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Introduction   

In the United States, heart disease is the leading cause of death in women and affects over 60 million females with more than 400,000 women dying from the disease each year (6, 16). Even though one in five female deaths is attributed to heart disease, research indicates that only roughly half (56%) of American women recognize the prevalence and severity of heart disease (11).

Many women are more concerned about developing breast cancer than heart disease, but statistics indicate that more women die from heart disease than breast cancer, diabetes, and accidents combined (19).

Women experience myocardial infarctions (MIs) at an older age than men, yet they are more likely to die within a few weeks after an MI than men (19). Heart disease can affect women of any age and is not a concern restricted to older females only.

Additionally, heart disease is the leading cause of death in women of most racial and ethnic groups in the United States, including African Americans, Caucasians, and Hispanics, and the disease costs the nation about $219 billion every year (19).

A lifestyle that includes a healthy diet, regular exercise, and not using tobacco products can prevent heart disease. Although heart disease is preventable, many healthcare providers lack knowledge and awareness of the disease, which leads to late diagnosis and delayed treatment. In fact, one study indicates that less than half of primary care physicians identified heart disease as the top medical priority for women (4).

The Women’s Heart Alliance published the results from a national survey that showed only 22% of primary care physicians and 42% of cardiologists feel extremely well prepared to assess heart disease risk in women (8). Additionally, almost 70% of postgraduate medical trainees reported minimal to no training on sex-based medical concepts (9). These findings make it even more important for nurses to apply their knowledge of heart disease when caring for female patients.

Nurses can play a major role in preventing heart disease in women by applying appropriate assessment techniques, evidence-based interventions, and effective patient education.

Pathophysiology 

There are physiological differences of the cardiovascular system between men and women, which attribute to how women experience heart disease in relation to men.  

Females have smaller blood vessels and heart chambers, and the walls of their cardiac ventricles are thinner (12). Women have fewer red blood cells, which decreases the blood’s ability to carry as much oxygen. Additionally, females are more likely to experience postural hypotension, and women’s higher levels of estrogen and progesterone, and lower levels of testosterone, affect heart health.  

Heart disease encompasses several types of heart conditions that affect the blood flow to the heart. The main types of heart disease are coronary artery disease (CAD), arrhythmia (or dysrhythmia), and heart failure.  

Coronary Artery Disease (CAD) 

CAD is the most common type of heart disease in both men and women and is the leading cause of death around the world (20). It is caused by atherosclerosis, or plaque accumulation in the arterial walls, which leads to stress on the heart due to the need to pump the blood harder to move it through the narrowed and stiffened arteries. When blood flow to the heart is restricted, ischemia can occur. Coronary artery disease is known as a “silent killer” because a patient can have CAD for many years and not experience any symptoms until a MI occurs.  

There are two types of CAD: stable ischemic heart disease and acute coronary syndrome (15). Stable ischemic heart disease is a chronic condition where the coronary arteries gradually narrow over many years or decades, thus yielding minor to no symptoms for the patient. If the patient does experience symptoms, these are typically stable angina felt during physical activity or emotional distress, and dyspnea experienced during light physical activity (15).  

Conversely, acute coronary syndrome is a medical emergency that is caused by the rupture of plaque in the coronary artery that causes a blood clot that impedes blood flow to the heart. Women are at specific risk for CAD due to the use of hormonal birth control and reproductive and pregnancy-related conditions, including hormonal changes due to menopause (19).  

Symptoms associated with CAD in women are chest discomfort or pain, dyspnea, nausea or vomiting, abdominal pain, insomnia, and unexplained fatigue (16). 

Arrhythmias 

Arrhythmias are irregular heart rhythms or rates when the heart beats too quickly, too slowly, or with an irregular rhythm. Tachyarrhythmia is an abnormal rhythm with a ventricular heart rate of 100 beats or more per minute, and bradyarrhythmia is an abnormal rhythm with a ventricular heart rate of 60 beats or less per minute (7).  

Common causes of arrhythmia are MI, arterial stenosis, cardiomyopathy, hypertension, diabetes, COVID-19 infection, thyroid disease, sleep apnea, over-the-counter cold and allergy medications, excessive alcohol or caffeine intake, smoking, stress and anxiety, electrolyte imbalance, and illicit drug use (7). 

In a normally functioning heart, an electrical impulse starts in the sinoatrial (SA) node, also known as the “pacemaker” of the heart, and spreads throughout the atria, causing them to contract and force blood into the ventricles. The SA node works at a rate of 60-100 beats per minute (7). The impulse then travels through the internodal pathways to the atrioventricular (AV) node between the atria and ventricles where it rests for a fraction of a second to permit the ventricles to fill completely with blood received from the atria; this why the AV node is referred to as the “gatekeeper.”  

The AV node, which has a rate of 40-60 beats per minute, is also the “backup” pacemaker if the SA node fails (7). Once the ventricles are filled, the electrical impulse travels through the bundle of His to the left and right bundle branches that send impulses to the right and left ventricles.  

These impulses travel through the Purkinje fibers, a network of thin filaments, that cause the ventricles to contract and pump blood to the rest of the body. The heart’s electrical system maintains normal sinus rhythm unless the body becomes stressed (7). 

In heart disease, the electrical impulses misfire, thus impairing the heart’s ability to effectively pump blood that results in decreased oxygen and nutrient delivery to the tissues and organs. CAD is the most common cause of fatal arrhythmias because the heart tissue is compromised and thus cannot function as an effective pump, which throws off the cardiac electrical impulses.  

The arrhythmias most associated with heart disease are (7): 

• Sinus tachycardia due to coronary artery blockage, hypovolemia, or hypoxia. 

• Sinus bradycardia, which is common in patients with acute MI, can lead to decreased cardiac output, heart failure, and lethal ventricular dysrhythmias. 

• Atrial dysrhythmias include premature atrial contractions, atrial flutter or fibrillation, and atrial supraventricular tachycardias that reduce cardiac output. 

• Ventricular dysrhythmias are premature ventricular contractions or ventricular premature beats, ventricular tachycardia, and ventricular flutter or fibrillation that are associated with MI and diminished cardiac output. 

• Heart blocks that are associated with decreased cardiac output, lethal ventricular arrhythmias, or cardiac standstill. 

Symptoms of arrhythmia include chest pain, dyspnea, anxiety, fatigue, syncope, vertigo, diaphoresis, and racing, fluttering, pounding, or crushing sensation in the chest (7). 

Heart Failure 

Heart failure is a chronic condition that occurs when the heart is unable to effectively pump nutrient-rich blood to the rest of the body, which is required to keep tissues and organs functioning properly (10). Cardiomyopathy, coronary heart disease, hypertension, and valvular disease contribute to heart failure. Also, chemotherapy medications like doxorubicin (Adriamycin) that are used to treat breast cancer are toxic to the myocardium, making cancer survivors more susceptible to heart disease (5). 

Common symptoms of heart disease include dyspnea, orthopnea, edema, hepatic congestion pain, ascites, fatigue, and weakness. Based on these symptoms, patients can be grouped according to the New York Heart Association (NYHA) functional classification (1): 

• Class I: Symptom onset with more than ordinary level of activity 

• Class II: Symptom onset with an ordinary level of activity 

• Class III: Symptom onset with minimal activity 

• Class IV: Symptoms at rest 

There are certain types of heart problems that can be linked to heart disease that affect women more than men; these are angina, cardiac syndrome X, and broken heart syndrome.  

Four million women in the United States suffer from angina, particularly stable and variant (Prinzmetal’s) angina (17). Stable angina is exacerbated by physical activity and stress but dissipates with rest. Variant angina, which is an unstable form of the disorder, is rare and is caused by a spasm in the coronary arteries. Triggers include exposure to cold weather, stress, smoking, and cocaine use.  

In cardiac syndrome X, people with healthy, unblocked arteries experience angina and coronary artery spasms. One cause is coronary microvascular disease (MVD), which often affects women younger than 50 years. The other cause is hormonal changes, specifically involving estrogen during and after menopause.  

Broken heart syndrome, also referred to as stress-induced cardiomyopathy (or takotsubo cardiomyopathy), is triggered by intense grief, anger, or surprise. Women who experience broken heart syndrome tend to be age 50 or older, which also coincides with a drop in estrogen levels after menopause. (14)

Risk Factors 

According to the American Heart Association, one in three American adults has three or more risk factors that contribute to cardiovascular disease, metabolic disorders, and kidney disease (2). Risk factors for heart disease that affect both women and men are age, race, family history, dyslipidemia, hypertension, severe lung disease, sleep apnea, diabetes, metabolic syndrome, smoking, excessive alcohol use, poor diet, obesity, inactivity, stress, and depression.  

These risk factors are both modifiable and nonmodifiable. Nonmodifiable factors are age, race, and family history; the modifiable factors are dyslipidemia, hypertension, diabetes, metabolic syndrome, smoking, excessive alcohol use, poor diet, obesity, inactivity, stress, and depression. 

Women also face sex-specific and reproductive risk factors for heart disease, including (13): 

• Early and late menarche 
• Premature menopause 
• Polycystic ovary syndrome 
• Endometriosis 
• Infertility 
• Gestational diabetes 
• Preterm delivery 
• Intrauterine growth restriction 
• Peripartum cardiomyopathy 
• Anemia during pregnancy 
• Hypertensive disorders of pregnancy 
• Absence of breastfeeding 

Measures to lower the risk factors for heart disease include quitting smoking (the most preventable risk factor), improving cholesterol levels, controlling hypertension and diabetes, eating a healthy diet, limiting alcohol consumption, maintaining a healthy weight, and managing stress.

Symptoms 

The symptoms of heart disease depend on the underlying causative disorder, such as CAD, dysrhythmia, and heart disease. 

The symptoms of heart disease include (15, 19): 

• Angina 
• Arrhythmia 
• Ascites 
• Bradycardia 
• Cyanosis 
• Dyspnea 
• Edema 
• Fatigue 
• Nausea 
• Pain (neck, jaw, throat, upper abdomen, back) 
• Paresthesia 
• Presyncope 
• Syncope 
• Tachycardia 
• Vertigo 
• Vomiting 

Of these symptoms, women are most likely to experience nausea and vomiting, dyspnea, abdominal pain, insomnia, and fatigue (19). Women are more likely than men to experience angina at rest, and angina often happens during routine daily activities like shopping or cooking rather than exercise in women who have CVD (12). Mental and emotional stress is more likely to trigger angina pain in women than men (12). 

Since many of these symptoms can be associated with any number of potential underlying conditions, nurses need to be diligent in their assessment of female patients, particularly their lifestyles that may contribute to heart disease.

Prevention 

There are several preventative measures women can take to guard against heart disease, and these all relate to living a healthy lifestyle.  

These steps include (3, 18): 

1. Do not use tobacco products. Abstaining from tobacco use and refraining from secondhand smoke improves heart health. The chemicals in tobacco products damage the heart and blood vessels and lower the oxygen carrying capacity of red blood cells. The risk of heart disease starts to drop the first day after quitting tobacco use. The risk of heart disease drops to half that of a smoker after tobacco cessation. 
2. Engage in daily physical activity. Physical activity helps control weight gain and lowers susceptibility to co-morbid factors. An ideal exercise plan includes 150 minutes a week of moderate aerobic exercise, 75 minutes of vigorous aerobic activity, and two or more strength training sessions per week. If these guidelines cannot be met, it’s important that individuals move their bodies by engaging in activities like housework, gardening, taking the stairs, and recreational activities (bowling, golfing, skating, etc.). 
3. Eat a healthy diet. A heart-healthy diet includes fruits and vegetables, beans and other legumes, lean meats, fish, low-fat or fat-free dairy products, whole grains, and healthy fats like olive oil and avocados. The Dietary Approach to Stop Hypertension (DASH) and the Mediterranean diet are beneficial eating plans. 
4. Maintain a healthy weight. Extra weight, especially weight carried around the middle of the body, raises the risk of heart disease. A body mass index (BMI) of 25 or higher is considered overweight, which is linked with higher cholesterol levels and higher blood pressure. Additionally, the risk of heart disease is higher when a woman’s waist circumference is greater than 35 inches. 
5. Get quality sleep. Lack of quality sleep is linked with higher risk of obesity, hypertension, MI, diabetes, and depression. Most adults need 7-8 hours of quality sleep for the body to repair itself. Obstructive sleep apnea can also lead to heart disease.  
6. Manage stress. High levels of stress and poor coping measures for stress can contribute to heart disease. Many individuals who experience consistent high levels of stress engage in unhealthy behaviors, such as overeating, drinking alcohol excessively, using tobacco products, and abusing illicit drugs, which can lead to heart disease.  
7. Get regular health screenings. Monitoring blood pressure, cholesterol levels, and blood glucose levels can prevent heart disease. Starting at age 18, blood pressure should be monitored every two years. Individuals ages 18 to 39 who have risk factors for hypertension should have their blood pressure screened annually. Individuals aged 40 and older should have their blood pressure monitored every year.
   1. The National Heart, Lung, and Blood Institute (NHLBI) recommends that cholesterol screenings start between the ages of 9 and 11. Screenings are then repeated every five years. Women ages 55 to 65 and men ages 45 to 65 should be screened every one to two years, and individuals over age 65 should be tested annually. Diabetes screening is recommended early for those at high risk and starting at age 45 for those with low risk. 
8. Prevent infections via immunizations. Vaccines for influenza, COVID-19, pneumococcal disease, tetanus, diphtheria, and pertussis can decrease heart complications.

Diagnostics and Treatment 

The diagnostics and treatments for heart disease in women and men are similar, but women may experience delays in diagnosis or treatment. For example, doctors are less likely to refer women for diagnostic tests for coronary heart disease, and when women go to the hospital with cardiac symptoms, they experience more delays in receiving an initial EKG than men (12).  

Additionally, while hospitalized, women are less likely to receive care from a cardiac specialist, and younger women are discharged from emergency departments with more misdiagnoses and untreated cardiac events than their male counterparts (12). Women are less likely than men to receive aspirin, statins, and beta blockers for cardiac symptoms and females don’t receive treatment with pacemakers or defibrillators as frequently as men although the benefit is equal for both genders (12). 

Diagnostics for heart disease in women include a thorough medical history that explores female reproductive and social histories. Blood tests, such as a complete blood cell count (CBC), lipid profile, C-reactive protein test, electrolyte levels, and kidney and liver function tests are effective.  

Additional diagnostic tests include EKG, echocardiogram, Holter monitoring, arrhythmia monitoring, stress test, cardiac catheterization, computed tomography (CT), and magnetic resonance imaging (MRI). Common medications used to treat heart disease are aspirin, beta blockers, statins, diuretics, and vasodilators. Surgical interventions may include angioplasty, stent placement, coronary artery bypass grafting (CABG), heart valve repair or replacement, pacemaker placement, and heart transplant.

Patient Education 

Nursing education for women at risk of heart disease results in increased knowledge of self-care measures and lifestyle modifications, which can lower the prevalence of the condition (19). Education measures include explaining the risk factors and symptoms specific to women, encouraging a healthy lifestyle and regular screenings, and addressing any female reproductive issues and emotional stressors that can increase the risk of heart disease (17, 19).  

Referring women to resources that can educate and support them is critical in maintaining healthy outcomes (19).

Resources for Women 

There are many resources available to assist women in the diagnosis and treatment of heart disease.  

A few examples include: 

• Well-Integrated Screening Evaluation for Women Across the Nation (WISEWOMAN) helps low-income women ages 40 to 64 with little or no health insurance understand and reduce their risk for heart disease. WISEWOMAN includes risk factor screenings, referrals to lifestyle programs, individual health coaching, and community resources. https://www.cdc.gov/wisewoman/index.htm 

• The CDC’s Interactive Atlas of Heart Disease and Stroke is an online mapping tool that allows users to create state and county maps of heart disease and stroke by age group, ethnicity, race, and other factors. The stroke map widget allows local health departments and other organizations to add this information to their websites, and the CDC updates the maps with the most recent statistics. https://www.cdc.gov/dhdsp/maps/atlas/index.htm 

•  Predicting Risk of cardiovascular disease EVENTs (PREVENTTM) is a new calculator that estimates a person’s risk for cardiovascular disease over the next 30 years. The calculator estimates heart attack, stroke, and heart failure risk, and helps incorporate cardiovascular-kidney metabolic (CKM) syndrome into heart disease prevention.  

https://www.heart.org/en/news/2023/11/10/new-tool-brings-big-changes-to-cardiovascular-disease-predictions 

• The Surgeon General’s Call to Action to Control Hypertension guide identifies evidence-based interventions that can be utilized in diverse settings to help prevent heart disease.  

https://www.hhs.gov/sites/default/files/call-to-action-to-control-hypertension.pdf 

• Million Hearts® 2027 is a national initiative to prevent one million heart attacks and strokes within five years. The webpage includes partnership opportunities, tool kits, and action guides. https://millionhearts.hhs.gov/ 

• The National Heart, Lung, and Blood Institute’s Listen to Your Heart: Women and Heart Disease website includes women’s stories, social media resources, and publications and fact sheets about the disease.  

https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-truth/listen-to-your-heart 

• The Heart Truth® was the first federally sponsored national health education program to raise awareness about heart disease in women. The Red Dress® is the initiative’s national symbol that signifies that heart disease is not a man’s disease. The organization funds fashion events and National Wear Red Day to raise awareness of its cause.  

https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-truth 

• The American Heart Association’s (AHA) Women’s Health website includes a guidelines resource center, fact sheets, tips for healthy living, and guidance for community involvement in helping educate women about heart disease.  

https://www.heart.org/en/news/category-womens-health 

• The Office on Women’s Health initiative Make the Call: Don’t Miss a Beat website provides information for women about MI.  

https://www.womenshealth.gov/heart-attack 

• WomenHeart: The National Coalition for Women with Heart Disease was founded by three women who had heart attacks and experienced obstacles such as misdiagnosis, inadequate treatment, and social isolation. The organization provides resources such as a support network map, SisterMatch and HeartSister Online peer support groups, and educational materials.  

https://www.womenheart.org/ 

Conclusion

Although heart disease is currently the number one killer of women, it doesn’t need to be in the future. Women’s awareness of their risk factors, specific symptoms, and preventative measures can decrease the incidence of the disease.

Additionally, nurses’ understanding that many doctors misdiagnose and delay treatment for women with heart disease can lead nurses to act more proactively in their assessment of heart disease symptoms and education to women to live more healthy lifestyles to prevent the disease.

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