Heart attacks in women are often caused by different mechanisms than in men, which helps explain why they’re frequently missed or diagnosed late. While cholesterol-laden plaque buildup in major arteries is still the most common cause overall, women are far more likely to experience heart attacks from less obvious sources: tears in artery walls, spasms in tiny blood vessels, and plaque that erodes rather than ruptures. Heart disease kills more women than any other condition in the United States, contributing to over 919,000 cardiovascular deaths in 2023 alone.
Plaque Behaves Differently in Women
The classic heart attack story involves a chunk of plaque bursting open inside a coronary artery, triggering a blood clot that blocks blood flow. This does happen in women, but less often than in men. Imaging and pathology studies show that women are more likely to experience plaque erosion, where the surface of a fatty deposit wears away gradually rather than cracking open. Women also tend to have less calcium buildup and smaller areas of dead tissue inside their plaques, even when the overall plaque burden is similar to men’s.
This distinction matters because eroded plaques can still cause dangerous clots, but they don’t always show up as dramatic blockages on standard angiograms. A woman can have a heart attack with arteries that look relatively clear on imaging, a scenario that has historically led to missed diagnoses and delayed treatment.
Heart Attacks Without Major Blockages
Up to 10% of heart attacks occur in people whose large coronary arteries show less than 50% blockage. This condition, known as MINOCA, is significantly more common in women. The causes are varied: coronary artery spasms that temporarily choke off blood flow, small clots that travel to the heart from elsewhere, or plaque disruption in vessels that aren’t severely narrowed. Because stents aren’t useful when there’s no major blockage to prop open, treatment relies on medications to prevent future events.
A closely related problem is coronary microvascular disease, which affects the tiny blood vessels that branch off the main coronary arteries. Damage to the inner walls of these small vessels causes spasms and reduced blood flow, producing chest pain and, in some cases, actual heart muscle damage. Women develop microvascular disease more often than men, particularly after menopause when estrogen levels drop. One hallmark that sets it apart: symptoms typically show up during routine daily activities or periods of mental stress rather than during physical exertion. Standard heart tests often miss it entirely, since they’re designed to detect blockages in large arteries.
Spontaneous Coronary Artery Dissection
One of the most striking differences between male and female heart attacks involves spontaneous coronary artery dissection, or SCAD. This occurs when the wall of a coronary artery tears on its own, allowing blood to collect between the layers and narrow or block the vessel. SCAD is responsible for an estimated 23% to 36% of heart attacks in women under 60, making it a major cause of cardiac events in younger women who may have no traditional risk factors like high cholesterol or obesity.
The triggers also split along gender lines. In women, emotional stress is the most common precipitating factor, reported in 56% of SCAD-related heart attacks compared to just 17% of heart attacks caused by traditional plaque disease. Physical exertion plays a role too, but less frequently. Intense straining, such as heavy lifting, forceful vomiting, or even vigorous coughing, can also set off a dissection by suddenly increasing pressure inside the coronary arteries.
How Estrogen Loss Raises Risk
Estrogen helps keep blood vessels flexible and responsive. It encourages the inner lining of arteries to relax and widen when the body needs more blood flow. After menopause, when estrogen production drops sharply, those protective effects fade. Blood vessels become stiffer, less able to dilate properly, and more prone to damage.
But menopause isn’t the only path to estrogen deficiency. Younger women who lose their periods due to extreme dieting, excessive exercise, or chronic stress develop a condition called functional hypothalamic amenorrhea. Research has found that these women show the same kind of blood vessel dysfunction typically seen in postmenopausal women: impaired ability to dilate arteries, chronic low-grade inflammation, and an overactive stress response system. Their blood vessels don’t expand appropriately even when given medication specifically designed to open them. This means women can face elevated heart attack risk decades before the age most people associate with cardiac events.
Pregnancy Complications as a Warning Sign
Preeclampsia, a condition marked by dangerously high blood pressure during pregnancy, is one of the strongest predictors of future heart disease in women. A large meta-analysis found that women who experienced preeclampsia face roughly 2.5 times the risk of coronary heart disease later in life, a four-fold increase in heart failure risk, and about double the risk of dying from cardiovascular disease. These elevated risks persist for decades after delivery.
Gestational diabetes tells a similar story. Pregnancy essentially acts as a cardiovascular stress test, and complications during that period can reveal underlying vulnerabilities in blood vessel function that may not cause problems for years. Women who had preeclampsia, gestational diabetes, or preterm delivery benefit from closer cardiovascular monitoring starting well before the age when heart disease screening typically begins.
Autoimmune Diseases and Chronic Inflammation
Autoimmune conditions hit women disproportionately hard, and they carry significant cardiovascular consequences. Women with lupus face two to three times the normal risk of heart disease. Rheumatoid arthritis raises the risk by about 50% to 100%, putting it on par with diabetes as a cardiovascular threat. The connection is chronic inflammation, which accelerates plaque formation and damages blood vessel walls over time, even in women who don’t have traditional risk factors like high blood pressure or smoking.
Heart Attacks Are Rising in Younger Women
While heart attack rates have declined among older adults in recent decades, the opposite trend is emerging among people aged 35 to 54, with women in this group seeing a particularly notable increase. Researchers studying more than 28,000 heart attack hospitalizations across four U.S. cities confirmed this shift. The reasons likely involve rising rates of obesity, diabetes, and high blood pressure in younger populations, combined with the unique mechanisms like SCAD and microvascular disease that affect younger women specifically.
Symptoms Women Actually Experience
Women can and do get chest pain during heart attacks, but it often feels different from the crushing pressure that men describe. Women more commonly report a dull heaviness or ache rather than sharp, sudden pain. Beyond the chest, common symptoms include pain in the neck, jaw, throat, upper back, or upper abdomen. Nausea, vomiting, extreme fatigue that comes on suddenly, shortness of breath, dizziness, heartburn, and heart palpitations all appear frequently. Some women describe overwhelming tiredness in the days or weeks leading up to a heart attack, with no obvious explanation.
These symptoms overlap with so many other conditions that both women and their doctors may not immediately suspect the heart. That delay costs lives.
A Diagnostic Gap That Costs Lives
Part of the problem is biological, but part is also how heart attacks are detected. The blood test used to diagnose heart attacks measures a protein called troponin, which heart muscle cells release when they’re damaged. Most hospitals use a single threshold for both sexes. But women naturally have lower baseline troponin levels, meaning a heart attack can push their numbers into a range that looks “normal” by the standard cutoff.
A landmark study tested what would happen if hospitals used sex-specific thresholds, setting the diagnostic cutoff at 16 ng/L for women instead of the standard 50 ng/L used for everyone. The result: the diagnosis rate of heart attacks in women doubled, jumping from 11% to 22% of suspected cases. Men’s diagnosis rate barely changed. The women who were newly identified through the lower threshold turned out to be at high risk for future heart attacks and death, meaning they weren’t borderline cases. They were genuinely having cardiac events that the standard test was missing.