They do not appear to be typical candidates for a heart attack. Slim and healthy, they are fit young people who don’t smoke, and may not show any signs of type 2 diabetes, high cholesterol or high blood pressure – the usual red flags for cardiovascular disease.
Yet for some, like 22-year-old Faith Harrison, that does not seem to matter.
Earlier this year the fitness coach from Shropshire was driving back from a hockey match when she suffered tingling sensations in her arms followed by a crushing pain in her chest.
Rushed to Royal Stoke University Hospital, doctors discovered she had suffered a type of heart attack which is usually so deadly – and most commonly found in men – that it is known as ‘the widow maker’.
A huge clot was almost totally blocking one of the main arteries leading to Faith’s heart, and had it not been swiftly removed she would almost certainly have died.
It would be easy to dismiss what happened to Faith as a rare and unusual case – particularly in someone not only so young, but female. While cardiovascular disease is the biggest killer of women in the UK – causing one in 14 female deaths every year – it is still largely considered a male problem, especially in younger people.
That is partly because it is men who are more likely to suffer a heart attack earlier in life.
Women’s risk tends to increase in their 50s, after the menopause, as levels of the sex hormone oestrogen, which protects the heart, naturally decline. But in fact there are worrying signs that younger women – and particularly those in their late 30s and 40s – are being increasingly affected.
Data from the Office for National Statistics show that the rate of deaths from cardiovascular disease has increased for women aged 35 to 39, and 45 to 49, since 2019. These are subtle increases – an extra couple of deaths per every 100,000 people – but it has been enough for experts to take note.
A recent UK study published in the British Medical Journal (BMJ) also found that, while the number of people hospitalised for heart attacks has generally fallen since the mid-1980s, thanks to public health campaigns, they rose by up to five per cent a year for women aged 35 to 49.
And since 2012, one of the most marked increases – of around seven per cent a year – has been in women aged 40 to 49.
The authors, from the University of Oxford, said the rise among younger women ‘is of concern’ and that public information campaigns should ‘include the message that coronary disease is not just a disease of men and the elderly’.
Researchers in the US have found a similar trend. Nearly one third of women hospitalised for heart attacks are now aged 35 to 54, compared with 20 per cent two decades ago.
In Canada, too, the number of women aged 20 to 49 having heart attacks is rising by 1.2 per cent a year. It’s serious enough that experts now say public health campaigns, which have focused on the over-40s, should be directed at younger adults.
And they say even women in their 20s and 30s should make sure they know their cholesterol levels and blood pressure to manage their risk.
Sian Harding, professor of cardiac pharmacology at Imperial College London, says: ‘We’ve aggressively treated the over-40s for heart disease. We launched initiatives to lower cholesterol and blood pressure, and to encourage people to stop smoking. We have health checks for the over-40s to identify and manage heart attack and stroke risks. And these have done a great job.’
Recent data shows almost a 20 per cent drop in heart disease diagnoses and a major 30 per cent reduction in heart attacks and strokes between 2000 and 2019.
However Prof Harding adds: ‘Several studies now show an uptick in women aged 35 to 49 – and in younger women, heart issues are rarer but still possible, particularly if you have a family predisposition to such things.
‘It would be a very good idea to start looking for risk factors in younger people and treating them early.’
Professor Derek Connolly, cardiologist at the Midland Metropolitan University Hospital in Birmingham, added: ‘We need to intervene earlier to save lives. But we can only identify younger women at risk of heart attacks if they know their numbers – that means having their cholesterol, blood pressure and blood sugar levels checked by their GP.’
So why is the risk going up in younger women?
Most women in their 20s who have heart problems will generally have a family history of disease, such as familial hypercholesterolemia, which causes high cholesterol levels from birth, or other inherited defects. There is also a rare one-in-1,000 risk of blood clots – which can travel to the heart – from taking the contraceptive pill. But for most women, the risk is inextricably linked to lifestyle.
Obesity rates for women aged 25 to 54 in England have increased over the past decade. The number of under-40 diagnosed with type 2 diabetes, a condition linked to too much body fat, has increased by nearly 40 per cent in both men and women and is rising faster than in the over-40s – there have been particular increases in women aged 45 to 54 over the past ten years.
Fewer younger women also get the recommended 150 minutes of exercise a week, compared with men, surveys show.
Prof Connolly said most of the younger women he treats have these typical risk factors.
‘Less exercise is being done and the population is getting fatter, which means more heart attacks and more diabetes and kidney disease,’ he says. ‘The population is also changing, with more people from a South Asian background who are more at risk of heart problems at a younger age. That might be playing into the statistics.’
But there may be other factors, including Covid. Research has linked the virus to problems such as myocarditis, a rare inflammation of the heart, and atrial fibrillation, which causes an irregular heartbeat.
A study published last week found adults who had a Covid infection were nearly twice as likely to have a heart attack or stroke in the three years afterwards. The study, based on figures from the genetic database UK Biobank, involved adults who were at least 50 at the start of the pandemic, and not younger adults – so whether the same risks apply is not clear.
But one of the lead authors, Hooman Allayee, from the University of Southern California Keck School of Medicine, said: ‘The results suggest that people with prior Covid infection may benefit from preventative care for cardiovascular disease.’
Stress may be playing a role, too. Prof Harding points out that some studies showing an increase in heart attacks for women coincide with periods of economic instability, such as the 2008 financial crash and subsequent austerity.
‘The timescales are interesting,’ she says. ‘People talk about the impact of high blood pressure and cholesterol, but stress is a huge factor too. There’s a strong association between cardiac health and mental health, and these women – at the age where they’re balancing kids and jobs – may have taken on much more stress around this time.
‘Could that have led to an uptick? It’s possible.’
Young women aged 16 to 24 are three times more likely to report symptoms of anxiety and depression as men the same age. It ramps up again when a woman hits midlife, coinciding with the menopause when the loss of oestrogen can also raise blood pressure and cardiovascular risk.
And the prevalence of mental health issues in women overall has been steadily rising from 19 per cent in 1993 to 23 per cent in 2014. Research has also found this may have worsened during the pandemic.
It’s important to point out, too, that at least some of the rise in hospital admissions might be good news – it may mean that women’s heart problems are being better detected and diagnosed.
Historically, women have had symptoms dismissed and are less likely to be investigated or treated for heart issues, partly because it has been seen as a male disease.
But more sensitive tests to pick up levels of troponin, a protein which is released by heart muscles following damage or injury and which can indicate a heart attack, may be detecting more cases in women.
Dr Shazia Hussain, an interventional cardiologist at University Hospitals of Leicester NHS Trust, adds that doctors have also got better at spotting a type of heart attack called SCAD – spontaneous coronary artery dissection – which most commonly affect women in their 40s.
It involves a spontaneous tear in the artery, and while it isn’t clear what causes it, it can be linked with pregnancy.
‘These aren’t women with traditional risk factors for heart attacks, but they’ll present at hospital with chest pain and will have high troponin levels,’ Dr Hussain says. ‘It can be tricky to pick it up on an angiogram as the arteries won’t be blocked, but we’re better at detecting it now, so these cases could well be filtering into these statistics.’
Sadly, some young women who suffer heart attacks do not get speedy treatment because clinicians mistake their symptoms for a mild illness.
Lauren Page Smith was just 29 when she died of a heart attack at her home in Wolverhampton in January last year.
The young mother had called NHS 111 after experiencing pain in her chest and arm, but an electrocardiogram test [ECG] on her heart was wrongly interpreted by paramedics who said there was no cause for concern.
She was later found dead in her bathroom, with her two- year-old daughter clinging to her body. Her mother, Emma Carrington, said that Lauren had been taken less seriously ‘because of her age’.
Prof Connolly says the key message for younger women is that everyone – regardless of their age – should understand their risk better.
That involves keeping tabs on your body mass index (BMI) – anything over 30, or 27.5 if you’re Black, Chinese or Asian, is obese – and regularly checking your blood pressure with a home monitor or at a GP clinic.
But it is also worth asking your GP to check HbA1c, a measure of blood sugar, and get cholesterol levels measured if you are worried you might be at risk.
‘Make sure you ask for a full lipid profile as many GPs will only give you a measure of your total cholesterol,’ says Prof Connolly. ‘But that won’t tell you what type of cholesterol you have, which is important for your risk.
‘Some people have high levels of a type of cholesterol called lipoprotein (a), which means you may be more likely to have a heart attack at a younger age.
‘Other people have very low HDL, which can also be bad because it’s a type of cholesterol which helps clear other, more harmful forms of cholesterol from the blood.’
This knowledge may not prevent every heart attack, experts say – but it will undoubtedly save lives.
It’s a fact…
– Heart disease kills around 68,000 Britons every year – and accounts for the deaths of one in 14 women.
– Around eight million people in the UK are currently taking statins, even though 15 million could benefit, according to the NHS.
