Why heart symptoms in women are often missed

If you're a woman who has been dismissed at the GP with reassurance that "it's probably anxiety" or "just menopause", or you're trying to work out whether your fatigue, breathlessness or jaw discomfort could be heart-related, you're not alone. Heart symptoms in women are genuinely more likely to be missed, delayed or misattributed than the same symptoms in men. Research has shown women are around 50 per cent more likely to be initially misdiagnosed after a heart attack, and only about a third of participants in cardiovascular research studies have historically been women. That gap in evidence has shaped how heart disease is described, taught and recognised for decades.

In my experience caring for patients across Kingston-upon-Thames and South West London, this isn't usually a story of any single person being dismissive. It's a combination of factors: symptoms that don't fit the classic "man clutching his chest" picture, patients who are used to putting others first and minimising their own symptoms, and diagnostic tools that were largely built around male physiology. From working with the patients I see in clinic, I'd estimate at least four in ten women who come to me with clear cardiac symptoms have already been told at least once that their symptoms were probably not their heart. The purpose of this article isn't to alarm anyone, but to help you recognise what to look for, and when to push for a proper cardiology assessment.

The Perception That Heart Disease Is a Man's Issue

Ask most people to picture someone having a heart attack and they'll describe a middle-aged man collapsing while clutching his chest. That image is deeply embedded in public health messaging, television dramas and even how medicine has been taught. The problem is that it's only half accurate. Heart and circulatory diseases are the leading cause of death in women in the UK, just as they are in men.

Before the menopause, women do genuinely have a lower risk of coronary artery disease than men of the same age, partly because oestrogen has a protective effect on blood vessels. After the menopause, that protection fades, and by the time women reach their late 60s and 70s their risk has caught up with, and in some conditions exceeded, that of men. Yet the persistent perception that heart disease is a "man's issue" means many women (and many clinicians) hesitate before considering cardiac causes, particularly in patients under 60.

In my experience, this delay matters. The earlier a heart condition is identified, the more options we have for treatment, and the better the long-term outcome tends to be.

How Heart Symptoms Often Present Differently in Women

The single biggest reason women's heart symptoms are missed is that they often don't look like the textbook description of a heart attack. Chest pain does still occur, but it's more likely to be pressure, tightness, burning or heaviness rather than the dramatic crushing pain shown on television. Women are also more likely to have symptoms that seem to have nothing to do with the heart at first glance.

The presentations I look out for particularly in women include:

Unusual fatigue. Not the tiredness of a busy week, but a persistent, unexplained lack of energy that has crept up over weeks or months and is out of keeping with normal life.

Breathlessness. Particularly on exertion, when lying flat, or waking up short of breath at night. This is often the presenting symptom of coronary disease and heart failure in women.

Jaw, neck, back or upper stomach discomfort. These are more commonly reported as heart symptoms in women than in men, and they can easily be mistaken for dental problems, muscle strain, indigestion or gallbladder issues.

Nausea, sweating and lightheadedness. Alone or combined with other symptoms, these can be signs of a cardiac event, particularly during a heart attack.

Palpitations. New or unusual palpitations, particularly ones that come with breathlessness or dizziness, deserve to be investigated rather than attributed to stress or hormones.

Anxiety-like symptoms. A sudden feeling of dread or unusual anxiety, especially if it feels physically different from previous episodes, has occasionally been the earliest warning of a cardiac event.

In my experience, women who present with atypical angina, particularly discomfort that is not clearly "chest pain" but has a reproducible relationship to effort or emotional stress, benefit hugely from having a low threshold for proper cardiac investigation. Approaching the assessment with an open mind about how symptoms might present works better than trying to fit them into a male-derived template.

Cardiac Conditions That Affect Women Differently

Beyond how symptoms present, there are several cardiac conditions that either occur more often in women or affect them differently, and these are among the ones most commonly missed.

Coronary microvascular disease. In this condition, the very small blood vessels of the heart don't dilate properly, even when the main coronary arteries look normal on imaging. It's a well-recognised cause of angina in women. Because standard tests focus on the main arteries, microvascular disease is often missed, and patients can be told there's nothing wrong when in fact there is a treatable problem.

Spontaneous coronary artery dissection (SCAD). A rare but important cause of heart attacks predominantly affecting women, often younger women, sometimes during or shortly after pregnancy. SCAD occurs when there is a spontaneous tear in a coronary artery wall. It doesn't fit the typical risk-factor profile, and it's easy to dismiss in a young, healthy-looking woman.

Takotsubo cardiomyopathy (broken heart syndrome). A stress-induced, usually reversible weakening of the heart muscle that overwhelmingly affects women, particularly post-menopausal women. It can be triggered by intense emotional stress, bereavement or acute illness. It looks like a heart attack initially but the coronary arteries are typically clear.

Heart failure with preserved ejection fraction (HFpEF). A form of heart failure in which the heart pumps normally but doesn't fill properly. It's more common in women, particularly those with a history of high blood pressure or diabetes, and it can present quietly with fatigue, breathlessness and exercise intolerance.

Atrial fibrillation and stroke. Women with untreated atrial fibrillation have a higher risk of stroke than men with the same condition, yet historically they've been less likely to be prescribed anticoagulation to protect them.

Pregnancy-related cardiovascular risk. Conditions such as pre-eclampsia, gestational hypertension and gestational diabetes increase a woman's long-term risk of heart disease well after pregnancy has ended. These are still not routinely factored into cardiac risk assessment, but they matter.

In my experience, the patients who benefit most from a specialist cardiology review are those where the standard tests have come back normal but the symptoms have persisted. Ruling out a "normal" coronary picture is not the same as ruling out heart disease.

The Barriers to Diagnosis

Several factors combine to make the diagnostic path harder for women.

Research bias. Cardiology guidelines have historically been developed from studies in which women were significantly under-represented. This has affected how symptoms are described, how risk is calculated, and how effective certain treatments are believed to be in women.

Symptom minimisation. Many women I see in clinic tell me they didn't want to make a fuss, or that they were the ones caring for other family members and didn't want to worry anyone. The pressure to "get on with it" can mean that symptoms are downplayed or explained away for weeks or months.

Misattribution to anxiety, hormones or menopause. All three are real and can genuinely cause physical symptoms. But they can also be used, sometimes unconsciously, as convenient explanations for symptoms that deserve a more thorough assessment. In my experience, an exercise ECG works less accurately in women than in men because of higher false-positive rates, and this in turn can be used to dismiss symptoms that would have been taken further in a male patient. That's why we increasingly favour tests such as CT coronary angiography, stress echocardiography and cardiac MRI when investigating heart symptoms in women.

Practical delays. Balancing work, caring responsibilities and everything else means women often delay seeking help until symptoms become impossible to ignore.

None of these are a criticism of women. They're a description of the system in which many women navigate their health, and understanding them is the first step towards better outcomes.

What Women Should Watch For

The most important thing isn't remembering every possible symptom. It's trusting your own sense that something has changed. New symptoms that aren't easily explained deserve attention rather than reassurance. The pattern I'd particularly encourage women to take seriously includes:

• Any new chest discomfort, however atypical, particularly if it has a relationship to effort or stress

• Unexplained breathlessness, whether on exertion, when lying flat, or waking you at night

• Persistent unusual fatigue that doesn't respond to rest

• New jaw, neck, back or upper stomach discomfort that you can't otherwise account for

• Palpitations that come with dizziness, breathlessness or a fall in exercise tolerance

• Ankle swelling that doesn't settle

• Fainting or near-fainting

None of these symptoms individually mean something is definitely wrong. But if you've noticed one or more of them for more than a couple of weeks, or if they've been dismissed without proper investigation, they deserve a proper look.

When to Seek Specialist Review

If you have chest pain, breathlessness or other symptoms that are severe, sudden, or associated with sweating, nausea or a feeling of impending doom, call 999. This may be a heart attack, and delay costs heart muscle.

For symptoms that are ongoing rather than acute, a proper cardiology assessment is the right next step. This is particularly true if you've already seen your GP, been told your symptoms are unlikely to be cardiac, but you still feel that something isn't right. In my experience, women who advocate clearly for further investigation, and who bring a partner or friend along to their appointments when possible, are more likely to get the assessment they need. There is no downside to a proper specialist review, and there is a real cost to leaving cardiac symptoms unexplained.

A good assessment will include a careful history, an examination, an ECG, an echocardiogram and blood tests, with further imaging arranged when the clinical picture warrants it. From working with the patients I see in clinic, a joined-up model where all of this happens in a single visit is usually far more useful than piecing together fragmented investigations across weeks or months.

Conclusion

Heart symptoms in women are often missed, but they don't have to be. Recognising that symptoms may present differently, understanding the specific conditions that affect women, and having the confidence to push for proper investigation when things don't feel right are all things that genuinely change outcomes. The direction of travel in cardiology is towards better recognition, better tests and better tailored treatment for women, but until that catches up fully, being an informed advocate for your own health is one of the most important things you can do.

If you're experiencing symptoms you're not sure about, have been told your symptoms are unlikely to be cardiac but still feel something isn't right, or would simply like a proper baseline assessment of your heart health, you can contact me, Dr Roy Jogiya, at Kingston Cardiologists to arrange a private consultation across Kingston-upon-Thames, Wimbledon, or central London. Appointments are available in person and virtually, with full diagnostic support including same-day ECG, echocardiography and onward imaging where needed.