Women and Coronary Artery Disease

Coronary artery disease is often not typical in women

chest pain
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Women die of cardiovascular disease more than of any other cause, and most of these deaths are due to coronary artery disease (CAD). However, in several important ways, the CAD some women experience can be substantially different from the “classic” CAD that is described in medical textbooks. In these women, the differences may cause a delay in making the correct diagnosis, and thus, may impact their outcomes.

Most women with CAD have a fairly "typical" form of the disease — the disease behaves the way the textbooks say it is “supposed” to behave, which is to say, the way it behaves in men. On average, women who develop CAD are about 10 years older than men who develop CAD, and these "older" women have roughly the same outcomes as men, when matched age for age — at least when their CAD is diagnosed and treated in a timely fashion.

The majority of women with CAD fall into this "older patient, typical CAD" pattern.

”Atypical” CAD in Women

Unfortunately, many more women than men display "atypical" patterns when they develop CAD, and these atypical patterns all too often lead to missed diagnoses and inadequate therapy, and therefore, to worse outcomes. 

In particular, there are three aspects CAD that are often problematic in women:

  • The symptoms of CAD can be different in women.
  • Standard methods of diagnosing CAD can be misleading in women.
  • The CAD itself can be atypical in women.

These atypical features of CAD, when coupled with the false notion (still held by too many doctors) that "women just don't get heart disease," contribute mightily to critical delays in the diagnosis and treatment of CAD in women.

Let's look at these three factors more closely:

The Symptoms of CAD Can Be Different In Women.

When women have angina, they are more likely than men to experience "atypical" symptoms.

Instead of chest pain, they are more likely to experience a hot or burning sensation, or even tenderness to touch, which may be located in the back, shoulders, arms or jaw — and often women have no chest discomfort at all.

An alert doctor will think of angina whenever any patient (man or woman) describes any sort of fleeting, exertion-related discomfort located anywhere above the waist, and they really shouldn't be thrown off by such "atypical" descriptions of symptoms.

However, unless doctors are thinking specifically of the possibility of CAD, they are all too likely to write such symptoms off to mere musculoskeletal pain or gastrointestinal disturbances.

Myocardial infarctions (heart attacks) also tend to behave differently in women. Frequently, instead of the crushing chest pain that is considered typical for a heart attack, women may experience nausea, vomiting, indigestion, dyspnea (shortness of breath), or extreme fatigue — but nothing they construe as chest pain. Unfortunately, these “atypical” symptoms are also easy to attribute to something other than the heart.

Furthermore, women (especially women with diabetes) are more likely than men to have "silent" heart attacks — that is, heart attacks that occur without any noticeable symptoms at all, and which are diagnosed only at a later time..

The Diagnosis of CAD in Women Can Be More Difficult.

Diagnostic tests that usually work quite well in men sometimes can be misleading in women. The most common problem is seen with stress testing.  In women, the electrocardiogram (ECG) during exercise can often show changes suggesting CAD, whether CAD is present or not, thus making the study difficult to interpret.

Many cardiologists routinely add an echocardiogram or a thallium study when doing a stress test in a woman, which greatly improves diagnostic accuracy.

In women with typical CAD, coronary angiography is every bit as useful as in men; it identifies the exact location of any obstructing plaques  (i.e., blockages) within the coronary arteries, and guides therapeutic decisions. However, in women with atypical coronary artery disorders (to be discussed in the next section), coronary angiograms often appear misleadingly normal. Thus, in women angiography is often  not  the gold standard for diagnosis, as it is for most men.

CAD in Women Can Take Atypical Forms.

At least four “atypical” types of coronary artery disorders can occur in women, usually in younger (i.e., pre-menopausal) women. Each of these conditions can produce symptoms of angina with apparently "normal" coronary arteries (that is, the diseased coronary arteries may appear normal on angiogram). The problem, obviously, is that if the physician places all of his/her trust in the results of the angiogram, he/she is likely to miss the real diagnosis.

Here are the four atypical forms of coronary artery disease that are seen in women more often than in men. Follow the links for a more detailed discussion of each one.

A Word From Verywell

While CAD is quite common in women, it has become clear that CAD in women can be quite different from CAD in men. This makes the correct diagnosis a particular challenge in women.

If you or a loved one are are concerned that you might have CAD, make sure you know about the atypical symptoms that often accompany CAD in women, and of the atypical results of diagnostic tests you may encounter during your evaluation. And just as importantly, make sure your doctor is aware of these atypical patterns as well, before he or she writes off your symptoms as being non-cardiac.


Hemal K, Pagidipati NJ, Coles A, et al. Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease: Insights From the PROMISE Trial. JACC Cardiovasc Imaging 2016; 9:337.

Poon S, Goodman SG, Yan RT, et al. Bridging The Gender Gap: Insights From A Contemporary Analysis Of Sex-Related Differences In The Treatment And Outcomes Of Patients With Acute Coronary Syndromes. Am Heart J 2012; 163:66.

Stangl V, Witzel V, Baumann G, Stangl K. Current Diagnostic Concepts To Detect Coronary Artery Disease In Women. Eur Heart J 2008; 29:707.