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Cardiology

Women’s hearts give silent warnings

In the beginning, it was only a feeling. No stabbing pain, no dramatic collapse. Just this diffuse, hard to grasp sense that “something isn’t right.” Mira first noticed it during her long walks. “I always had to sit down somewhere … I couldn’t really assess it,” she recalls. Her husband asked her what was wrong, but Mira only shrugged. “Strange feeling,” she said and continued walking with a sense that “something isn’t right.”
Christine Rösch
Published on February 13, 2026
This marks the beginning of a topic medical societies worldwide have been highlighting for years. Women like Mira – in the midst of life, active, full of energy – often do not experience classic chest pain in coronary artery disease, but rather symptoms that are far too easy to attribute to something else: restlessness, nausea, dizziness, abdominal pain, jaw pain.

Interventional cardiologist Professor Irene Lang, MD, summarizes these atypical symptoms: “Coronary artery disease in women is a very particular condition that does not follow textbook patterns.”

Prof. Irene Lang, MD

When awareness fades, risk increases

What Mira did not know is clearly reflected in the data: General risk awareness is declining. Already in 2009, the American Heart Association surveyed women – at that time, 65 percent knew that heart disease is the leading cause of death. Ten years later, it was only 44 percent [1]. The decrease was particularly pronounced among younger women.

Women’s heart health: Gaps in diagnosis and declining awareness

Atypical symptoms – and why they matter

This knowledge gap coincides with a second risk: More often than not, women show atypical symptoms. In a large, well-known analysis of more than 1.1 million heart attacks, 42 percent of women had no chest pain, yet still experienced a myocardial infarction. In comparison, 31 percent of men had no chest pain [4]. A systematic review confirms that about one-third of women do not report chest pain, even when asked directly [5].


A nighttime episode

Much later – after experiencing weakness during walking and two months of shortness of breath – Mira woke up in the middle of the night with a heavy pressure on her chest, accompanied by shortness of breath. She remembers she did not want to alarm her family with these symptoms. So, she kept them to herself and did not call emergency services. Instead, she took the subway.

Mira remembers that she did not want to alarm her family with the symptoms.
Doctor and patient walking through a hospital corridor
Doctor reviewing cardiac imaging with a patient
Portrait of Prof. Irene Lang, MD
Mira remembers that she did not want to alarm her family with the symptoms.

The silent gap in care

These delays are not isolated cases. A large public health analysis over almost two decades shows that women with angina pectoris significantly more often receive no or delayed diagnosis – even with comparable symptoms [8].

The ESC Patient Forum summarizes it clearly: Women experience underdiagnosis and undertreatment. The appeal to the medical community is unmistakable: Targeted training, checklists, and structured systems are necessary [9].

When unremarkable initial findings are not enough

Mira’s story illustrates why unremarkable initial findings sometimes are not enough. 

When she arrived at the hospital, the first tests were unremarkable: “Lab normal, ECG normal,” Lang recalls. But her family history and pregnancy-related hypertension made the physician suspicious.

Many cardiovascular risks in women arise in the context of menopause, hormonal changes, or pregnancy – areas in which gynecology plays a key role. Therefore, an interdisciplinary perspective is essential.

The turning point in the CT scanner

Normal initial findings would often lead to women being sent home. But in Mira’s case, the physician did the decisive thing: She remained skeptical.

Despite unremarkable initial findings, the team decided, “We’ll go ahead with a coronary CT anyway.”

What became visible then explains the whole course of events: 
a noncalcified, high-grade stenosis in the right coronary artery. This is a dangerous type of narrowing as noncalcified plaques are particularly prone to rupture and are therefore unstable.

Plaque rupture as a typical cause of heart attack

When such a “soft,” noncalcified plaque ruptures, highly thrombogenic material becomes exposed, rapidly triggering the formation of a thrombus. This clot can acutely occlude the artery. 

For the patient, this could mean the blood flow stops abruptly, and a myocardial infarction can occur – even when all previous tests appeared normal.

Advanced diagnostics

For Mira, the imaging data confirmed that coronary CT diagnostics can be of central value for women in such instances. In her case, it enabled the identification of a high-grade stenosis of the right coronary artery.

Typical measurements such as the CAC (coronary artery calcium) score are less accurate for women than men, and symptom patterns such as impaired microvascular perfusion or vasospastic constriction of the coronary vessels – the so-called INOCA (ischemia with nonobstructive coronary artery disease) spectrum – often occur disproportionately in women.

In a consensus paper by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the European Society of Cardiology (ESC), both organizations explicitly recommend a differentiated, stepwise coronary physiological diagnostic approach when classical procedures - coronary angiography (ICA) or coronary CT angiography (CCTA) - do not provide explanatory findings [10].

Plaque morphology under CT

A central element of modern diagnostics for coronary artery disease is the analysis of plaque morphology.

Cardiovascular radiologist Christian Löwe emphasizes: “The fascinating thing is that CT not only shows the stenosis but also shows what causes it. The plaque – the vascular thickening causing the stenosis – can be visualized and analyzed with great precision.”

Prof. Christian Loewe, MD

Coronary CT angiography was the turning point for Mira. The findings led to timely coronary stent implantation because a high-grade stenosis of the right coronary artery was identified, which could have resulted in a critical reduction of blood flow to the heart muscle if left untreated.

Without this decision, her risk of acute infarction would have remained significant.

Interventional cardiology equipment in a catheterization lab.
Cardiac CT image displayed on a monitor.
Cardiac imaging and interventional procedure in a catheterization laboratory.
Image of a doctor siitng in front of screens
Interventional cardiology equipment in a catheterization lab.

Why women require a different approach in interventions

“Women are sensitive – in their body shape and in their vessel size,” explains Lang.

Smaller vessel diameters mean greater risk of injury, higher bleeding rates, and higher thrombosis rates – as confirmed by the ESC analysis on acute coronary syndrome in women [11].

These differences do not mean that women benefit less from invasive or antithrombotic therapies. They simply require adapted strategies: Access routes, anticoagulation, thresholds for imaging, and monitoring must be gender sensitive.

Why Mira hesitated – and why many women do

A qualitative study in Frontiers in Global Women’s Health describes exactly the pattern reflected in Mira’s behavior: Women are more likely to hesitate when seeking medical help.

The reasons are similar:

  • lack of symptom knowledge
  • family responsibilities
  • fear of “overreacting”
  • previous experiences in the healthcare system [12]

Mira’s statement – “I didn’t want to cause panic” – captures this.

Mira’s case illustrates where care can be improved:

Conclusion: Listen, take seriously, act early

Mira’s story begins quietly – with an undefined feeling. It ends well only because someone listened, took her seriously, and stayed committed to a better outcome. 

Women’s hearts sometimes send quieter signals. Hearing them clearly makes decisive action possible.


Portraitphoto of author Christine Rösch
Portraitphoto of author Christine Rösch
By Christine Rösch
Christine is a sociologist with a special interest in medical and health sociology, health communication, and design thinking. She works as a communications specialist for the Content Lab.

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  1. The statements by the patient described herein are based on results that were achieved in this specific patient case. Since there is no "typical" patient case and many variables exist there can be no guarantee that other patients achieve the same results.


    The statements by customers of Siemens Healthineers described herein are based on results that were achieved in the customer's unique setting. Because there is no “typical” hospital or laboratory and many variables exist (e.g., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results.

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  4. [3] Cushman M, Shay CM, Howard VJ, Jiménez MC, Lewey J, McSweeney JC, et al. Ten-year differences in women’s awareness related to coronary heart disease: Results of the 2019 American heart association national survey: A special report from the American heart association. Circulation [Internet]. 2021;143(7). Available from: http://dx.doi.org/10.1161/cir.0000000000000907

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