Cardiovascular disease (CVD) remains the leading cause of death among women, with a mortality rate exceeding that of all cancers combined [1]. Despite a longer life expectancy (86.6 years on average, approximately 6 years longer than men), Korean women experience lower overall health quality [2]. Chronic diseases such as hypertension and diabetes are highly prevalent, particularly among older women. As the proportion of women relative to men increases with aging, it is critical to accurately understand and address women's cardiovascular health. Nevertheless, the importance of CVD in women's health is frequently underestimated and overlooked by both the public and healthcare providers [1–3]. Despite legislative efforts, women remain underrepresented in cardiovascular clinical trials, resulting in limited evidence regarding sex-specific treatment efficacy and safety [3].

Women's heart disease presents unique challenges, including atypical symptoms, nontraditional risk factors (such as pregnancy-related conditions and autoimmune diseases), and differential responses to therapy. These sex-specific differences in epidemiology, clinical presentation, and treatment outcomes are inadequately addressed by conventional prevention and management strategies. To reduce the burden of CVD in women, there is an urgent need for increased awareness, tailored screening, and more aggressive preventive measures.

Globally, life expectancy is increasing, with Korea experiencing one of the highest growth rates. Women generally live longer than men, and as age increases, the proportion of women relative to men also rises. Among those aged 70 years and older, women outnumber men by approximately 1.5 times. Women's longer life expectancy (by approximately 6 to 8 years) results in a higher prevalence of CVD compared to men in Korea [4]. Although Korean women live longer than men, they experience poorer health outcomes due to chronic diseases, mental health issues, and socioeconomic disparities [4].

Mortality rates from circulatory system diseases (including hypertension, cerebrovascular disease, and heart disease) show that women's mortality rate is 126.7 per 100,000 individuals, which is higher than men's rate of 115.5 in Korea [5]. According to 2020 mortality statistics, CVD was a major cause of death for both sexes, yet women exhibited a 1.1 times higher mortality rate compared to men, with a notable increase in deaths starting from the age of 70 years [5]. This disparity in mortality rates is partly due to the misconception that heart disease is predominantly a "men’s disease," resulting in lower awareness among women. Additionally, studies indicate that women are less likely to receive explanations about heart disease from their physicians [6].

A 50-year-old woman has a 40% lifetime risk of developing CVD, a 30% risk of coronary artery disease (CAD), and a 20% risk of heart failure [7–10]. Nevertheless, CVD is still perceived primarily as a disease affecting men. Public and healthcare professional awareness of CVD among women remains low. Although 74% of women have at least one cardiovascular risk factor, fewer than 20% recognize their personal risk [11]. In the United States, surveys indicate higher awareness of breast cancer and diabetes compared to heart disease, despite heart disease being the leading cause of death among women. Awareness is particularly low among younger women, those of lower socioeconomic status, and those with less education [11]. They have limited recognition of heart disease, low awareness of cardiovascular risk factors such as diabetes, hypertension, and obesity, and typically take less initiative in managing these risks. Physicians also exhibit lower awareness of heart disease in women. Studies reveal that physicians evaluate risk factors more conservatively in women than in men, perform fewer diagnostic tests (such as coronary angiography), and refer women to cardiologists less frequently [6,11,12]. Consequently, women receive less preventive care for heart disease than men.

Biological and hormonal differences significantly contribute to sex-specific patterns in CVD. Estrogen confers cardiovascular protection in premenopausal women, but its decline during menopause—typically beginning in the late 40s—marks a turning point, elevating the risks of hypertension, dyslipidemia, and ischemic heart disease. Notably, the prevalence of hypertension becomes higher among women compared to men after age of 70 years.

Anatomically, women have smaller coronary arteries and reduced endothelial function, rendering them more susceptible to microvascular dysfunction and inflammation [13]. These factors contribute to distinct pathophysiological characteristics, including nonobstructive CAD and increased susceptibility to plaque erosion rather than rupture [14]. Coronary artery calcification—a marker of atherosclerosis—is associated with greater relative mortality risk in women than in men, even at low scores [15,16].

Clinically, ischemic heart disease in women often manifests with atypical symptoms such as dyspnea, fatigue, nausea, indigestion, dizziness, back pain, or pain in the neck and shoulders. These atypical presentations contribute to delays in diagnosis and treatment [13,17]. While CAD in men typically causes occlusive lesions impairing blood flow, coronary artery lesions in women are often nonocclusive and associated with functional abnormalities due to microvascular disorders, leading to atypical symptoms. Diagnostic tools such as exercise stress testing and coronary angiography demonstrate lower sensitivity and specificity in women due to these nonobstructive or functional abnormalities [17].

Certain conditions disproportionately affect women, including spontaneous coronary artery dissection (especially in younger women during the perinatal period) and stress-induced cardiomyopathy, which occurs more frequently in women aged 60 to 70 years [18,19]. Spontaneous coronary artery dissection is difficult to diagnose unless suspected, as it often occurs suddenly in young, healthy women without traditional cardiovascular risk factors. Women are also twice as likely as men to develop heart failure with preserved ejection fraction [7], highlighting the importance of sex-specific approaches to diagnosis and management.

While traditional cardiovascular risk factors—namely, hypertension, diabetes, dyslipidemia, smoking, obesity, and physical inactivity—affect both sexes, their impact differs in women [13,20,21]. Women experience steeper increases in blood pressure with age and tend to have higher nighttime blood pressure, factors that significantly elevate their CVD risk. Women with type 2 diabetes have a 50% higher risk of CVD mortality than men with diabetes [12]. According to the 2022 Fact Sheet of the Korean Society of Lipid and Atherosclerosis, the prevalence of hypercholesterolemia was higher among women than men (25.0% vs. 22.9%), showing a significant increase in women over time [22]. The prevalence of dyslipidemia increases notably with age, with particularly marked rises observed in women (26.0% in their 20s, 34.6% in their 30s, 56.7% in their 50s, and 71.0% in their 60s). According to the 2021 Fact Sheet from the Society of Cardiometabolic Syndromes, the prevalence of metabolic syndrome was also higher in women aged 65 years and older than in men (49.4% vs. 40.2%) [23]. Although women generally have lower rates of abdominal obesity and hypertriglyceridemia, the prevalence of low high-density lipoprotein cholesterol is significantly higher in women compared to men. Women with obesity, insulin resistance, hypertension, and elevated triglycerides have a notably increased risk of CVD.

Women also face unique cardiovascular risk factors, including pregnancy-related risks, autoimmune diseases, early menopause, and depression [24]. Conditions such as preeclampsia, preterm delivery, hypertensive pregnancy disorders, gestational diabetes, and postpartum weight retention considerably raise a woman’s long-term risk of CVD [24]. Women with rheumatoid arthritis and systemic lupus erythematosus have a twofold to threefold higher risk of myocardial infarction. Early menopause is similarly associated with an increased risk of CVD [25]. Depression is more common in women and is linked to higher CAD risk [12]. Therefore, assessments of atherosclerotic CVD risk should explicitly incorporate women-specific risk factors. Additionally, routine screening for pregnancy history, autoimmune conditions, and regular postpartum cardiovascular follow-up are strongly recommended [20]. Furthermore, treatments for breast cancer (e.g., radiation and chemotherapy) also contribute to long-term CVD risk in women [13].

Despite growing awareness, substantial gaps persist in the prevention and management of CVD in women. Women are less likely than men to receive evidence-based diagnostic evaluations, guideline-directed medical therapies, and interventions such as statins or reperfusion treatments [20]. Statin therapy is less frequently prescribed to women, despite similar benefits in reducing atherosclerotic CVD risk [12]. Compared to men, women are less likely to achieve guideline-recommended targets for total cholesterol, low-density lipoprotein cholesterol, and glucose levels, and they are less frequently physically active or nonobese [26].

Young women with ST-segment elevation myocardial infarction are less likely to receive timely reperfusion therapy and more likely to experience delays compared to similarly aged men. These sex disparities are particularly pronounced among patients transferred to percutaneous coronary intervention facilities or those undergoing fibrinolytic therapy [27]. Delays in initiating guideline-directed medical therapy in women result in higher rates of readmission, reinfarction, and mortality within the first year after myocardial infarction [28]. A meta-analysis indicated that men were approximately one-third more likely to be enrolled in cardiac rehabilitation than women [29]. Furthermore, among individuals with or at high risk for CVD, appropriate preventive medications were prescribed more frequently to older women but less frequently to younger women compared to their male counterparts [30].

Sociocultural factors may exacerbate these disparities, with traditional gender roles contributing to delayed care-seeking behaviors and reduced prioritization of personal health due to caregiving responsibilities. Comprehensive strategies addressing both biological and sociocultural barriers are essential for closing the gender gap in cardiovascular care.

CVD in women remains underdiagnosed and undertreated, largely due to atypical symptom presentations, limited awareness, and insufficient sex-specific research. Biological, pathophysiological, and sociocultural differences contribute to distinct clinical characteristics and disparities in the prevalence, awareness, and management of traditional cardiovascular risk factors between women and men. Additionally, women experience unique risk factors—including hypertensive pregnancy disorders, gestational diabetes, and preterm birth—that are frequently overlooked in conventional risk assessment models.

These differences underscore the necessity of age- and sex-specific strategies for the prevention, diagnosis, and treatment of CVD. While heart-healthy behaviors and early risk identification are crucial, existing guidelines often fail to adequately reflect the specific needs of women. Developing and implementing gender-tailored prevention frameworks can improve risk stratification and facilitate individualized therapeutic approaches.

To effectively reduce the burden of CVD among women, greater efforts are required to increase public and professional awareness, enhance clinician education, and promote the inclusion of women in cardiovascular research. Advancing sex-specific clinical evidence is critical for improving diagnostic accuracy and optimizing outcomes for women with CVD.