Crushing, squeezing chest pain is widely recognized as the hallmark sign of a heart attack. Yet in women, cardiovascular disease frequently presents as shortness of breath, unexplained fatigue, or nausea—atypical symptoms that nearly 6 in 10 adults fail to recognize.
A research team led by Korea University Anam Hospital has published the first nationwide Korean survey evaluating public awareness of sex differences in cardiovascular disease. Supported by the National Institute of Health under the Korea Disease Control and Prevention Agency (KDCA), the findings were published in the international journal JACC: Advances (Journal of the American College of Cardiology: Advances).
Cardiology professor Kim Hyun-jin of Hanyang University Guri Hospital served as first author, with cardiology professor Park Sung-mi of Korea University Anam Hospital as corresponding author.
Biological Drivers Behind Gendered Symptoms
Biological mechanisms explain why heart disease manifests differently in men and women. In male patients, major coronary arteries are more prone to localized, large-vessel blockages that trigger classic chest pain. In female patients, dysfunction more commonly affects the microscopic blood vessels surrounding the heart.
A 2024 study by Park’s team revealed that among patients experiencing angina symptoms without major arterial blockages, coronary microvascular dysfunction was present in 46% of women compared to 31% of men. Because this damage is diffuse across the microvasculature rather than confined to a single large vessel, symptoms manifest as generalized shortness of breath, persistent fatigue, and nausea.
Hormonal factors further compound these differences. Estrogen protects blood vessels by dilating arteries, reducing inflammation, and regulating cholesterol, delaying the average onset of cardiovascular disease in women by roughly a decade compared to men. However, when estrogen levels plummet post-menopause, cardiovascular risk surges. Female-specific conditions such as preeclampsia and gestational diabetes also heighten long-term heart risks.
Historically, clinical diagnostic criteria were developed around male symptom patterns, creating systemic biases in care. A Health Insurance Review & Assessment Service (HIRA) dataset of 630,000 Korean acute myocardial infarction patients from 2003 to 2018 showed that 63.2% of men underwent diagnostic coronary angiography, compared to just 39.8% of women.
Nationwide Survey Reveals Widespread Awareness Gaps
To measure public understanding of these discrepancies, the researchers conducted a web-based survey of 2,003 adults aged 20 to 80, stratified proportionally by age, sex, and region.
Only 39.7% of respondents demonstrated a high awareness of sex-specific symptoms, risk factors, and treatment outcomes—meaning roughly 6 in 10 adults remain unaware of these critical differences. Lack of knowledge was equally prevalent among men and women, underscoring the need for universal public health education.
Awareness varied significantly across demographic lines. Individuals with a family history of cardiovascular disease were 1.84 times more likely to demonstrate high awareness. Conversely, awareness was notably lower among unemployed and low-income respondents, reflecting reduced access to medical information among socioeconomically vulnerable groups.
Public Demand for Sex-Specific Health Education
The survey exposed a stark disconnect between public exposure to health information and demand for education. A striking 96% of respondents reported encountering little to no information regarding sex differences in heart disease over the past year (68.9% none; 27.0% occasionally). However, 60.2% stated that sex-differentiated cardiovascular education is essential, while only 27.7% felt current government and societal support was adequate.
"While sex-differentiated diagnosis and treatment have become international standards in cardiology, public awareness continues to lag far behind," said Professor Park Sung-mi, who also serves as director of the Rosetta Hall Women’s Heart Center at Korea University Anam Hospital. "Public health campaigns must reach both men and women, with targeted outreach for socioeconomically vulnerable populations."
Park added that the study provides crucial baseline evidence for the Korean government to formulate equitable national health policies and sex-specific educational strategies. Medical experts emphasize that women experiencing unusual shortness of breath, sudden fatigue, or nausea—even in the absence of chest pain—should seek cardiovascular evaluation, particularly if they have a family history of heart disease.
