We’ve all seen this movie…a man clutches his chest, showing intense pain and collapses on the floor—heart attack. It’s usually the first symptom of heart disease in these movie scenes.

You probably think women are different, right? That’s been the “new” story in the last several years—that women have very different symptoms from men, often not experiencing the classic chest pains but more often complaining of nausea or back pain or extreme fatigue.

It turns out that almost everything we think we know about women and heart disease symptoms is wrong. That’s the finding of a major new study of gender differences in heart disease.

When it comes to heart disease, women are indeed very different from men—even chest pain symptoms are subtly different. Plus, doctors often miss important risk factors in women—or order the wrong diagnostic tests.


“Every aspect of the evaluation for heart disease seems to differ between men and women, whether looking at risk factor profile, risk scores, symptoms, the tests that doctors selected and the test results,” says Pamela Douglas, MD, Ursula Geller Professor for Research in Cardiovascular Disease at Duke University School of Medicine, and leader of the study team.

While most studies have looked at how to evaluate patients who show up in the ER with a suspected heart attack, we know very little about everyday patients who go to their regular doctors with symptoms that may be a sign of heart disease. So Dr. Douglas’s team analyzed data from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial, which evaluated about 10,000 patients with suspected coronary artery disease (CAD)—the most common kind—who were seen in outpatient settings. The average age of women was 62 (for men it was 59).

The differences were so big that Dr. Douglas, along with other experts, believes that there should be unique prevention and diagnostic guidelines just for women. Her team’s research is supporting that aim and has already uncovered some key differences that all women should know about to protect their hearts—now. Here’s what they found…


Chest pain was the number-one complaint: Nearly 75% of men and women who went to their primary care doctors to be evaluated for heart disease showed up because they had chest pain. However, there were subtle differences in the types of pain. Women were more likely to experience squeezing or crushing chest pain, while men were more likely to experience aching, dull or burning chest pain.

Both men and women were equally unlikely to complain of less classic symptoms—about 16% of both men and women went to the doctor because they were experiencing shortness of breath, for example. There were some differences in more minor symptoms, but these only brought patients to their doctors less than 4% of the time—women complained of back, neck or jaw pain and palpitations, whereas men complained of fatigue or weakness.

Bottom line: When it comes to heart disease symptoms, both men and women should pay attention to chest pain and, to a lesser extent, shortness of breath. Says Dr. Douglas, “Women don’t need to worry so much about unusual symptoms like fatigue or nausea.”


When women went to the doctor for suspected heart problems, they had a higher prevalence of risk factors for heart disease than men. They were more likely to have hypertension, high cholesterol, vascular disease and a family history of premature CAD, and about as likely to have diabetes. They were also more likely to have nontraditional risk factors that are not measured on risk scales, such as depression and a sedentary lifestyle.

Here’s what it means—women, at least until menopause, are somewhat protected against heart disease. It takes more risk factors for them to get to the point that it starts affecting their heart.

While that’s a good thing, it also means there is a big missed opportunity for prevention—treating these risk factors before you turn up at your doctor’s office with chest pain! Even if these risk factors show up at, say, your annual physical, some doctors may be letting them slide with women.

Another trap: A low score on a heart disease risk calculator such as the Framingham Heart Risk Score. Because these scores don’t include factors such as depression or a sedentary lifestyle, they often can underestimate a woman’s real heart disease risk. That is, even if your doctor diagnoses you with depression, it wouldn’t raise your official heart risk score—even though it does actually increase your risk.

Bottom line: Primary care physicians shouldn’t ignore creeping high blood pressure, cholesterol problems, mood conditions or a couch potato lifestyle in their female patients. Says Dr. Douglas, “Doctors should be more aggressive in treating women for risk factors.”


Compared with men, women were more likely than men to be referred for imaging echocardiography stress tests, which use ultrasound to create an image that shows how well your heart pumps while you exercise. That makes sense since since these tests are known to be more accurate than electrocardiograms in women than men, says Dr. Douglas.

But another difference concerned her. Physicians ordered more stress nuclear tests, in which a radioactive dye is injected, over stress echocardiography tests, for women compared with men. Why the concern? For one, there isn’t good evidence that nuclear tests are any better than standard non-nuclear echocardiographs. Second: Women are more sensitive to the negative health effects of radiation, resulting in a small increase in cancer risk.

Bottom line: If your doctor suggests a nuclear to test your heart health, ask if it’s really necessary. (Sometimes there’s a good reason, such as comparing new results against previous nuclear test results or because you have breast implants.)


To really understand how heart disease differs between the genders, much more work like that of Dr. Douglas’s team needs to happen. One example of what we still don’t know: Women are less likely to have a result that indicates a problem (a so-called “positive” test result) from one of these diagnostic tests, compared with men. That sounds like good news, but it’s really a paradox. It should mean that women’s hearts are healthier than men’s. But they’re not.

“The same percentage of women die from cardiovascular disease as men,” says Dr. Douglas. “This would suggest that, somehow, we are missing something here—we’re just not sure what.”

Stay tuned.