Heart Disease in Women: Symptoms and Why It Is Often Missed

Heart disease is sometimes thought of as a man's condition, but it isn’t.

According to the Singapore Heart Foundation, cardiovascular disease causes around 1 in 3 female deaths in Singapore each year, making it one of the leading causes of death among women here. Cardiovascular disease accounted for 30.5% of all deaths in Singapore in 2024.

Awareness has not kept pace. In the Singapore Heart Foundation's 2024 Women's Heart Health Survey of 1,000 women, about 40% still believed breast cancer was the leading cause of death in women.

The difficulty is that heart disease in women is frequently missed. Symptoms can be subtler or simply different from the classic presentation described in men, and they are easy to attribute to stress, ageing, indigestion or being unfit. Women themselves often delay seeking help, and the delay matters: by the time heart disease is picked up, it may be more advanced.

Understanding how heart disease shows up in a woman's body, what raises your risk, and when to get checked can make a real difference to outcomes.

Why heart disease in women is often missed

Women's symptoms are more likely to be atypical and attributed to something else.

Women are more likely to have conditions affecting the heart's smaller blood vessels, which standard tests looking at the major arteries may not detect. And women tend to present later, which narrows the treatment options available.

This is not only a Singapore issue.

A 2024 review in the Journal of the American College of Cardiology described under-recognition, under-treatment and under-representation in research as a global pattern in women's cardiovascular care.

Are heart disease symptoms different in women and men?

Partly. The common symptoms of heart disease occur just as often in women as in men, including central chest discomfort or tightness, pain spreading to the neck, jaw or back, and breathlessness. Women should not assume that chest pain is a male symptom.

What differs is that women are more likely to also experience symptoms that do not obviously point to the heart, and more likely to have these as their main or only complaint. Women also tend to develop heart disease around a decade later than men, with risk rising notably from perimenopause onwards, typically from the mid-40s.

Does heart disease risk increase after 40?

Yes, and the increase appears to begin earlier than many women expect. It is not menopause itself that marks the turning point so much as perimenopause, the transition into it, which typically begins in the mid-40s.

An analysis of more than 9,000 women published in the Journal of the American Heart Association in 2026 scored participants using the American Heart Association's Life's Essential 8 measures of cardiovascular health.

Median scores declined across reproductive stages: 73.3 out of 100 in premenopausal women, 69.1 in perimenopausal women and 63.9 after menopause. After the effect of ageing was accounted for, perimenopausal women were twice as likely to have a low overall cardiovascular health score compared with premenopausal women, driven largely by higher cholesterol and blood sugar levels.

That distinction matters. Some of the rise in risk is simply ageing, which affects everyone. But the evidence indicates the hormonal transition contributes on top of that. A 2020 American Heart Association scientific statement drew the same conclusion, describing the menopause transition as a period of accelerating cardiovascular risk and a critical window for early prevention.

The practical implication is that your 40s are not too early to establish a baseline. Blood pressure, cholesterol and blood sugar are worth checking during perimenopause rather than waiting until after menopause to start paying attention.

Symptoms of heart disease in women to watch for

Symptoms that clearly point to the heart:

• Central chest discomfort, pressure, tightness or pain
• Discomfort spreading to the neck, jaw, throat, upper abdomen or back
• Breathlessness, particularly on light exertion or when lying flat
• Palpitations, or a fluttering sensation in the chest
• Pain, numbness, weakness or coldness in the legs or arms, if the vessels supplying them have narrowed

Symptoms that are commonly mistaken for something else:

• Unusual or persistent fatigue that is out of proportion to activity
• Indigestion, nausea or upper abdominal discomfort
• Cold sweats while at rest
• Feeling lightheaded, dizzy or faint
• Swelling in the legs, feet or ankles
• A dry cough or wheezing that does not settle

None of these symptoms on its own confirm heart disease, and most have benign explanations. What matters is the pattern: symptoms that are new, that are getting worse, that come on predictably with exertion, or that occur together are worth investigating.

Symptoms of an acute heart attack are a separate and urgent matter. If you have chest pain or pressure lasting more than a few minutes, especially with breathlessness, cold sweats or nausea, treat it as an emergency. Read more about the signs of a heart attack in women and what to do.

Types of heart disease that affect women

The most common heart condition in women is coronary artery disease, a narrowing of the blood vessels supplying the heart. Other conditions include:

• Heart failure, where the heart muscle struggles to pump or relax effectively
• Arrhythmia, an abnormal heart rhythm
• Valvular heart disease, involving problems with the heart's valves
• Cardiomyopathy, disease of the heart muscle itself

Several cardiovascular conditions disproportionately affect women or are unique to pregnancy. These conditions are also relevant to women in Singapore:

• Coronary microvascular disease, which affects the heart's smallest blood vessels. A woman can have significant symptoms and a genuinely restricted blood supply while her major arteries appear clear on standard imaging.
• Takotsubo cardiomyopathy, also called broken heart syndrome, in which a surge of stress hormones after an intense emotional or physical event causes the heart to suddenly weaken.
• Peripartum cardiomyopathy, a weakening of the heart muscle that develops in late pregnancy or in the months after delivery.
• Spontaneous coronary artery dissection (SCAD), a tear in a coronary artery wall that predominantly affects women, including younger women without conventional risk factors.

Risk factors for heart disease in women

Some risk factors cannot be changed:

• Increasing age
• A family history of heart disease, particularly early-onset heart attack in a close relative
• Ethnicity
• Menopause. Oestrogen has a protective effect on the blood vessels, and its decline from perimenopause onwards is associated with rising cholesterol, blood pressure and cardiovascular risk.

Some medical conditions raise heart disease risk in both men and women:

• Diabetes, which raises cardiovascular risk more sharply in women than in men
• High blood pressure
• High cholesterol
• Being overweight or obese
• Depression and other mental health conditions

Other risk factors are specific to women, or affect women more than men.

Dr Deanna Khoo, cardiologist at Gleneagles Hospital, notes: "Beyond the conventional risk factors shared with men, women have several risk factors of their own: early menopause, complications during pregnancy, previous breast cancer treatment, and autoimmune conditions, which are more common in women. These are often overlooked, but they matter just as much for long-term heart health."

And some risk factors are within your control: a diet high in saturated fat, salt and sugar, physical inactivity, chronic stress, smoking, and drinking too much alcohol.

How heart disease in women is diagnosed

Assessment usually starts with your history, symptoms and risk factors, followed by some combination of:

• Blood tests, to check cholesterol, blood sugar and other markers
• An electrocardiogram (ECG), which records the heart's electrical activity
• An echocardiogram, an ultrasound scan showing the heart's structure and how well it is pumping
• A treadmill or pharmacological stress test, which assesses how the heart performs under exertion
• A CT coronary angiogram or other targeted imaging, where more detail on the coronary arteries is needed

How to reduce your risk of heart disease

• Stop smoking, and avoid second-hand smoke
• Aim for at least 150 minutes of moderate activity a week, or 75 minutes of vigorous activity, such as brisk walking, cycling or swimming
• Eat a diet built around whole grains, fruit, vegetables and lean protein, and limit added sugar, salt and saturated fat
• Maintain a healthy weight and waist circumference
• Manage stress, and prioritise sleep
• If you have diabetes, high blood pressure or high cholesterol, keep up with regular reviews and take medication as prescribed
• Go for regular health screening, so that risk factors can be identified and treated before they cause damage

When to see a doctor

Make an appointment with our cardiologists if you have new, recurring or worsening chest discomfort, breathlessness, palpitations, unusual fatigue or swelling in the legs, particularly if you also have risk factors such as diabetes, high blood pressure, high cholesterol, a history of pregnancy complications or a family history of heart disease.

Women's heart health deserves the same attention and urgency as any other area of women's health. Knowing your risk factors, knowing your numbers, and knowing your own body well enough to notice when something has changed.