Coronary artery disease, a type of cardiovascular disease that often presents with angina, is commonly perceived as a condition that predominantly affects men. In reality, women are equally vulnerable, frequently experiencing chest discomfort due to reduced blood flow to the heart.

Coronary heart disease, which is a result of coronary artery disease, is the leading cause of death for women in the US. “Two out of three women have one or more risk factors for coronary heart disease, and this increases with age,” according to the US’ National Heart, Lung and Blood Institute. India is no different. According to data, heart diseases are the leading cause of death among women in the country too.

However, despite this prevalence, heart disease among women is understudied, underestimated and misunderstood, mainly due to certain biases against women in the research and pedagogy. For instance, “The risk of heart disease in women is often underestimated due to the misperception that females are ‘protected’ against cardiovascular disease,” according to a 2010 review. Others have stated that even if the prevalence of heart disease is higher among men, women were more likely to die after a heart attack than men. The reasons for these disparities range from under-representation of women in clinical trials to insufficient awareness.

What is angina?

Angina is chest pain or discomfort that occurs when the heart does not receive enough blood and oxygen. It is a symptom of underlying heart disease, most often caused by plaque buildup or blockages in the coronary arteries. While generally treatable, angina can signal serious complications, including heart attacks or cardiac arrest, if left unmanaged.

Angina can vary in severity, from a mild ache to crushing chest pressure. It may appear suddenly or gradually and can sometimes serve as a warning of a heart attack days or weeks in advance. Healthcare providers may classify angina severity on a scale of one to four, based on the intensity and triggers of symptoms. Another term for this condition is angina pectoris, though in clinical practice, it is most commonly referred to simply as angina.

There are four main types of angina. Stable angina appears in predictable patterns, usually triggered by physical activity or stress, and typically resolves with rest or medication within a few minutes. Unstable angina is more severe, unpredictable, and may occur at rest. Episodes are long-lasting, often exceeding 15 minutes, and require immediate medical attention.

Microvascular angina involves the small blood vessels of the heart and can cause prolonged chest tightness. Early treatment can help prevent heart damage caused by oxygen deprivation. Prinzmetal (variant) angina results from temporary spasms in the coronary arteries. This type usually occurs at rest or during sleep, with episodes lasting five to 15 minutes.

What are the causes and symptoms of angina? 

Angina often presents as pressure, heaviness, tightness, or burning in the chest, and it may radiate to the jaw, teeth, shoulders, arms, or back. Many people describe it as a vague discomfort rather than sharp pain. Other accompanying symptoms can include sweating, dizziness, weakness, nausea, bloating, clammy skin, paleness, or a feeling of impending doom.

The primary cause of angina is reduced blood flow to the heart, which can result from coronary artery disease (CAD), the most common cause, arising from plaque accumulation in the coronary arteries; coronary microvascular disease, which damages the heart’s tiny arteries; or coronary artery spasms, which can occur even without underlying CAD.

Certain factors increase the likelihood of developing angina, including age (men over 45, women over 55), pre-existing cardiovascular risk factors such as high blood pressure, high cholesterol, diabetes, obesity, or a family history of heart disease. Other contributing conditions include severe anaemia, heart valve disease, heart failure, and hypertrophic cardiomyopathy, which force the heart to work harder. Lifestyle and environmental exposures such as smoking, vaping, second-hand smoke, recreational drugs, and air pollution also elevate risk. Recognising these symptoms early and identifying triggers is crucial, as prompt consultation with a healthcare provider can help manage angina effectively and prevent serious cardiac events.

Angina in women

Dr Shivani Rao, associate professor of cardiology at Dr Ram Manohar Lohia Hospital, explained that women often present with angina symptoms very differently from men. Unlike the “typical” central chest pain radiating to the arms that is commonly seen in men, women may experience what are considered atypical symptoms.

“They might feel breathlessness while walking, unexplained fatigue, or chest pain in the epigastrium — that is, in the stomach area. Some women also report nausea and vomiting. Because these symptoms don’t match the conventional profile of chest pain, they often recognise them late, and even in hospitals, they are treated late,” Dr Rao said.

She added that while angina in women was earlier seen mostly after menopause, when hormone levels begin to decline, a worrying trend has emerged in recent years. “Now we are seeing women in their 20s and 30s coming in with these symptoms. Family history of heart disease, along with lifestyle changes such as rising rates of smoking, are pushing the onset of cardiovascular problems to a much younger age,” Dr Rao added.

International data, she noted, also reflects this disparity: “Sadly, it is seen that females are not treated to the level that men are treated. Atypical symptoms are a big reason for this, as both patients and doctors may not immediately suspect heart disease, which results in delayed treatment.”

According to the American Heart Association, while heart disease in men is more commonly due to blockages in the larger coronary arteries—termed obstructive coronary artery disease (CAD)—women more frequently develop disease within the small arteries branching from the coronary arteries, known as microvascular disease. This condition primarily affects younger women, and studies show that up to 50 per cent of women with angina symptoms who undergo cardiac catheterisation do not have obstructive CAD.

A recent study of 874 participants with previously undiagnosed angina found that 63 per cent were women. Women with missed angina were more likely than men to be younger, belong to ethnic minorities, be uninsured, and smoke. Even after adjusting for multiple factors such as age, race, education, and comorbidities, women still had 2.6 times higher odds of missed angina compared to men, and three times higher odds among those who ultimately died of cardiac causes.

Similar disparities have been documented in India. A cross-sectional study in Goa found that “women attending general practices in Goa, India are at greater risk of angina than men. Depression/anxiety is strongly associated with angina.” The study emphasised that greater awareness among general practitioners regarding sex-based differences in angina and its link with psychological distress is necessary to improve diagnosis and care for female patients.

Furthermore, analysis of data from the Longitudinal Ageing Study in India (2017–2018), which included 58,830 individuals aged 45 and above, revealed that “angina pectoris was more prevalent among females, rural respondents and adults aged 45–54 with chronic obstructive pulmonary disease (COPD) compared to males, urban respondents and those aged 65 and above, respectively, with COPD.”

What can be done?

In a Lok Sabha reply a couple of months ago, the ministry of health and family welfare said cardiovascular diseases are being tackled under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD). It noted that over 770 district NCD clinics, 6,410 Community Health Centre clinics, and 233 Cardiac Care Units have been established, alongside a population-based screening initiative for people over 30.

The ministry added that these efforts align with Sustainable Development Goal (SDG) target 3.4, aiming to reduce premature mortality from non-communicable diseases, including cardiovascular disease, by one-third by 2030

Dr Rao emphasised the importance of timely reporting and regular screening for women at risk of heart disease. “Any female who is having any kind of chest pain should report to the hospital and at least get an ECG,” she said. “Even if she thinks it’s not the typical kind of chest pain, the minimum she can do is go to a hospital, get an ECG, and have a troponin test done three hours after the pain begins. It is always better to overtreat rather than undertreat and land in trouble.”

She stressed that women above 30 should undergo regular blood tests, including checks for diabetes, hypertension, and lipid profiles. “The incidence of diabetes has increased at a very early age, and many women don’t even know they are diabetic. They should at least screen themselves to know their 10-year risk of developing heart disease,” she noted, adding that those with higher risk factors must remain under continuous medical follow-up.

She also highlighted the need for broader awareness through community programmes in schools, workplaces, and especially in the IT sector, where sedentary lifestyles prevail. “Even if they are having such symptoms, reporting to the hospital is very important,” she said.

On preventive measures, Dr Rao advised that mobility and regular exercise should be a priority. “The guidelines say that women should do moderate-to-strenuous exercise for at least 30 to 40 minutes a day, along with strength training at least twice a week,” she explained. Diet, she added, should focus on moderation: “Less oil, less salt, and as much home-cooked food as possible. Fast food should be limited.”

Smoking cessation, stress management, and mindfulness practices like yoga and meditation were also cited as critical. Dr Rao pointed out that “stress as well as air pollution are two new risk factors which have come forward compared to what we saw in the past.” While air pollution is harder to control individually, she said, women can at least take steps to reduce stress levels.

She stressed the importance of proactive screening. “Screening is the major part that is lacking in India. People only go to hospitals when they have symptoms. If there’s a family history of heart disease, especially in females, screening should start much earlier — even 10 years before the age when a relative was diagnosed.”