Ischemic Heart Disease
There are three main types of ischemic heart disease: obstructive coronary artery disease; nonobstructive coronary artery disease; and coronary microvascular disease. Coronary artery disease affects the large arteries on the surface of the heart and many people have both obstructive and nonobstructive forms of this disease. Coronary microvascular disease affects the tiny arteries in the heart muscle. It may occur with or without coronary artery disease.
Obstructive coronary artery disease
Obstructive coronary artery disease occurs whenbuilds up in the large arteries, causing them to narrow gradually. This reduces the supply of oxygen-rich blood to the heart. Obstructive coronary artery disease means the heart’s arteries are more than 50 percent blocked. The blood flow may eventually be completely blocked in one or more of the three large coronary arteries.
Nonobstructive coronary artery disease
In nonobstructive coronary artery disease, the large arteries are narrowed by plaque, but not as much as they are in obstructive disease. It is diagnosed if imaging studies show less than 50 percent obstruction of the heart’s large arteries caused by plaque buildup. Between 20 and 50 percent of people undergoing heart imaging studies have nonobstructive coronary artery disease. This condition can also be caused by disease or injury to the lining of the large arteries, affecting the arteries’ ability to expand in response to physical, chemical, or electrical signals that normally would stimulate more blood flow to the heart. Damage to the inner walls of the coronary arteries can cause them to spasm, leading to temporarily decreased blood flow to the heart.
Coronary microvascular disease
Coronary microvascular disease affects the heart’s smallest arteries. Coronary microvascular disease can happen either alone or with obstructive or nonobstructive coronary artery disease or other heart diseases. This type of heart disease most often occurs when molecular changes in the microvascular system—the tiny blood vessels—of the heart prevent normal blood flow through the small arteries.
Plaque buildup in the arteries is called atherosclerosis. When this buildup happens in the heart's arteries over many years, the arteries become narrower and harden, reducing blood flow to the heart. The result is coronary artery disease.
Small pieces of plaque orcan also stick in the small arteries, causing coronary microvascular disease. This can happen when pieces of plaque or blood clots break off during a medical or surgical procedure and travel to the small arteries.
Learn more about the important role, which is the body's reaction to an injury, plays in the development of ischemic heart disease.
Plaque can attractand white blood cells to the area of buildup in the large coronary arteries, causing inflammation. Inflammation can also prevent the small arteries of the heart from responding to the physical, electrical, and chemical signals that tell the arteries when the heart needs more oxygen-rich blood. This can lead to coronary microvascular disease. Research suggests that inflammation may also reduce levels of .
Molecular changes in the small blood vessels
The causes of coronary microvascular disease are not fully clear, but they may involve molecular changes in the small vessels of the heart that are part of the normal aging process. They may also involve damage to the small vessels from chronic inflammation, high blood pressure, or diabetes. Molecular changes affect the way and proteins are controlled inside cells. These changes mean that the small arteries of the heart may not respond correctly when they receive signals indicating that the heart needs more oxygen-rich blood, such as when a person is physically active. Instead of expanding to allow more blood flow, the size of these arteries does not change or may even decrease.
There are many risk factors for ischemic heart disease. Your risk of ischemic heart disease increases with the type and number of risk factors you have and how serious they are. Some risk factors—such as high blood pressure and high blood cholesterol—can be changed through heart-healthy lifestyle changes. Other risk factors, such as sex, older age, family history and , and race and ethnicity, cannot be changed.
Unhealthy lifestyle habits
Over time, unhealthy lifestyle habits increase your risk for developing coronary artery disease because they can lead to plaque buildup in the heart's blood vessels. These habits also may increase the risk for coronary microvascular disease. Unhealthy lifestyle habits that are risk factors include the following:
- Being physically inactive, which can worsen other heart disease risk factors, such as high blood cholesterol and overweight and obesity. levels, high blood pressure, diabetes and prediabetes, and
- Smoking tobacco or long-term exposure to secondhand smoke, which can damage the blood vessels. This increases your risk of atherosclerosis, which itself raises the risk for ischemic heart disease.
- Stress, which can trigger the tightening of your arteries, which increases your risk of ischemic heart disease, especially coronary microvascular disease. Stress may also indirectly raise your risk of ischemic heart disease if it makes you more likely to smoke or overeat foods high in fat and added sugars.
- Unhealthy eating patterns, such as consuming high amounts of saturated fats or , which can lead to overweight and obesity, high blood cholesterol, atherosclerosis, and plaque buildup in the heart's arteries.
Genetic or lifestyle factors cause plaque to build up in your arteries as you age. In men, the risk for ischemic heart disease starts to increase around age 45. Before menopause, women have a lower risk for ischemic heart disease than men. After around age 55, however, the risk increases at the same rate in both women and men. This is likely because the protective effects of the female hormone estrogen diminish after menopause. Also, changes in the small blood vessels of the heart as you age increase the risk for coronary microvascular disease.
Environment and occupation
Air pollution can increase your risk of ischemic heart disease. The increase in risk is mostly for older adults, women, and people who have diabetes or obesity. Air pollution may cause or worsen other conditions, such as atherosclerosis and high blood pressure, which are known to increase your risk for ischemic heart disease.
Your work life can affect your risk for ischemic heart disease in several ways, such as if it involves or exposes you to certain conditions, including:
- Hazards such as toxins or radiation
- High stress
- Long periods of sitting or inactivity
- Limitations on the time available for you to sleep
Working more than 55 hours per week is also associated with a higher risk for ischemic heart disease.
Family history and genetics
A family history of early cardiovascular disease is a risk factor for ischemic heart disease. This is especially true if your father or brother was diagnosed before age 55, or if your mother or sister was diagnosed before age 65. Research shows that some genes are linked with a higher risk for ischemic heart disease.
Other medical conditions
Other medical conditions that can increase your risk of developing ischemic heart disease include:
- and inflammatory diseases such as psoriasis, lichen planus, pemphigus, histiocytosis, lupus erythematosus, and rheumatoid arthritis
- Chronic kidney disease
- Congenital heart defects
- High blood
- High blood pressure
- High blood triglycerides
- HIV/AIDS, which increases risk for cardiovascular disease, especially among older people. Part of the risk might be due to side effects of HIV treatments.
- Metabolic syndrome
- Overweight and obesity
- Sleep disorders such as sleep apnea or sleep deprivation and deficiency
Race or ethnicity
Ischemic heart disease is the leading cause of death for people of most racial and ethnic groups in the United States, including African Americans, Hispanics, and whites. For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer. However, some of these populations have higher rates than whites do for known risk factors of ischemic heart disease such as high blood pressure, diabetes, and obesity.
Many Americans have risk factors for heart disease, including a higher body weight, lack of regular physical activity, smoking, and high levels of blood pressure, sugar, or cholesterol. This includes more than half of whites, 3 in 4 Mexican Americans, and 8 in 10 African Americans.
Ischemic heart disease affects men and women. Obstructive coronary artery disease is more common among men than women. Nonobstructive coronary artery disease is more common among women.
Women may have a higher than normal risk for developing ischemic heart disease if they have one of the following conditions:
- Endometriosis, which raises the risk for heart disease in younger women
- Gestational diabetes, which can increase the risk for diabetes and metabolic syndrome even after pregnancy, and the risk of developing ischemic heart disease
- HIV infection
- Polycystic ovary syndrome, an condition that causes large ovaries and prevents proper ovulation, which can reduce fertility
- Preeclampsia, a condition that can happen during pregnancy and is linked to an increased lifetime risk for ischemic heart disease
Screening and Prevention
Screening tests and risk assessments for developing ischemic heart disease should start around age 20 for people who do not have any ischemic heart disease risk factors. Children may need screening if they have risk factors, such as obesity, low levels of physical activity, or a family history of heart problems.
To screen for ischemic heart disease, your doctor will determine whether you have any known risk factors, test your cholesterol and blood sugar levels, and check your blood pressure. Your doctor may use a risk calculator to determine whether you are in a low-, intermediate-, or high-risk group. Your doctor may recommend treatments such as heart-healthy lifestyle changes to help prevent ischemic heart disease.
Screening tests and results
To screen for ischemic heart disease, your doctor will review your medical history and perform some tests. The screening may include:
- Assessment of risk factors to help evaluate your risk of developing ischemic heart disease
- Blood pressure readings to see whether you have high blood pressure
- Calculation of your body mass index to see whether you have an unhealthy weight
- Blood tests to see whether you have high blood cholesterol, high blood triglycerides, or diabetes
Screening usually occurs in a doctor's office, but sometimes screenings are done at health fairs, drug stores, or other places. Blood samples might be collected at your doctor's office, a hospital, or a laboratory.
Do not eat or drink anything besides water for eight to 10 hours before blood tests for diabetes or cholesterol. Ask your doctor whether you need to do anything to prepare for any other tests that will be done.
Your doctor may evaluate your risk using a calculator such as the Atherosclerotic Cardiovascular Disease Estimator. This calculator estimates your risk of having a heart attack or stroke in the next 10 years. It considers your total and levels, age, and blood pressure. It also factors in whether you have diabetes, smoke, or use medicines to control high blood pressure. The calculator uses your ischemic heart disease risk factors to estimate your risk.
- High risk: A greater than 20 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.
- Intermediate risk: A 10 to 20 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.
- Low risk: Less than 10 percent risk that you will develop a heart attack or die from coronary disease in the next 10 years.
Risk calculators can be useful to help people understand their risk factors and encourage them to make healthy lifestyle changes. Your doctor will consider your 10-year risk calculation in association with other factors, such as your family history, when deciding how best to manage your risk of cardiovascular complications from ischemic heart disease. Risk assessments should be repeated every 4 to 6 years in adults 20 to 79 years of age who do not have cardiovascular disease.
Risk calculators may not be as accurate for certain populations, including women, Asian, Americans, Hispanics, Native Americans, and people taking.
Commonly used risk calculators might not accurately estimate risk in certain situations, such as when you are taking a statin for high blood cholesterol, or for certain populations. Your doctor may need to use a special risk calculator for predicting risk of ischemic heart disease if you are a woman or a member of a racial or ethnic minority.
Ask your doctor about your risk factors and how your risk is evaluated.
Heart-healthy lifestyle changes to prevent ischemic heart disease
To prevent ischemic heart disease, or if you have certain risk factors, your doctor may recommend that you adopt heart-healthy lifestyle changes, including eating healthy, being physically active, aiming for a healthy weight, quitting smoking, and managing stress. Studies support these changes as an effective approach to preventing ischemic heart disease and its complications.
- Diagnosis will explain tests and procedures that your doctor may use to diagnose ischemic heart disease.
- Living With will discuss what your doctor may recommend to prevent ischemic heart disease from getting worse or causing complications.
- Research for Your Health will explain how we are using current research and advancing research to prevent ischemic heart disease.
- Participate in NHLBI Clinical Trials will discuss our open and enrolling clinical studies that are investigating prevention strategies for ischemic heart disease.
Signs, Symptoms, and Complications
Signs, symptoms, and complications will vary based on the type of ischemic heart disease you have. Some people report severe of ischemic heart disease, but others have no or symptoms at all. If you have “silent” ischemic heart disease, you may not experience any symptoms until you have complications, such as coronary events including a heart attack.
Signs and symptoms
An acute coronary event, such as a heart attack, may cause symptoms such as:
- Angina, which can feel like pressure, squeezing, burning, or tightness during physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back. The pain may feel like indigestion.
- Cold sweats
- Light-headedness or dizziness
- Nausea or a feeling of indigestion
- Neck pain
- Shortness of breath, especially with activity
- Sleep disturbances
ischemic heart disease can cause signs and symptoms such as the following:
- Anxiety or nervousness
- Neck pain
The severity of these symptoms can vary. They may get worse as the buildup of plaque continues to narrow the coronary arteries. Chest pain or discomfort that does not go away or occurs more often or while you are resting might be a sign of a heart attack. If you do not know whether your chest pain is angina or a heart attack, call 9-1-1 immediately. All chest pain should be checked by a doctor.
How may symptoms differ for women?
Doctors usually rely on descriptions of chest pain when diagnosing ischemic heart disease. Men commonly report squeezing chest pain that occurs with exertion and stops with rest. Although women’s symptoms may be similar to men’s, women are less likely to describe pain; instead, they may mention feeling pressure or tightness in the chest. Women often report other symptoms, such as nausea, abdominal pain, vomiting, fatigue, and dizziness. Women are also more likely than men to have no symptoms of ischemic heart disease.
Because women and their doctors may not recognize ischemic heart disease symptoms that are different from men's, women may not be diagnosed and treated as quickly as men. It is important to seek care right away if you have symptoms of ischemic heart disease.
Your doctor will ask about your eating and physical activity habits, family history, and risk factors for ischemic heart disease. Your doctor may ask whether you have any other signs or symptoms. This information can help your doctor determine whether you have complications or other conditions that may cause ischemic heart disease.
Depending on your risk factors, your doctor may recommend diagnostic tests for ischemic heart disease even if you do not have symptoms.
Diagnostic tests and procedures
To diagnose ischemic heart disease, your doctor may order some of the following tests:
- Blood tests to check the levels of cholesterol, triglycerides, sugar, , or proteins that are markers of inflammation. Abnormal levels are risk factors for ischemic heart disease.
- Echocardiography (echo) to check the heart's pumping capacity and observe the function of its valves and chambers. This imaging study can also show areas of poor blood flow that could be caused by narrowing or blockages in the coronary arteries. A type of echo called transthoracic Doppler ultrasound can show how well your heart's small arteries respond to a drug given to increase blood flow. This test can help diagnose coronary microvascular disease.
- Electrocardiogram (EKG or ECG) to determine whether the heart's rhythm is steady or irregular. An EKG also records the strength and timing of electrical signals as they pass through the heart.
- Stress tests to check how your heart works during physical stress. During stress testing, you walk or run on a treadmill or pedal a stationary bike to make your heart work hard and beat fast. Tests are done on your heart while you exercise. If you have a medical problem that prevents you from exercising, your doctor may give you medicine to make your heart work hard, as it would during exercise.
- Cardiac CT (computed tomography) scan to detect or evaluate the presence and extent of coronary artery disease. This test may also be used to follow up on abnormal findings from chest X-rays or other tests.
- Cardiac MRI (magnetic resonance imaging) to detect tissue damage or problems with blood flow in the heart or coronary arteries. It can help your doctor diagnose coronary microvascular disease or nonobstructive or obstructive coronary artery disease. Cardiac MRI can help explain results from other imaging tests such as chest X-rays and CT scans.
- Cardiac positron emission tomography (PET) scanning, a type of nuclear heart scan, with radioactive tracers to diagnose coronary microvascular disease by assessing blood flow through the small arteries and into the heart tissues.
- Coronary calcium scan to detect and measure the amount of calcium in the walls of your coronary arteries. Buildup of calcium can be a sign of atherosclerosis, coronary artery disease, or coronary microvascular disease. Coronary calcium scans can also help assess ischemic heart disease risk for people who smoke or for people who do not have heart symptoms.
- Coronary angiography to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. This procedure is often used if other tests show that you are likely to have coronary artery disease. Standard angiography cannot be used to diagnose coronary microvascular disease, because the tiny blood vessels are too small to visualize. However, it is possible to indirectly assess the function of the small arteries by tracking the amount of time it takes for the dye to travel from the large arteries into the small arteries.
- Coronary guidewire sensor technology to assess microvascular function in the heart. A guidewire equipped with sensors is inserted into the heart's arteries with cardiac catheterization. The sensors can detect coronary blood pressure and temperature to measure how easily blood flows through the small arteries. Usually measurements are done before and after giving you medicine to enhance blood flow in your heart. Your doctor may diagnose coronary microvascular disease if your small arteries do not respond to the drug by increasing blood flow. This type of technology can also show nonobstructive disease in the larger coronary arteries if the arteries spasm or narrow when exposed to a drug called acetylcholine.
Why may it take longer to diagnose nonobstructive coronary artery disease and coronary microvascular disease?
Nonobstructive coronary artery disease and coronary microvascular disease can be missed because patients or doctors may not recognize symptoms as warning signs. This can lead to missed or delayed diagnoses, especially for women, who are less likely to have typical chest pain and are more likely to report other symptoms, such as nausea, abdominal pain, vomiting, fatigue, and dizziness.
Your doctor may recommend diagnostic tests such as standard stress tests, imaging procedures, and risk assessments to detect obstructive coronary artery disease. Diagnosing nonobstructive coronary artery disease and coronary microvascular disease often requires more invasive tests or specialized testing procedures, such as cardiac PET scanning, that are not widely available.
- Return to Risk Factors to review family history, lifestyle, or other environmental factors that increase your risk of developing ischemic heart disease.
- Return to Signs, Symptoms, and Complications to review common signs and symptoms of ischemic heart disease.
- Return to Screening and Prevention to review how to screen for ischemic heart disease.
Treatment depends on the type and severity of your disease and other complications or health conditions you may have. Possible treatments for ischemic heart disease include heart-healthy lifestyle changes, medicines, or procedures such as coronary artery bypass grafting or percutaneous coronary intervention.
Your doctor will consider your 10-year risk calculation when deciding how best to treat your ischemic heart disease.
Heart-healthy lifestyle changes
Your doctor may recommend that you adopt lifelong heart-healthy lifestyle changes, including:
- Aiming for a healthy weight. Losing just 3 percent to 5 percent of your current weight can help you manage some ischemic heart disease risk factors, such as high blood cholesterol and diabetes. Greater amounts of weight loss can also improve blood pressure readings.
- Being physically active. Routine physical activity can help manage ischemic heart disease risk factors such as high blood cholesterol, high blood pressure, or overweight and obesity.
- Heart-healthy eating, such as the DASH (Dietary Approaches to Stop Hypertension) eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, trans fats, , added sugars, and alcohol.
- Managing stress. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.
- Quitting smoking. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute's Your Guide to a Healthy Heart. Although these resources focus on heart health, they include basic information about how to quit smoking. For free help and support to quit smoking, you can call the National Cancer Institute's Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848).
Your doctor may recommend medicines to manage your risk factors or treat underlying causes of ischemic heart disease. Some medicines can reduce or prevent chest pain and control other medical conditions that may be contributing to your ischemic heart disease.
- ACE inhibitors and beta blockers to help lower blood pressure and decrease the heart's workload.
- Calcium channel blockers to reduce blood pressure by allowing blood vessels to relax.
- Medicines to control blood sugar, such as empagliflozin, canagliflozin, and liraglutide, to help lower your risk for complications if you have ischemic heart disease and diabetes.
- Metformin to control atherosclerosis if you have diabetes.
- Nitrates, such as nitroglycerin, to relieve or prevent chest pain from angina. Nitroglycerin dissolves under your tongue or between your cheek and gum.
- Ranolazine to treat coronary microvascular disease and the chest pain it may cause.
- Statins or non-statin therapies to control high blood cholesterol. Your doctor may recommend statin therapy if you have a higher risk for ischemic heart disease complications or stroke or if you have diabetes and are between ages 40 and 75. Non-statin therapies may be used to reduce cholesterol when statins do not lower cholesterol enough or cause side effects. Your doctor may prescribe non-statin drugs, such as gemfibrozil, ezetimibe, sequestrants, fenofibrate, alirocumab, evolocumab, or omega-3 fatty acids.
Procedures or surgery
You may need a procedure or heart surgery to treat more advanced ischemic heart disease.
- Coronary artery bypass grafting (CABG) to improve blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries,. Surgeons typically use CABG to treat people who have severe coronary artery disease in multiple coronary arteries.
- Percutaneous coronary intervention (PCI) to open coronary arteries that are narrowed or blocked by the buildup of atherosclerotic plaque. A small mesh tube called a stent is usually implanted after PCI to prevent the artery from narrowing again.
- Transmyocardial laser revascularization to treat severe angina associated with ischemic heart disease when other treatments are too risky or did not work.
- Living With will explain what your doctor may recommend, including lifestyle changes and medicines, to prevent ischemic heart disease from getting worse or causing complications.
- Research for Your Health will discuss how we are using current research and advancing research to treat people with ischemic heart disease.
- Participate in NHLBI Clinical Trials will explain our open and enrolling clinical studies that are investigating treatments for ischemic heart disease.
Receive follow-up care
It is important to get routine medical care and to take all medicines regularly, as your doctor prescribes. Do not change the amount of your medicine or skip a dose unless your doctor tells you to. Talk with your doctor about how often you should schedule office visits and blood tests. Between visits, call your doctor if you have any new symptoms, if your symptoms worsen, or if you have problems with your blood pressure or blood sugar.
Return to Treatment to review possible treatment options for ischemic heart disease.
If your doctor diagnoses you with ischemic heart disease or if you have a heart attack or another serious event, you may be referred for exercise-based cardiac rehabilitation, also called cardiac rehab, to manage symptoms and reduce the chances of future problems. Studies have shown that exercise-based cardiac rehabilitation reduces the risk of hospitalization and death. Many people who have participated in cardiac rehab also report better quality of life.
Prevent complications over your lifetime
Your doctor will consider your 10-year risk calculation when deciding how best to manage your risk of cardiovascular complications. He or she will work with you to manage medical conditions that can raise your risk for heart problems and complications.
- You will likely be given a statin to lower your , especially after a heart attack.
- Your doctor may recommend aspirin to prevent a heart attack or stroke. Low-dose aspirin may help prevent blood clots and reduce the risk for heart attacks and other complications of ischemic heart disease for most people, including those with diabetes.
- If you have diabetes, you will need to check your blood sugar and keep taking any prescribed medicines.
- If your ischemic heart disease has gotten worse or led to a heart attack or sudden cardiac arrest, your doctor may recommend a pacemaker or defibrillator to detect and treat certain types of serious arrhythmias.
- Anemia treatment may help if you have been diagnosed with coronary microvascular disease and also have anemia. Anemia is thought to slow the growth of cells needed to repair damaged blood vessels.
Your doctor will likely also suggest heart-healthy lifestyle changes, such as eating heart-healthy foods, being physically active, and quitting smoking. Your doctor may refer you to other professionals, such as a registered dietitian or exercise physiologist, to help you meet your goals.
There are benefits to quitting smoking no matter how long or how much you have smoked. Ischemic heart disease risk associated with smoking begins to decrease soon after you quit, and it generally continues to decrease over time.
Living with heart disease may cause fear, anxiety, depression, and stress. You may worry about having heart problems or making lifestyle changes that are necessary for your health. Talk with your health care team about how you feel. Your doctor may recommend you take steps that include:
- Talking to a professional counselor. If you are depressed, your doctor also may recommend medicines or other treatments that can improve your quality of life.
- Joining a patient support group. This may help you adjust to living with heart disease. You can find out how other people who have the same symptoms as yours have coped with them. Your doctor may be able to recommend local support groups, or you can check with an area medical center.
- Seeking support from family and friends. Letting your loved ones know how you feel and what they can do to help you can help relieve stress and anxiety.
Learn the warning signs of serious complications and have a plan
Ischemic heart disease can lead to serious cardiovascular complications, such as heart attack or stroke. If you think that you are or someone else is having the following symptoms, call 9-1-1 immediately. Every minute matters.
The signs and symptoms of a heart attack include:
- Nausea, vomiting, light-headedness or fainting, or breaking out in a cold sweat. These symptoms of a heart attack are more common in women.
- Prolonged or severe chest pain or discomfort not relieved by rest or nitroglycerin. This involves uncomfortable pressure, squeezing, fullness, or pain in the center or left side of the chest that can be mild or strong. This pain or discomfort often lasts more than a few minutes or goes away and comes back.
- Shortness of breath. This may accompany chest discomfort or happen before it.
- Upper body discomfort. This can be felt in one or both arms, the back, neck, jaw, or upper part of the stomach.
Learn the signs and symptoms of a stroke. If you think someone may be having a stroke, act F.A.S.T. and do the following simple test:
F—Face: Ask the person to smile. Does one side of the face droop?
A—Arms: Ask the person to raise both arms. Does one arm drift downward?
S—Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange?
T—Time: If you observe any of these signs, call 9-1-1 immediately. Early treatment is essential.
What Should Women Know?
Heart disease is the leading cause of death for women. Women who have symptoms of ischemic heart disease are less likely than men to have obstructive coronary artery disease. However, they may be at greater risk for coronary microvascular disease and for serious complications of coronary artery disease, including blood clots in the heart's arteries.
Eighty percent of women ages 40 to 60 have one or more risk factors for ischemic heart disease. Having multiple risk factors significantly increases a woman's chance of developing ischemic heart disease.
Learn more about how the causes, risk factors, symptoms, diagnosis, and treatment of ischemic heart disease may be different for women than for men.
Why does ischemic heart disease affect women differently?
Ischemic heart disease is different for women than men because of hormonal and anatomical differences.
- Hormonal changes affect a woman’s risk for ischemic heart disease. Before menopause, the hormone estrogen provides women with some protection against ischemic heart disease. Estrogen raises “good” HDL cholesterol and helps keep the arteries flexible so they can widen to deliver more oxygen to the tissues of the heart in response to chemical and electrical signals. After menopause, estrogen levels drop, increasing a woman’s risk for ischemic heart disease.
- The size and structure of the heart is different for women and men. A woman’s heart and blood vessels are smaller, and the muscular walls of women’s hearts are thinner.
What conditions affect risk differently for women?
Women are more likely than men to have medical conditions or life issues that raise their risk for ischemic heart disease.
- Anemia, especially during pregnancy
- Hormonal birth control
- High blood pressure after age 65
- Inflammatory and autoimmune diseases
- Lack of physical activity
- Mental health issues, such as stress, marital stress, anxiety disorders, depression, or low social support
- Overweight and obesity
- Problems during pregnancy, including gestational diabetes and preeclampsia and eclampsia
Some factors raise women's risk for ischemic heart disease more than they increase risk in men.
- Low levels of HDL cholesterol
Visit The Heart Truth ® to learn more about ischemic heart disease risk factors for women and how to lower them.
Can symptoms differ for women?
Although men and women can experience the same symptoms of ischemic heart disease, women often experience no symptoms or have other symptoms than men do:
- Activity that brings on chest pain. In men, angina tends to worsen with physical activity and go away with rest. Women are more likely than men to have angina while they are resting or sleeping. In women who have coronary microvascular disease, angina often happens during routine daily activities, such as shopping or cooking, rather than during exercise.
- Location and type of pain. Women are more likely to describe their chest pain as crushing, or they say it feels like pressure, squeezing, or tightness. Men say their pain is aching or dull. Women more often say they have pain in the neck and throat. Men usually describe pain in the chest.
- Mental stress. Mental stress is more likely to trigger angina pain in women than in men.
- Other symptoms. Common signs and symptoms for women include nausea, vomiting, shortness of breath, abdominal pain, sleep problems, fatigue, and lack of energy.
What do women need to know about diagnosis and treatment?
Tests and procedures for diagnosing ischemic heart disease are very similar for women and men. But women may experience delays in diagnosis or treatment. Learn about important diagnostic tests and treatment options.
- Ask about important diagnostic tests. Doctors are less likely to refer women for diagnostic tests for ischemic heart disease. When women go to the hospital for heart symptoms, they are more likely than men to experience delays receiving an initial EKG, are less likely to receive care from a heart specialist during hospitalization, and are less likely to receive certain types of therapy and medicines. Younger women are more likely than men to be misdiagnosed and sent home from the emergency department after cardiac events that occur from undiagnosed and untreated vascular heart disease.
- Ask about treatment options that are effective for men and women. Women may be less likely than men to receive aspirin, statins, and beta blockers for treating their heart disease. Although women may be as likely as men to benefit from a pacemaker or a defibrillator, women are less likely to receive these treatments for complications of ischemic heart disease. Women are often less likely to receive coronary artery bypass grafting or percutaneous coronary intervention than men are, even though research shows that both men and women can benefit from these procedures.
- Know and share your risk factors. Doctors may not recognize women's risk for ischemic heart disease. Commonly used risk-scoring systems may not accurately predict risk in women. Also, in one survey, fewer than one in four women reported that their doctors had ever discussed their risk for heart disease.
- Learn the symptoms and seek medical care right away. Being familiar with the symptoms of ischemic heart disease and how they may differ in women may help you recognize when to talk to your doctor or when to seek medical care. Immediate care may help prevent complications such as heart attack or sudden cardiac arrest.
Improving health with current research
Learn about the following ways the NHLBI continues to translate current research into improved health for people with heart disease. Research on this topic is part of the NHLBI's broader commitment to advancing heart and vascular disease, population and epidemiology studies, and women's health scientific discovery.
- NHLBI Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. We support the development of guidelines based on up-to-date research to evaluate and manage risk of ischemic heart disease in children and adolescents. Visit Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents for more information.
- NHLBI Systematic Evidence Reviews Support Development of Guidelines for Blood Cholesterol in Adults. We continue to perform systematic reviews of the latest science. These reviews help partner organizations update their clinical guidelines, which health professionals use to treat adults who have high blood cholesterol. Visit Managing Blood Cholesterol in Adults: Systematic Evidence Review From the Cholesterol Expert Panel, 2013 for more information.
- Following Ischemic Heart Disease in Generations of Families. NHLBI's landmark Framingham Heart Study (FHS), launched in 1948, has contributed transformative discoveries related to the risk factors and treatment of heart disease. Through the FHS, scientists learned that many of those risks can be changed. Such findings are paving the way for new interventions to preempt, prevent, or treat these conditions more effectively. To mark the 70th anniversary of the FHS, the project director delivered a special lecture highlighting the history and accomplishments of the study.
- Global Leadership in Cardiovascular Health. We are proud to serve as a global leader and respond to legislative calls to increase U.S. global health efforts. The Health Inequities and Global Health Branch seeks to stimulate global health research, education, and training for many conditions, including ischemic heart disease.
- Recommendation Against Hormone Replacement Therapy in Postmenopausal Women. The NHLBI-sponsored Women's Health Initiative, one of the country's largest clinical trials of women ever undertaken, recruited more than 161,000 postmenopausal women to allow researchers to study strategies to prevent ischemic heart disease, among other conditions. The initiative provided evidence that hormone replacement therapy does not protect older postmenopausal women from ischemic heart disease and its complications. As a result, doctors no longer routinely prescribe long-term hormone therapy for postmenopausal women.
- National Education Program for Women. NHLBI's The Heart Truth® raises awareness about heart disease and its risk factors and educates women about steps for preventing heart disease.
- NHLBI's Women's Ischemia Syndrome Evaluation (WISE) Study. The WISE study, which started in 1996, is advancing the understanding of heart disease in women, leading to improved diagnosis and treatment. Most of what is known about coronary microvascular disease comes from the study. The WISE study revealed that 8 percent of women who had chest pain but no sign of obstructive coronary artery disease actually had scars in their heart muscle, indicating that they had had an undetected heart attack at some point, which could increase their risk of serious heart complications.
Learn about some of the pioneering research contributions we have made over the years that have improved clinical care.
- Depression's link with ischemic heart disease. Thirty years of data from large population studies provide evidence of a link between depression and heart disease. NHLBI-sponsored research is tackling the question of whether depression causes heart disease or whether depression is a risk factor on its own. Visit Heart Disease and Depression: A 2-Way Relationship to learn more.
- Effect of early adulthood factors on future risk of cardiovascular diseases, including ischemic heart disease. Findings from the NHLBI's Coronary Artery Risk Development in Young Adults (CARDIA) study have contributed substantially to our knowledge about the importance of lifestyle and environmental factors in the development of cardiovascular disease later in life. Doctors encourage young people to maintain a healthy lifestyle to reduce their risk of ischemic heart disease and other cardiovascular conditions in middle age.
- Evaluation of risks for heart disease in school children. From 1970 to 1991, the multigenerational Muscatine Heart Study followed school-aged children into adulthood to study their heart disease risk factors. The study continues to evaluate heart disease risk factors in the children of the initial study participants.
- Heart disease symptoms may vary according to sex or racial or ethnic group. Participants in the Multi-Ethnic Study of Atherosclerosis (MESA) are from six U.S. communities and represent diverse racial and ethnic groups. MESA researchers are identifying factors that contribute to cardiovascular disease that occurs with or without obvious symptoms. They also are studying why certain groups may be at higher risk for ischemic heart disease. MESA has developed an online tool and a smartphone app (for iPhone and Android) to help consumers assess risk factors and estimate their risk of ischemic heart disease.
- Importance of silent coronary heart disease in older adults. The goal of the NHLBI's Cardiovascular Health Study (CHS) is to identify risk factors for cardiovascular disease related to the onset of ischemic heart disease and stroke in adults age 65 or older. CHS investigators found that a large amount of plaque buildup can occur before symptoms of ischemic heart disease appear, demonstrating the importance of identifying the earliest stages of the disease process.
- Improving life for people living with HIV/AIDS. Investigators with the NHLBI HIV/AIDS Program have demonstrated that people living with HIV are at significantly greater risk of developing ischemic heart disease than the general population is. In addition, the mechanisms of HIV-related heart disease may be different because of the effects of antiretroviral therapy and a greater contribution of inflammation and other factors. The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) is testing the effect of statins on the risk of heart and vascular disease, such as ischemic heart disease, in adults living with HIV.
- Increased risk of ischemic heart disease among African Americans. The Jackson Heart Study (JHS) is the largest study of causes of ischemic heart disease and other cardiovascular conditions in African Americans, involving more than 5,300 men and women in Jackson, Mississippi. The study has enhanced our knowledge of the genetic and environmental factors that increase African Americans risk of cardiovascular diseases, including ischemic heart disease and its complications.
- Learning about ischemic heart disease risk in Hispanics in the United States. The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is the most comprehensive study of Hispanic/Latino health and disease in the United States. Researchers are learning about how widespread cardiovascular disease is in various groups, protective or harmful factors, and changes in participants' health over time. Because cardiovascular disease risk varies among different groups of Hispanics and Latinos, more personalized approaches to screening and prevention of ischemic heart disease are needed.
- Nearly half of U.S. deaths caused by heart disease, stroke, and type 2 diabetes are linked to poor nutrition. An NHLBI-sponsored study suggests that reducing the consumption of sodium, red meat, and sugar-sweetened beverages while increasing intake of fruits, vegetables, nuts and seeds, whole grains, polyunsaturated fats, and omega-3 fatty acids found in seafood could reduce deaths caused by these health conditions. Visit High number of deaths from heart disease, stroke and diabetes linked to diet to learn more.
- Unique risk factors for ischemic heart disease among American Indians. The NHLBI's Strong Heart Study (SHS) is the largest and longest study of heart disease in American Indians. The study has identified some unique risk factors in this population, such as having high amounts of the protein albumin in the urine. This knowledge has led to new clinical calculators that doctors can use to assess the risk of developing ischemic heart disease and diabetes.
Advancing research for improved health
In support of our mission, we are committed to advancing ischemic heart disease research in part through the following ways.
- We perform research. Our Division of Intramural Research, which includes investigators from our Cardiovascular Branch and Population Sciences Branch, is engaged in research on diseases that affect the heart and blood vessels, including ischemic heart disease.
- We fund research. The research we fund today will help improve future health. Our Division of Cardiovascular Sciences oversees much of the research on ischemic heart disease we fund, helping us to understand, prevent, and manage ischemic heart disease and other cardiovascular conditions. Through the Center for Translation Research and Implementation Science, we plan, foster, and support research to identify the best strategies for ensuring successful integration of evidence-based interventions within clinical and public health settings, such as health centers, worksites, communities, and schools in the United States and abroad. Search the NIH RePORTer to learn about research that we are funding on ischemic heart disease.
- We stimulate high-impact research. Our Trans-Omics for Precision Medicine (TOPMed) program includes participants with ischemic heart disease, which may help us understand how genes contribute to differences in disease severity and how patients respond to treatment. The NHLBI Strategic Vision highlights ways in which we may support research over the next decade, including new efforts to understand ischemic heart disease.
Learn about exciting research areas the NHLBI is exploring about ischemic heart disease.
- The NHLBI is exploring the relationship between social and environmental exposures and the risk of ischemic heart disease. Data from nearly 12 million people in Sweden will be used to construct a database linking anonymous health records, environmental records, and death records collected over two or more decades. This NHLBI-supported project will increase knowledge about how social and physical neighborhood exposures influence ischemic heart disease risk in different population groups and across different stages of life.
- The NHLBI is studying the association between sleep deficiency and health problems, including ischemic heart disease and its risk factors. About 50 to 70 million Americans have sleep or wakefulness disorders. One NHLBI-sponsored study is exploring the complex genetic network governing sleep duration. Another study funded by the NHLBI is using wrist-worn devices and telephone interviews to study the effects of sleep apnea on women's risk for ischemic heart disease and other serious health problems. Visit To Sleep or Not: Researchers explore complex genetic network behind sleep duration.
- Post-traumatic stress disorder (PTSD) affects heart disease risk factors. We support a study to find out whether a therapy for PTSD affects risk of ischemic heart disease. The study could help inform strategies for ischemic heart disease prevention and guide medical management for vulnerable men and women with PTSD.
- Determining the most effective therapies to manage stable ischemic heart disease. The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) is a 5,000-participant, 350-site international trial comparing invasive and conservative strategies to prevent heart and vascular events in patients with stable ischemic heart disease. Results from ISCHEMIA and ISCHEMIA-Chronic Kidney Disease Trial (ISCHEMIA-CKD) will inform future clinical care.
What do your genes say about your ischemic heart disease risk?
Are you an adult who takes a statin to prevent ischemic heart disease?
Are you an African American adult who is curious about your heart disease risk?
Are you a healthy adult with no history of heart problems?
Do you need an imaging test for a heart or blood vessel problem?
Do you want to take part in research about the heart?
Do you want to prevent your kids from developing ischemic heart disease and other health problems?
Are you an African American adult living in the Washington, D.C. metro area?
Are you being treated for coronary artery disease?
Are you living with HIV and ischemic heart disease?
Are you an adult who wants to help improve MRI scans for assessing blood vessels of the heart?
Are you an adult who has psoriasis?
Has a doctor recommended that you or your child have a cardiac catheterization?
Do you want to help test a new type of scanner for detecting heart problems?
Do you have diabetes and a history of heart attack?
Have you had a cardiac MRI to diagnose ischemic heart disease?
After reading our Ischemic Heart Disease Health Topic, you may be interested in additional information found in the following resources.
Related Health Topics
- Aim for a Healthy Weight
- Aim for a Healthy Weight Patient Booklet
- Cardiovascular Health Study (CHS)
- Framingham Heart Study (FHS)
- Heart & Vascular Diseases
- Hispanic Community Health Study/Study of Latinos (HCHS/SOL)
- International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)
- Jackson Heart Study (JHS)
- Keep the Beat™ Heart Healthy Recipes
- Multi-Ethnic Study of Atherosclerosis (MESA)
- Population and Epidemiology Studies
- Strong Heart Study (SHS)
- The Heart Truth® for Women Campaign
- Women's Health
- Women's Health Initiative
- Your Guide to a Healthy Heart
- Your Guide to Lowering Your Blood Pressure With DASH
- Your Guide to Physical Activity and Your Heart