Cardiovascular disease (CVD) is the leading cause of death for both men and women globally, including in the Middle East and North Africa (MENA) region. According to the data published by the UAE Ministry of Health and Prevention in 2023, non-communicable diseases (NCDs) account for over 55% of all deaths, with cardiovascular disease accounting for 34% of all deaths and 70% of NCD-related deaths. Moreover, CVD accounts for 35% of the global female mortality rate yearly, exceeding the rate of all cancers combined! It affects women across all age groups.  According to the Global Burden of Disease (GBD) 2019 study, 6,403 women per 100,000 lived with CVD worldwide. North Africa and the Middle East had the highest prevalence, with 7,651 cases per 100,000. Despite this significant and serious impact, cardiovascular disease in women unfortunately remains notably under-researched, under-recognized, under-diagnosed, and under-treated. This is mainly due to ongoing misconceptions, including the general belief that cardiovascular disease primarily affects men, leaving many women at increased risk due to the major gap in awareness and care.

In this article, I aim to highlight how cardiovascular disease affects women differently, covering various factors contributing to this disparity, including hormonal influences, unique risk factors, differences in disease presentation, and barriers to appropriate care. By bridging the knowledge gap, we can understand the sex-specific differences in cardiovascular disease and strive to improve cardiac health outcomes for women.

Unique risk factors for women

Women face several unique risk factors that contribute to cardiovascular disease, and highlighting them is essential to understanding why heart disease remains the leading cause of death among women. Although the traditional risk factors—obesity, smoking, and hypertension—affect both sexes, their impact and prevalence in women are often greater and more serious.

Obesity is a major risk factor for cardiovascular disease, predominantly affecting women, with a global prevalence up to 50% higher than in men. While overall smoking rates have declined, it is concerning that the prevalence is greater among younger women, who are now picking up the habit at alarming rates.  Notably, smoking is associated with a 25% higher risk of ischemic heart disease in women compared to men. Similarly, hypertension is noted to be particularly more prevalent and more poorly controlled in older women than men. According to the American Heart Association, 51.9% of hypertension-related deaths are in women. It is also important to highlight that diabetes is increasing globally among women. Diabetic women have a 2–4 times greater risk of ischemic heart disease compared to diabetic men.

Hypertensive and metabolic disorders of pregnancy are unique to women and predominantly affect women of colour. Hypertensive disorders, gestational diabetes, preterm birth, and delivering small for gestational age infants are all associated with an increased chance of cardiovascular disease.  Additionally, gestational diabetes and hypertensive disorders of pregnancy increase the risk of chronic kidney disease and its progression. Women with reduced kidney function or those on dialysis face a higher risk of cardiovascular disease compared to men with similar kidney function.

Moreover, Women are 2 to 10 times more likely to experience autoimmune diseases compared to men. Autoimmune diseases, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), disproportionately affect women and are linked to elevated CVD risk, particularly atherosclerotic CVD (ASCVD). The chronic inflammation associated with these conditions causes inflammatory damage to cardiomyocytes, resulting in cardiac injury. Inflammation also damages the inner lining of blood vessels promoting the buildup of fatty plaque that narrows the arteries, a hallmark of ASCVD, which elevates the risk of myocardial infarction (heart attack) and stroke.

Polycystic ovary syndrome (PCOS) is another condition that increases cardiovascular risk in women. Studies have shown that women with PCOS have a greater risk of developing cardiometabolic disorders and obstructive sleep apnea compared to women without the condition.  It is also important to note that cancer treatments, such as anthracyclines and trastuzumab used for breast cancer, can cause symptomatic cardiotoxicity in 1%–4% of patients and asymptomatic cardiotoxicity in 10%–40%. Moreover, radiation therapy is linked to the rapid progression of severe, diffuse coronary artery disease, as well as calcification and stenosis of the heart valves.

Also Read: Obesity Epidemic: Can Bariatric Surgery Be the Answer?

Most of the conditions mentioned above are linked to a sedentary lifestyle, and women of all age groups generally have less active routines. Therefore, it is necessary to educate about the benefits of physical activity since it is directly associated with reducing the risk of cardiovascular disease.  In addition, stress plays a significant role in women’s cardiovascular health, especially since they experience more stressors such as discrimination, intimate partner violence, caregiving and domestic responsibilities. Women are also at a higher risk of developing Takotsubo cardiomyopathy, or “broken heart syndrome,” which is often seen in postmenopausal women.

Cardiovascular risks after Menopause

The transition to menopause is a critical and physiologically challenging time for women, particularly concerning cardiovascular health. Before menopause, estrogen has a significant cardioprotective function. It helps keep blood vessels flexible and dilated, supporting proper circulation and lowering the risk of atherosclerosis. Estrogen also has a positive effect on cholesterol levels, helping to increase the high-density lipoprotein (HDL, commonly known as the  “good” cholesterol) and reduce the low-density lipoprotein (LDL, commonly known as the “bad”  cholesterol). 

As the estrogen levels drop, the risk of developing cardiovascular disease starts to rise.  Consequently, postmenopausal women have an increased risk of developing hypertension, increased LDL cholesterol, and elevated triglycerides—all are contributing risk factors for cardiovascular disease. Moreover, studies have shown that the likelihood of coronary artery disease markedly elevates after menopause, with an increase in the incidence of myocardial infarctions within the first 10 years following its onset.

Different onset and presentation

A heart attack can present differently in women compared to men. While men often seek medical attention for chest pain, women may also experience chest pain but are more likely than men to report more symptoms such as nausea, sweating, vomiting, and pain in the neck, jaw, throat, abdomen, or back. Moreover, due to sex differences in the risk factors and pathophysiology of CVD, the onset and presentation can also vary. When cardiovascular events occur, women are more likely to present with a stroke, while men are more commonly affected by acute myocardial infarction. Coronary artery disease tends to manifest in women at a later age than in men, which is thought to be linked to the cardioprotective function of estrogen. 

Moreover, women with coronary ischemia frequently report symptoms beyond chest pain, such as fatigue, abdominal discomfort, and dizziness. They may also be less conscious of their condition, which delays seeking treatment. Women are more likely to have spontaneous coronary artery dissection and have a greater frequency of myocardial infarction with normal coronary arteries.  Additionally, heart failure in women is most often caused by hypertensive heart disease, whereas in men, it is more commonly due to ischemic heart disease.

Obesity is a major risk factor for cardiovascular disease, predominantly affecting women, with a global prevalence up to 50% higher than in men.

Shahd Abouelenen, Final Year Medical Student at Gulf Medical University, UAE

Prevention strategies for CVD

According to the World Health Organization, approximately 80% of all heart attacks and strokes are preventable. Although women have unique challenges when it comes to cardiovascular disease, many of the risks can be reduced by proactive prevention and management strategies. The following are important measures that women can take to help lower their risk of CVD:

• Know Your Numbers: Regular screening for blood pressure, cholesterol, and blood sugar levels can help detect and control the risk of developing cardiovascular disease.
• Adopt a Heart-Healthy Diet: A diet rich in fresh fruits, vegetables, whole grains, nuts,  lean proteins, and healthy fats (unsaturated fats) can help reduce the risk of heart disease.  Avoid processed food and food high in salt and sugar.
• Maintain a Healthy Weight: Monitor calorie intake to reduce the risk of being overweight or obese.
• Exercise Regularly: In all physical activity guidelines, adults should aim for at least 150 minutes of moderate-intensity exercise each week to improve and maintain good cardiovascular health. Children and adolescents should engage in at least 60 minutes of moderate- to vigorous-intensity physical activity daily.
• Manage Stress: Incorporating stress-reducing techniques such as meditation, yoga, or  regular physical activity can help minimize the negative impact of stress on cardiovascular  health.
• Quit Smoking and Alcohol: Smoking significantly raises the risk of CVD, and quitting can drastically improve heart health. Similarly, alcohol has no safe consumption level, and its detrimental effects greatly exceed any possible benefits.
• Know the Warning Signs: The earlier help is sought the higher the chances of a full recovery.

In addition to lifestyle modification, women should take a proactive approach by discussing their cardiovascular health with their physician. Routine check-ups and addressing risk factors and symptoms play a crucial role in early detection and prevention.

The future of cardiovascular care for women

Although awareness of cardiovascular disease in women has improved, there remains significant work and progress needed to bridge the gender gap and improve equity in women’s cardiovascular healthcare and research. Ongoing research is needed to better understand the biological variations in the effects of CVD on men and women. Moreover, healthcare providers should advocate for gender-specific treatment plans and ensure that women receive the same quality of care and attention as men regarding cardiovascular health. This includes encouraging participation in research specifically focused on women to enhance the understanding of cardiovascular health across all stages of life.

Ultimately, a “one-size-fits-all” approach to cardiovascular research, prevention, and treatment overlooks the biological, socioeconomic, healthcare system, and geopolitical factors that disproportionately impact the incidence and outcomes of cardiovascular disease in women. To reduce gender-specific disparities in CVD, the global community must consider proactive prevention, early detection, and equitable treatment, ultimately improving outcomes for women and reducing the burden of cardiovascular disease worldwide.