dizziness, slight shortness of breath, or palpitations.
These subtle differences in symptoms mean that women’s symptoms are often overlooked. In fact, many common symptoms in women have been considered “atypical” by doctors for decades, says Harmony Reynolds, MD, chair of the American Heart Association’s Committee on Cardiovascular Disease and Stroke for Women and Minority Populations and director of the Sarah Ross Souter Center for Women’s Cardiovascular Research at NYU Langone.
Only now are changes being made to educate healthcare professionals about heart disease symptoms, especially in women. “The latest chest pain guidelines, led by female cardiologists, advise against further use of the term ‘atypical’ to describe chest pain, as it reinforces stigma,” says Dr. Reynolds. But change is often slow, meaning cases still go unnoticed.
Primary care physicians, in particular, miss about one-third of heart failure diagnoses and are especially likely to miss symptoms of heart failure in women, black adults, and low-income people, according to a study published in the journal Circulation: Heart Failure.
Heart disease symptoms can also be downplayed by patients and healthcare professionals because of assumptions about what stage of life a woman is in, Dr Bhatt tells PS. “Women at risk of heart disease are often in the middle of life and have to juggle family commitments and caring for elderly parents, so they may simply attribute fatigue to being busy,” she says. Dizziness and shortness of breath are also often dismissed as general fatigue, and palpitations are often blamed on anxiety, she adds.
What’s more, while clinical trials are a crucial part of understanding and improving the diagnostic process and health, Dr Kohli says women are “grossly underrepresented” in cardiac clinical trials. “Typically, there are three men for every one woman in a clinical trial,” Dr Kohli told PS.
“We also know that women’s biology is a little bit different because of their reproductive cycle, which means a woman’s risk of heart disease changes throughout her life depending on whether she’s pre-menopausal, during menopause, post-menopausal, pregnant or not,” says Dr. Kohli. All of this can affect the heart and blood vessels, and ultimately, her heart disease risk profile. But these complexities have been largely unexplored in research.
On top of that, education remains biased. Even in CPR training, the mannequins used are all often male-looking and not female-looking, Dr. Burt says. This may seem like a small thing, but it can subconsciously influence people to miss female cardiac arrests. And bystanders and clinicians are left poorly informed about the techniques needed to save the person. A 2024 study from Duke University analyzed data from more than 309,000 cardiac arrests from 2013 to 2019 and found that women were 14% less likely than men to receive bystander CPR or defibrillation.
How women can protect themselves from heart disease
“We as women face gender disparities in everything from pay to number of promotions, and now we’re seeing gender disparities in heart disease detection and management,” says Dr Kohli, which is why patient and healthcare provider advocacy remains as important as ever.
Reynolds is hopeful for the future because of advances being made in research centered on diagnostic and treatment equity for women. Some of this research is shedding light on bias in the medical field, and over time, doctors and other healthcare professionals will likely be more willing to listen to their patients, she told PS. Reynolds also sees increased investment in learning and education about heart disease risk factors by professionals outside of the heart health field, such as obstetrician-gynecologists, dentists and PCPs.
Calcium scores, which use x-rays of the heart to check for calcium deposits and plaque, and genetic risk scores, which use genes to identify risk factors for heart disease, are other important avenues of innovation, Dr Kohli said.
But there’s also a lot you can do preventatively to reduce your risk early on, including certain lifestyle choices like avoiding smoking, monitoring high blood pressure, eating a heart-healthy diet, managing weight gain, limiting alcohol, prioritizing sleep and focusing on stress management.
For Dancy, the latter, in addition to being regular with her medication, has been crucial in keeping her heart disease symptoms in check. “Stress is a huge trigger for my heart health,” she told PS. Finding a therapist to help de-stress and process overwhelming emotions is something she always recommends as a preventative measure.
Meanwhile, Dr. Kohli says she can’t stress the importance of testing enough. There are three in particular that she recommends. The first is a lipid panel, which measures cholesterol, and you should start getting one in your 20s. The second is a hemoglobin A1C test, which can tell you about your blood sugar control and is recommended for adults over 45.
And once in your life, you should get a Lipoprotein A test, which measures the level of Lp(a) in your bloodstream. High Lp(a) levels can indicate an increased risk for heart disease and stroke, but they don’t change significantly throughout your life, so you only need to get the test once. This test isn’t one that’s talked about or well-known. But if the test results show you’re at increased risk, it can raise some “red flags” for you as a patient, says Dr. Kohli. “Now I know, as your doctor, I need to treat you more aggressively.” So it’s something you can and should ask your health care provider about, Dr. Kohli tells PS.
In general, when it comes to heart disease, you should never be afraid to get more help — after all, if Dancy hadn’t seen a different doctor and had other tests, she might not be here today, sharing her story with others.
Alexis Jones is PS’s Senior Health & Fitness Editor. Her passions and areas of expertise include women’s health and fitness, mental health, racial and ethnic disparities in health care, and chronic disease. Prior to joining PS, she was a senior editor at Health magazine. Her other work can be found in Women’s Health, Prevention, Marie Claire, and more.