Women's Heart Health By Dr Gosia Wamil May 2025 Evidence reviewed May 2025
Cardiovascular Disease: The Leading Killer of Women
Why heart disease remains the number one cause of death in women — and why it is still being missed.
Key Facts
Cardiovascular disease (CVD) — encompassing coronary heart disease, stroke, heart failure, and related conditions — is the number one cause of death in women worldwide. It accounts for approximately 35% of all female deaths globally, claiming more lives than all cancers combined. In the United Kingdom, CVD kills more women than any other condition, yet it continues to be widely underrecognised, underdiagnosed, and undertreated in female patients.
This article summarises the current evidence, explains why women's heart disease presents differently, and outlines what needs to change.
Topics covered: global and UK burden · sex-specific pathophysiology · the menopause transition · diagnostic gaps · clinical trial underrepresentation · what women can do
~35%
of all female deaths globally are from CVD
Source: JACC 2024; WHO 2022
204
women per 100,000 die from CVD annually worldwide
Source: JACC State-of-the-Art Review 2024
1 in 3
women in the UK will die from a cardiovascular cause
Source: British Heart Foundation 2025
1. The Scale of the Problem
Cardiovascular diseases are the leading cause of mortality globally, responsible for approximately 19.8 million deaths in 2022 — around 32% of all deaths worldwide (WHO, 2022). Among women specifically, CVD accounts for roughly 35% of all female deaths, according to a 2024 State-of-the-Art Review published in the Journal of the American College of Cardiology (JACC). The global age-standardised CVD mortality rate in women stands at 204 per 100,000 — a figure that underscores the enormous scale of the problem.
In the United Kingdom, the British Heart Foundation's 2025 statistics confirm that CVD remains the leading cause of death across both sexes, with over 4 million women currently living with heart and circulatory disease. Coronary heart disease (CHD) is the single largest killer, with stroke the second. Progress against CVD mortality in the UK has begun to stall in recent years — driven in part by rising rates of obesity, diabetes, and disruption to healthcare services during and after the pandemic.
2. Why Heart Disease in Women Looks Different
One of the most important — and most consequential — facts about cardiovascular disease in women is that it often does not look like the textbook picture. Classic heart attack symptoms — central chest pressure radiating to the left arm — are more commonly reported by men. Women more frequently experience atypical presentations: nausea, jaw or back pain, extreme fatigue, breathlessness, or a vague sense of unease. Research published in 2024 found that women are nearly twice as likely as men to receive an incorrect diagnosis after a heart attack, and 30% more likely to have stroke symptoms misdiagnosed in the emergency department.
The underlying disease process also differs. Obstructive coronary artery disease — large vessel blockages visible on angiography — is the dominant pattern in men. Women, by contrast, are twice as likely to have non-obstructive coronary artery disease (MINOCA — myocardial infarction with non-obstructive coronary arteries), where ischaemia arises through microvascular dysfunction, coronary vasospasm, or spontaneous coronary artery dissection (SCAD). Standard coronary angiography, which detects large vessel obstruction, can therefore appear normal even in women with significant and dangerous heart disease.
“Women are less likely to receive diagnostic imaging, less likely to receive guideline-recommended medical therapy, and less likely to undergo early angiography — even when presenting with comparable clinical indicators to men.”
— PMC Narrative Review, Gender Disparities in Ischaemic Heart Disease Management, 2025 3. The Menopause Transition and Cardiovascular Risk
Before the menopause, women have a significantly lower risk of coronary heart disease than age-matched men — a gap attributable in large part to the cardioprotective effects of endogenous oestrogen. The statistical evidence is striking: the incidence of coronary artery disease in women is delayed by approximately 7–10 years compared with men, and myocardial infarction by around 20 years. After the menopause, this protection is sharply withdrawn. CVD accounts for 50% of all deaths in post-menopausal women, with ischaemic heart disease responsible for 20% and stroke for 13%.
The menopause transition is therefore a critical window for cardiovascular risk assessment. The role of hormone replacement therapy (HRT/MHT) in modifying this risk remains nuanced. While earlier trials using older synthetic formulations raised concerns, more recent evidence suggests that timing matters: HRT initiated early in the post-menopausal period may reduce cardiovascular risk, whereas late initiation does not offer the same benefit. Contemporary low-dose transdermal oestrogen with micronised progesterone carries a more favourable cardiovascular risk profile than older oral formulations.
Clinical Note — Women-Specific CVD Risk Factors
Beyond traditional risk factors (hypertension, diabetes, smoking, high cholesterol), women carry additional sex-specific risks. A history of pre-eclampsia, gestational hypertension, or gestational diabetes significantly increases lifetime cardiovascular risk. Polycystic ovary syndrome (PCOS), premature menopause (before age 40), and certain autoimmune conditions including rheumatoid arthritis and systemic lupus are also recognised as female-specific cardiovascular risk enhancers (JACC State-of-the-Art Review, 2024). These are not routinely included in standard risk calculators.
4. The Research Gap: Women Underrepresented in Clinical Trials
A fundamental driver of the diagnostic and treatment gap is the persistent underrepresentation of women in cardiovascular clinical trials. Despite CVD being the leading killer of women, the evidence base for diagnosis and treatment has been built overwhelmingly on male populations. According to a 2024 JACC State-of-the-Art Review, women are underrepresented relative to disease distribution across trials of all phases — including early phase studies and drug dosing trials — and this pattern has not substantially improved over decades.
The consequences are tangible. Women experience higher rates of adverse drug reactions, lower rates of cardiac rehabilitation participation following a cardiac event, and receive evidence-based pharmacotherapy less frequently than men with comparable presentations. Guidelines calibrated on male populations risk both over-treating some women and — more commonly — under-treating others.
5. What This Means in Practice
The evidence points clearly toward several areas for change. At the clinical level, symptom recognition tools and risk calculators need to be validated in female populations and updated to include female-specific risk factors such as a history of pre-eclampsia or premature menopause. Diagnostic pathways should expand beyond standard coronary angiography to capture non-obstructive disease, microvascular dysfunction, and SCAD. Sex-disaggregated reporting should be mandatory in cardiovascular clinical trials.
For individual women, awareness is protective. Knowing that heart disease — not breast cancer, not dementia — is the most likely cause of death, and that its symptoms may not match the conventional picture, can prompt earlier presentation and earlier treatment. Blood pressure control, smoking cessation, regular physical activity, a heart-healthy diet, and blood glucose management remain the most powerful tools available. For post-menopausal women in particular, cardiovascular risk assessment should be part of routine care.
Sources & References
- World Health Organization. Cardiovascular diseases (CVDs) fact sheet. Updated 2022. who.int
- Vogel B, et al. Addressing the Global Burden of Cardiovascular Disease in Women: JACC State-of-the-Art Review. J Am Coll Cardiol. 2024;83(25):2690–2707. doi:10.1016/j.jacc.2024.04.028
- British Heart Foundation. Heart and Circulatory Disease Statistics 2025 Compendium. London: BHF; 2025.
- British Heart Foundation. CVD Statistics — UK Factsheet (updated January 2026). London: BHF; 2026.
- MedStar Health. Developing Solutions for Misdiagnosis of Heart Disease in Women. Published February 2024.
- Ahmad Z, et al. Gender Disparities in Ischemic Heart Disease Management. PMC Narrative Review. 2025.
- Vitale C, et al. Cardiovascular Disease in Women and the Role of Hormone Replacement Therapy. PMC Review. 2024.
- Anagnostis P, et al. Menopause-associated risk of cardiovascular disease. PMC / Endocrine Reviews. 2022. PMCID: PMC9066596
- Rana JS, et al. Cardiovascular Risk Associated with Menopause and Menopause Hormone Therapy. Current Atherosclerosis Reports. 2025. doi:10.1007/s11883-025-01343-6
- Paulis L, Kavousi M. Bridging the Gap: Sex- and Gender-Specific Insights in CVD Research. Netherlands Heart Journal. 2025. doi:10.1007/s12471-025-02002-w
- Woodward M. Cardiovascular Disease and the Female Disadvantage. Int J Environ Res Public Health. 2019;16(7):1165.
- Roth GA, et al. Global Burden of Cardiovascular Diseases 1990–2019. J Am Coll Cardiol. 2020;76(25):2982–3021.
About the author: Dr Gosia Wamil MD MSc PhD FRCP FESC is an Oxford-trained consultant cardiologist practising at Mayo Clinic Healthcare in London and the Nuffield Manor Hospital in Oxford, with a specialist interest in women's cardiovascular health and advanced cardiac imaging.
This article is written for general information and public education purposes. It does not constitute medical advice. If you have concerns about your heart health, please consult your GP or a qualified cardiologist.
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