Heart Attacks in Women: Lower Plaque Levels, Similar Risk
A recent study found that women’s risk of heart attack and other major cardiac events matches that of men, even with less plaque in the arteries. Lower plaque is not the same as lower risk.
Dr. Godbole contributed expert commentary in Happiest Health.
A study published in Circulation: Cardiovascular Imaging has an important message for how we think about heart disease in women. Researchers looking at more than 4,200 adults with stable chest pain — just over half of them women, with an average age of 60 — found that women faced a similar risk of major cardiac events, including heart attack, as men, despite having less plaque in their coronary arteries.
Plaque, or atherosclerosis, remains one of the principal drivers of a heart attack. When it ruptures or critically narrows an artery, blood flow to the heart muscle is cut off. What this study makes clear is that the amount of plaque that begins to matter is not the same in women and men.
A Significant Step in Transforming Risk Assessment
After more than two years of follow-up, risk of a major cardiac event began to rise in women once plaque burden reached about 20%. In men, that threshold was closer to 28%. As plaque increased further, risk rose more steeply in women than in men.
Most traditional risk scores and imaging cut-offs were built from predominantly male populations. Applied without adjustment, they can underestimate risk in women — particularly after menopause, when protective oestrogen levels decline. Sex-specific interpretation of coronary CT angiography, rather than a single “one-size-fits-all” plaque threshold, is a more honest way to assess risk and to intervene earlier.
Why Are Women at Risk Despite Lower Plaque Build-Up?
Women typically have smaller coronary arteries than men, even after accounting for body size. Key vessels such as the left main and left anterior descending arteries tend to be narrower, independent of body surface area or heart mass. In a smaller vessel, a modest volume of plaque occupies a larger share of the lumen. The same millimetres of plaque that might be tolerated in a larger male artery can meaningfully restrict flow in a woman — which is why lower plaque volume is not a guarantee of lower clinical risk.
Women Are Also More Prone to MINOCA
Women are also more susceptible to MINOCA — myocardial infarction with non-obstructive coronary arteries. This is a heart attack that occurs even when the angiogram does not show a major blockage (typically less than 50% stenosis). Although men can also experience a MINOCA heart attack, this risk is more prevalent in women due to their narrower arteries. Even a lower but lipid-rich plaque build-up in women can disrupt the vessel surface, impede blood flow, and trigger a MINOCA event.
MINOCA is easy to miss if we wait for a “typical” blocked artery on angiography. The heart muscle is still injured — troponin rises, symptoms are real — but the cause may be plaque erosion, spasm, spontaneous dissection, or another mechanism that a standard angiogram does not fully reveal. That is why symptoms in women should not be dismissed because the arteries look “only mildly diseased.”
Heart Health Risks for Women in India
Heart attacks remain a leading cause of death in both men and women. The average age of heart attack in India is around 59, and we are seeing a concerning rise among younger people. For women here, genetics is only part of the picture. Hypertension, diabetes, undiagnosed or poorly managed cholesterol, sedentary living, post-menopausal hormonal change, obesity, and chronic stress all raise risk. Women with long-standing diabetes and other comorbidities are also more likely to have silent or atypical heart attacks — fatigue, breathlessness, or vague discomfort rather than classic chest pain — which delays recognition and treatment.
Limited awareness and delayed access to care compound the problem. Women should not ignore even mild symptoms such as unusual fatigue, tiredness, or occasional breathing difficulty. Regular check-ups to monitor blood pressure, blood sugar, cholesterol, and overall heart health — and follow-up when those numbers are off — can meaningfully reduce risk.
Takeaways
- Lower plaque in women does not mean lower heart-attack risk. Risk begins to rise at a lower plaque burden than in men.
- Smaller coronary arteries mean modest, lipid-rich plaque can still obstruct flow — including in MINOCA, where the blockage is not “major” on angiography.
- Do not wait for dramatic chest pain. Fatigue, breathlessness, and other mild or atypical symptoms deserve timely evaluation.
- Know and manage blood pressure, diabetes, cholesterol, weight, activity, and post-menopausal risk. Regular follow-up is preventive care, not an afterthought.