When people picture a heart attack, they picture a man clutching his chest. That image is often wrong. Heart attack symptoms in women are regularly vaguer: extreme fatigue, nausea, shortness of breath, or pain in your jaw, neck or back. In the Netherlands, according to the Hartstichting (Dutch Heart Foundation), around 793,600 women live with a cardiovascular condition.
First things first, and the rest after that. Do you have symptoms right now that last longer than five minutes at rest? Call the emergency number, 112 in the Netherlands. Do not google it first, do not order a test first, do not wait for it to pass.
The rest of this article is about recognition. Why the female heart can give a different pattern of symptoms, and why that pattern gets picked up later. We wrote about your longer-term risk separately, in cardiovascular disease in women.
Do you have symptoms right now? Call 112
Call 112 straight away if your symptoms last longer than five minutes at rest. That is the advice of the Hartstichting, and it applies just as much to vague symptoms as to classic chest pain. Not sure? Call anyway. A false alarm is nothing to be ashamed of, calling too late can do harm.
A blood test has no place here. No blood test, ours included, shows a heart attack or prevents one. For acute symptoms, the ambulance is the route.
Do not wait for your partner, for the morning, or for a GP appointment either. In a heart attack, time counts, because heart muscle tissue is damaged without blood supply.
Heart attack symptoms in women: what is different?
The biggest difference is not in the chest pain itself, but in what surrounds it. Women more often report several accompanying symptoms at once: nausea, shortness of breath, overwhelming fatigue, cold sweat, and pain radiating to the jaw, neck, back or between the shoulder blades. That combination looks less like the classic picture.
In the VIRGO study, which interviewed 2,009 women and 976 men aged 18 to 55 after a heart attack, 61.9 percent of women had three or more accompanying symptoms. For men that was 54.8 percent (Lichtman et al., 2018).
The table below puts the classic picture next to what women more often describe. See it as help in naming symptoms, not as a list to assess yourself with.
| Classic picture | How it more often goes in women | Why that is confusing |
|---|---|---|
| Severe, crushing pain in the middle of the chest | Pressure, a band around the chest, or a burning feeling | It does not feel like the film version, so it gets waved away |
| Pain pulling into the left arm | Pain to the jaw, neck, back or between the shoulder blades | Resembles muscle pain or a bad posture |
| Symptoms start abruptly | Symptoms sometimes build up gradually | A slow start feels less alarming |
| Sweating and breathlessness | Nausea, vomiting, dizziness, cold sweat | Gets mistaken for flu or a stomach bug |
| Few other symptoms | Extreme fatigue, sometimes for days beforehand | Fatigue fits a hundred other things |
Note the words more often. Not one row above is a rule. Women get the classic version too, and men get vague symptoms too.
Is it true that women do not get chest pain?
No. This is the most stubborn misconception about the female heart, and it can cost you precious minutes. Most women having a heart attack do have chest pain. In the VIRGO study that applied to 87.0 percent of women, against 89.5 percent of men. That gap is smaller than the story suggests.
So where does the story come from? Partly from the definition. A US registry of more than 1.1 million heart attack patients found that 42.0 percent of women presented without chest pain, against 30.7 percent of men (Canto et al., 2012).
Those two numbers contradict each other less than it seems. VIRGO counted pressure, tightness and discomfort all as chest pain. Ask only about pain, and more women say no.
That difference in wording matters in practice. If you feel a band around your chest but no sharp pain, that is still a reason to call 112. You do not have to be in pain to be seriously ill.
Angina in women can feel different too. Symptoms sometimes come on with emotion or at rest, instead of only during exertion. That fits the classic pattern of pain while climbing stairs less well.
Why are heart symptoms in women recognised later?
Mostly because the reference material is skewed. The classic symptom picture comes from research with mostly male participants. What statistically fits women more often therefore got the label atypical. That is a property of research history, not of the GP or the ambulance nurse standing in front of you.
The numbers on this are surprisingly concrete. Across 156 randomised trials that the American prevention guideline for women leaned on, the share of female participants rose from 9 percent in 1970 to 41 percent in 2006 (Melloni et al., 2010). Twenty of those trials enrolled only men.
Build a symptom list on such a population, and that list mostly describes men. The female pattern was not ignored out of unwillingness. It simply sat far less in the data.
A scientific statement from the American Heart Association describes the same picture: a heart attack in women runs atypically more often and is recognised later (Mehta et al., 2016). In a German registry of 13,900 people with chest pain, atypical symptoms occurred more often in women, and times to treatment were longer (Settelmeier et al., 2020).
Something plays on our own side as well. In VIRGO, women attributed their symptoms to stress or tension more often than men, 20.9 against 11.8 percent. If you think it is tension yourself, you call later.
That is not a reproach, to anyone. It is a circle. The picture is male, so we recognise the female pattern less, so it lands in view less. Breaking that circle asks for better research, and that is coming. How this same pattern works outside the heart is in not taken seriously: why women's symptoms are missed more often.
What does oestrogen have to do with your heart?
Oestrogen appears to help keep your blood vessels supple, and that protection declines around menopause. Women therefore tend to develop cardiovascular disease at a later age than men. After menopause, part of that difference narrows. That partly explains why women are on average older when a heart attack happens.
A scientific statement from the American Heart Association sums up twenty years of follow-up research. During the menopause transition your hormones, your fat distribution and the state of your blood vessels shift at roughly the same time (El Khoudary et al., 2020). Not one switch, then, but several at once.
According to the Hartstichting, women who die of a heart attack are on average around seven years older than men. Later does not mean safer here. It means symptoms often arrive at an age where you attribute them to menopause or to getting older.
Search for heart attack symptoms in women and you keep meeting that overlap. Fatigue, shortness of breath and a low mood fit menopause, and they sometimes fit your heart too. The hormonal side is covered in more depth in cholesterol and heart health after menopause.
What can you do about your longer-term risk?
This is a different question from the acute one, and it matters to keep the two apart. Acute symptoms belong with 112. Your long-term risk belongs with your GP. There it is about blood pressure, smoking, blood sugar, cholesterol and your own history, such as pregnancy complications. That conversation is about years, not minutes.
Say you are 52, you are in the middle of menopause, and your mother had a heart attack at sixty. You have no symptoms now. Then 112 is not the question, and a conversation with your GP about your risk profile is.
Blood values can feed such a conversation. A lipid profile measures your total cholesterol, LDL, HDL, the ratio and triglycerides, and gives context alongside your other risk factors. It says nothing about whether you will have a heart attack, and it does not replace your GP.
Want to walk into that conversation with numbers instead of a gut feeling? Then you can have a lipid profile done at Lunara, assessed by a BIG-registered doctor. Take the result to your GP, who puts it next to your blood pressure and your story.
Which risk factors play a part exactly, and what else you can have measured, is in cardiovascular disease in women: risk and what you can test. If you want to prepare that conversation well, have a look at how to prepare for your GP appointment.
Remember this above all. Symptoms at rest that last longer than five minutes, the vague ones included, are a reason to call 112. Not a reason to order a test.
References
- Lichtman JH, Leifheit EC, Safdar B, et al. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study. Circulation. 2018;137(8):781-790. PMID 29459463.
- Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822. PMID 22357832.
- Mehta LS, Beckie TM, DeVon HA, et al. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016;133(9):916-947. PMID 26811316.
- Melloni C, Berger JS, Wang TY, et al. Representation of women in randomized clinical trials of cardiovascular disease prevention. Circ Cardiovasc Qual Outcomes. 2010;3(2):135-142. PMID 20160159.
- El Khoudary SR, Aggarwal B, Beckie TM, et al. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention. Circulation. 2020;142(25):e506-e532. PMID 33251828.
- Settelmeier S, Rassaf T, Hochadel M, et al. Gender Differences in Patients Admitted to a Certified German Chest Pain Unit. Cardiology. 2020;145(9):562-569. PMID 32781458.
- Hartstichting. Heart attack and heart symptoms in women. 2026. Available via hartstichting.nl.
Every blood test result at Lunara includes a professional assessment by a BIG-registered doctor. For treatment decisions, discuss your results with your GP. For acute symptoms, call the emergency number.
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