Heart disease is the biggest killer of women under 75 - so why are heart attacks so often misdiagnosed?

Ask anyone what the biggest killer of women is and most will probably say breast cancer or Alzheimer's disease. But, before the age of 75, heart disease is the leading cause of women's deaths around the world. Unbelievably, misdiagnosis of heart attack symptoms and incorrect treatment are just two of the reasons why that number is so large.

The British Heart Foundation (BHF) revealed that coronary heart disease (CHD) is the number one killer of women worldwide. Its worldwide mortality rate is four times that of Alzheimer's and, in the UK alone, it's double that of breast cancer. It sadly kills more women before they turn 75 than anything else.

CHD is the most common cause of a heart attack, a life-threatening medical emergency where blood supply to the heart is suddenly blocked. Along with strokes, heart attacks make up 85% of CHD deaths, per the World Health Organisation. 

Yet, a study by the University of Leeds found that over 50% of women who have a heart attack are initially misdiagnosed, leading to a 70% higher risk of death after 30 days. But what's the reason for this?

"The healthcare system is letting women down hugely," says women’s health specialist and GP Dr Shirin Lakhani. "Most of our understanding of health comes from the male perspective. Women are routinely underrepresented in clinical trials, which doesn’t help with research and there is a myth that heart disease is a man's disease, but women die of [it] more than anything else."

Why are heart attacks in women misdiagnosed? 

1. Heart attacks are thought of as a male condition

Largely, the perception is that heart attacks only affect a certain type of person and that person is a man, says Dr Chris Gale, a professor of cardiovascular health sciences and the honourary consultant cardiologist at the University of Leeds. "Typically, when we think of a person with a heart attack, we envisage a middle-aged man who is overweight, has diabetes and smokes. This is not always the case; heart attacks affect the wider spectrum of the population – including women," he says. 

Whether that perception has come about because more men than women have heart attacks throughout life, the fact that the majority of medical studies are conducted on men or another factor, the discussion around heart attacks centres on men. 

It’s also widely suggested that many women when suffering mild symptoms of heart failure, or even extreme symptoms, tend to ignore them or self-medicate as they don't immediately think they are having a heart attack. The same BHF research also found that women tend to arrive at the hospital later than men, which can lead to devastating consequences. Delaying even 30 minutes of immediate medical attention increases the risk of death dramatically.

Women are also less likely to focus on themselves and will prioritise the health of their family members over their own, Dr Lakhani says, which can lead to symptoms of heart attacks being missed or brushed aside.

Dr Shirin Lakhani

Dr Shirin Lakhani MBBS MRCGP DRCOG is a GP, aesthetic physician, an award-winning cosmetic doctor, and the founder of Elite Aesthetics, with a significant voice of authority within the women's health space. 

2. Women are not told what symptoms to look out for

Heart attack symptoms in men and women are the same, as confirmed by BHA senior cardiac nurse Chloe MacArthur. Yet the common misconception that women experience fewer severe symptoms or 'atypical' symptoms persists. 

Symptoms include chest pain or discomfort in the chest that comes on suddenly, Dr Lakhani says. "The pain may spread to one or both of your arms, your neck, jaw, back, or stomach. Other symptoms include shortness of breath, feeling dizzy, lightheaded or faint, feeling sick, indigestion, being sick, sweating or coming out in a cold sweat, a feeling of anxiety (like a panic attack), and a lot of coughing or wheezing."

It's important to note that you may only experience one of these symptoms, she adds. "Although the most common symptom for both women and men is chest discomfort, you can have a heart attack without experiencing chest pain or pressure."

3. Women are not warned about the increased risk factors

Most people have often been asked by their GPs about their family history of heart disease and most have had blood tests to check cholesterol levels and regular blood pressure checks. But what is not known to many women is even if you present the same high blood pressure or similar high cholesterol levels as a man, you’re more likely to become unwell as a result of those results. This is also the case when it comes to smoking, obesity and diabetes. 

A UK study showed that male smokers have more than double the heart attack risk of men who have never smoked, but female smokers have over three times the risk of women who have never smoked. An excess risk was also found among women with high blood pressure and diabetes. 

Dr Ghada Mikhail, a consultant interventional cardiologist, says, “As a cardiologist, I see women who are surprised to be diagnosed with a heart attack despite having risk factors such as a family history of heart disease. They may also be unaware that they have other risk factors such as high blood pressure, a high cholesterol level or diabetes.”

4. Women are not warned of the link between menopause and heart attacks

Hormones play a significant part in keeping the heart healthy when we're young as they help to control cholesterol levels and reduce the risk of fat building up in the arteries. But as we age and go through menopause and become postmenopausal, and the hormone levels drop, the heart is more susceptible to fat build-up and other factors that can affect heart health.

"There are oestrogen receptors in the heart so when your oestrogen levels go down, your risk of a heart attack goes up,” Dr Lakhani says. “When you are depleted in oestrogen, there are so many symptoms. An 80-year-old man will have more oestrogen than an 80-year-old woman who is not on HRT."

5. Doctors don't test women for a heart attack as quickly as they test men

When someone suffers from a heart attack, the speed of diagnosis and treatment is essential to help save their lives. However, the study by the BHF found that women, for reasons not fully known, are not tested as quickly as a man would be. 

According to the BHF research, women who have an NSTEMI heart attack (a heart attack where there is some loss of blood supply, causing damage) are 34% less likely to receive coronary angiography within 72 hours of their first symptoms compared to men. 

Coronary angiography is the procedure most often used to diagnose a heart attack. It involves administering a dye into the bloodstream to create images that show doctors where there are blockages or narrowings in the arteries. 

Other diagnostic tools are also available - such as testing for troponin, a protein released into the blood when there is heart damage. A simple blood test can reveal whether the protein is present but women release this protein slower than men, which also contributes to the misdiagnoses. However, there is now a new high-sensitivity test designed specifically for women that will indicate the levels more accurately. 

Treatments of heart attacks in women

The same study by the University of Leeds also highlights that women are just not receiving the same medical care as men, with an average of two women dying every day from heart attacks and heart failure needlessly in the UK. 

Dr Gale says the reasons for the difference in care are not clear. "We know women receive unequal heart care - and we have identified which vital treatments they are missing,” he said. “Understanding why these shortfalls exist and tackling them head-on could save lives. Health professionals have the best interests of their patients at heart, it’s not that they don’t care about women or wish to treat them differently," he says. 

"It’s likely to be a combination of biology and bias. We need to understand more about why this is happening, and the way health systems make it more likely to happen."

The study showed that of 16 endorsed lifesaving treatments available on the NHS, a huge 13 out of the 16 were less likely to be considered to treat a woman. 

Dr Mike Knapton, the associate medical director at the BHA, has an alternative explanation - and it has to do with the troponin test. "The research shows that when different limits are applied to the troponin test, a routine test for a heart attack, more women receive a correct diagnosis of heart attack." 

However, he adds: "More research is urgently needed into tests that will enable earlier and more accurate diagnosis of a heart attack, particularly in women."

How to reduce the risk of a heart attack 

Being fit and healthy is the number one most important thing we can do for our heart health but Dr Sonya Babu-Narayan, a consultant cardiologist and the associate medical director at the BHF has outlined other areas to focus on too.   

• Manage your weight: Focus on making small, achievable, long-term changes, such as reducing your portion sizes. This can help get your weight and waist circumference into a healthy range and, importantly, keep it there. 
• Prioritise a balanced diet: A healthy balanced diet is vital for heart health, so aim to eat less sugar or salt, avoid ultra-processed food, and instead eat more wholegrains, fruit and vegetables. 
• Move more: Aim for 150 minutes of moderate-intensity activity a week. You don’t have to hit the gym – a power walk or an activity like gardening can help keep you fit. 
• Know your numbers: If you live in England and are between 40 and 74 years old, you may be invited to your free NHS Health Check – do go along as you will have your cardiovascular risk levels calculated and explained.  
• Bring down your blood pressure and control your cholesterol: If you have been diagnosed with high blood pressure, seek advice from your GP about how to lower it and avoid developing high cholesterol with a healthy balanced diet.
• Stop smoking: If you’re a smoker, quitting for good is one of the best things you can do to help your heart. 
• Lower your stress levels: Working to reduce your stress levels could lower your blood pressure and help you avoid developing unhealthy habits that you may turn to to cope. It’s also important to make sure you’re well rested, as getting enough sleep is important for both our general well-being and the health of our heart and blood vessels.  
• Consider HRT: If you’re experiencing symptoms of perimenopause, you may wish to discuss using HRT with your GP to help manage them. If you have a high risk of heart disease or are living with a heart condition, you may still be able to take HRT. However, if HRT is not for you, other techniques may help manage your symptoms. 
• Know your medical and family history: When you need medical advice, your doctor may need to know if you have a family history of cardiovascular disease, or if you’ve had diabetes or high blood pressure during pregnancy to assess your risks appropriately. 

Dr Sonya Babu-Narayan

Dr Sonya Babu-Narayan is an Associate Medical Director at the British Heart Foundation and a consultant cardiologist with over 20 years of medical experience.

Not everyone who is diagnosed with heart disease will have a heart attack or a stroke. Heart attacks in women are common but coronary heart disease can also result in angina. This is a short-term pain or discomfort around the chest that can spread to other parts of the body, including the arms, neck, back, stomach, and jaw. It typically comes about after exercise and dissipates with rest but it can also come about with distressing news, cold weather, or post-meal. It doesn't necessarily lead to a heart attack, nor does it permanently damage your heart, but it does increase the risk. 

If you are experiencing adverse symptoms, speak to your doctor. In an emergency, always dial 999.