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November 29, 2018/Ob/Gyn & Women’s Health

Symptoms of Heart Disease In Female Athletes Tend to Be Atypical

Know the red flags and when to refer


Thirty years ago, 10 percent of marathon finishers were women. In 2017, that figure was between 40 and 45 percent.


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These statistics mirror a boom in female athletes participating in weightlifting as well as endurance sports. As more women become involved in sports of all types at all levels, there is growing awareness that heart disease can exist in this population. Nevertheless, unfamiliarity with symptoms — which often differ from those in men — can delay diagnosis and thwart prevention efforts.

“The symptoms of heart disease in female athletes tend to be different, more challenging to identify and often vary with age,” says Tamanna Singh, MD, a Cleveland Clinic sports cardiologist with a specialty interest in female athletes.

The burden falls on primary care physicians and gynecologists to understand the unique symptoms of heart disease in their athletic female patients and know when to refer to a sports cardiologist.

“It’s important to remember that cardiovascular disease is the No. 1 killer of women above age 25 in the United States,” she says. “We should screen female athletes appropriately and not take for granted that their above-average athletic capacity translates to freedom from cardiovascular disease.”

A troublesome trio

When abnormal menstruation is accompanied by low energy and by osteogenesis or broken bones, these findings represent a classic set of risk factors known as the female athlete triad syndrome.

“Prolonged lack of menses mimics a postmenopausal state,” explains Dr. Singh. “The reduction in estrogen slightly elevates cardiovascular risk by increasing total and LDL cholesterol and negatively impacting blood vessel function. The patient should be examined for traditional risk factors, such as high cholesterol, elevated blood pressure, abnormal blood sugar levels and a family history of heart disease.”

Similarly, female athletes who enter menopause before age 40 are at heightened cardiovascular risk and should be seen by a cardiologist.

Diminished exercise capacity

Diminished exercise capacity in an athlete of either sex is cause for concern. An example is a runner who can no longer achieve her usual times, or one who experiences shortness of breath or chest pain with exercise, particularly when her symptoms resolve with rest, occur at a slower pace or grow in intensity.

“When an athlete is weak or shows diminished exercise capacity, I recommend looking for an eating disorder in addition to performing a cardiac assessment,” says Dr. Singh. “You should examine electrolyte levels and nutritional status, particularly in a younger athlete who may be encouraged to lose weight for her specific sport.”


The risk of sudden cardiac death (SCD) is three to four times higher among male athletes than female athletes. However, data on SCD in female athletes are sparse, since most evidence regarding exercise-induced cardiac remodeling and other cardiac pathologies in athletes comes from studies performed on men. Nevertheless, pre-participation screening for SCD using the same parameters used in male athletes is advised.


“ECG screening is currently not mandated in the United States, but it’s recommended, so long as a sports cardiologist who is trained to identify abnormal ECG findings in athletes provides the interpretation,” notes Dr. Singh.

How to proceed

Dr. Singh’s advice to primary care physicians and gynecologists is simple: Don’t be afraid to ask questions.

“If you know your patient is athletic, ask if she has noticed a decline in performance — however minimal it may seem — despite appropriate nutrition and a balanced training program that incorporates recovery,” she counsels. “Does she have any symptoms with exertion? Does she ‘hit a wall’? Is she menstruating normally? These are all questions to ask.

“If you are concerned by her answers, or by what you find during your examination, you should have a low threshold for referral to a sports cardiologist for a more specific evaluation,” she says.

A trained sports cardiologist can identify which symptoms and findings are considered within normal limits for athletes and which diagnostic tests should be performed. “Otherwise, you risk missing a serious diagnosis or may make an incorrect diagnosis and unnecessarily restrict the athlete’s participation in her competitive or recreational sport,” she explains.

Dr. Singh encourages physicians to contact her with questions regarding appropriate care for female athletes. “I am happy to see any female patient requiring a cardiac evaluation specific to athletes at the Sports Cardiology Center on Cleveland Clinic’s main campus,” she notes.

Dr. Singh can be reached at singht2@ccf.org or 216.445.5323.


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