Why women may be less likely to receive CPR and lifesaving heart care
Heart disease is often imagined as a man’s illness. Cardiac arrest is often pictured as a man suddenly clutching his chest before collapsing.
Those pictures are incomplete, and they can be dangerous.
Heart disease and stroke are the leading cause of premature death in women in Canada. Yet women’s symptoms are more likely to be missed, minimized or blamed on anxiety. Women may also delay seeking help themselves, and women who experience cardiac arrest in public are less likely than men to receive CPR from a bystander.
This is not one isolated problem. It is a chain:
A woman may underestimate her risk.
Her heart attack symptoms may be subtle or unexpected.
She may try to carry on instead of asking for help.
Other people may dismiss her symptoms.
Healthcare providers may mistake a heart problem for anxiety.
If she deteriorates into cardiac arrest, bystanders may hesitate to perform CPR or use an AED.
Education can interrupt that chain at every stage.
Women do not always receive CPR at the same rate as men
A 2024 review examined 58 studies from around the world. Of those, 34 studies, or 59%, found that women were less likely to receive bystander CPR. Twenty-one found no significant difference, while only three found women more likely to receive it.
One major study examined 19,331 cardiac arrests in the United States and Canada. When cardiac arrest happened at home, women and men received bystander CPR at similar rates. In public, however, only 39% of women received CPR compared with 45% of men. After other factors were considered, men were 23% more likely to receive CPR in public.
A larger US study published in 2024 examined more than 309,000 cardiac arrests. It found that women experiencing cardiac arrest in public had 14% lower adjusted odds of receiving bystander CPR than men.
The results are not identical in every study. Age, location, whether the collapse was witnessed and how quickly cardiac arrest was recognized all affect whether CPR is started. However, the overall evidence shows a real disparity, especially when a woman collapses in a public place.
Why might someone hesitate to perform CPR on a woman?
CPR requires firm pressure in the centre of the chest. An AED must be applied to bare skin.
Some bystanders hesitate because they are worried about:
Touching a woman’s breasts
Opening or cutting her clothing
Moving or removing her bra
Being accused of inappropriate touching
Embarrassing her
Causing an injury
Placing their hands or AED pads incorrectly
A study of public perceptions found that fear of sexual assault accusations or inappropriate touching was commonly suggested as a reason men might hesitate to perform CPR on a woman. Fear of physically harming her was more commonly suggested as a concern among female rescuers.
The study cannot tell us what every responder thinks during a real emergency. It does, however, identify fears that can cause a fatal delay.
An unresponsive person who is not breathing normally needs immediate lifesaving care. Her privacy should be protected where possible, but it must not come before her survival.
Women’s heart attack symptoms can be easier to dismiss
Chest pain or discomfort is the most common heart attack symptom in both women and men. It is a myth that women rarely experience chest pain.
However, women are more likely to report other symptoms alongside chest discomfort, and some women experience a heart attack without obvious chest pressure.
Possible signs include:
Pressure, squeezing, burning, heaviness or discomfort in the chest
Pain in one or both arms
Pain in the back, shoulder, neck, jaw or upper abdomen
Shortness of breath
Sweating
Nausea or vomiting
Indigestion or heartburn-like discomfort
Dizziness, light-headedness or fainting
Sudden weakness
Unusual or extreme fatigue
A sudden feeling that something is seriously wrong
Research has found that nausea, back pain, dizziness and palpitations are reported more often by women, although chest pain remains the most common symptom overall.
These symptoms may seem less dramatic than the “Hollywood heart attack.” A woman may feel exhausted, short of breath, sick to her stomach or generally unwell without realizing that her heart is in danger.
An impending sense of doom is sometimes reported during serious medical emergencies, including heart attacks. It is not specific enough to diagnose a heart attack by itself. However, a sudden and unexplained sense that something is terribly wrong should not be dismissed when it occurs with chest discomfort, breathlessness, sweating, nausea, dizziness or unusual fatigue.
“Denial” is not a medical symptom, but it is a dangerous response
People sometimes say that the most common symptom of a heart attack is denial.
That is not a clinical fact, but it describes a real problem. People often explain away warning signs:
“It is probably indigestion.”
“I am just tired.”
“I am too young for a heart attack.”
“It is only anxiety.”
“I do not want to make a fuss.”
“I will finish what I am doing and see if it passes.”
“I have too much to do today.”
Women are often expected to keep working, caring for others and managing daily responsibilities while sick, in pain or exhausted. Many become used to functioning through menstrual pain, pregnancy symptoms, menopause symptoms, migraines and other health problems.
That does not mean every woman responds in the same way. It does mean that “pushing through” can feel normal, even when a new symptom needs urgent medical attention.
Indigestion, fatigue and nausea are common and usually are not caused by a heart attack. The danger comes from automatically assuming they are harmless when they are new, severe, unexplained or combined with other warning signs.
Do not wait for crushing chest pain. If symptoms suggest a possible heart attack, call 911.
Women’s symptoms are also dismissed by healthcare providers
The burden cannot be placed entirely on women to advocate more forcefully.
Women’s symptoms have historically been more likely to be blamed on stress, panic or anxiety. Heart & Stroke reports that one study found women who mentioned stress alongside physical cardiac symptoms were more likely than men to be diagnosed with anxiety.
Women are also less likely to receive care from a cardiologist or be referred for aggressive heart treatment.
Anxiety can cause chest discomfort, a racing heart, sweating, nausea, dizziness and shortness of breath. A heart attack can cause many of the same symptoms. The existence of anxiety does not rule out a physical emergency.
Telling a woman to discuss anxiety medication with her GP is not an adequate response until urgent physical causes have been properly considered.
This failure has measurable consequences. A large registry study examined 384,878 heart attack patients. Among patients younger than 50, women’s in-hospital death rate was more than twice the rate for men of the same age.
That study used data collected between 1994 and 1998, so it should not be treated as a current prediction for every younger woman. More recent research still finds that younger women can have worse outcomes after a heart attack and may receive less aggressive treatment.
A 2026 study of adults aged 18 to 54 found that women remained more likely than men to die in hospital following a severe first heart attack.
Heart attack and cardiac arrest are different
A heart attack happens when blood flow to part of the heart muscle becomes blocked or severely reduced. The person is usually conscious and her heart is still beating.
Cardiac arrest happens when the heart suddenly stops pumping blood effectively. The person collapses, becomes unresponsive and is not breathing normally.
A heart attack can lead to cardiac arrest.
If someone may be having a heart attack:
Call 911 immediately.
Keep her at rest.
Follow the 911 call-taker’s instructions.
Be ready to begin CPR if she becomes unresponsive and stops breathing normally.
If someone is in cardiac arrest:
Call 911 and send someone to get an AED.
Begin CPR immediately.
Use the AED as soon as it arrives.
Follow the instructions from the 911 call-taker and the AED.
Cardiac arrest itself does not have softer symptoms
Once cardiac arrest occurs, the recognition criteria are the same regardless of sex.
A person in cardiac arrest will be:
Unresponsive
Not breathing or not breathing normally
She may make occasional gasping, snorting or gurgling sounds. These sounds are not normal breathing.
The problem is not that women require a different cardiac-arrest assessment. The problem is that their collapse may be interpreted differently.
A 2024 Australian study found that emergency call-takers recognized cardiac arrest less often when the patient was a woman. In public cardiac arrests, recognition occurred in 84.6% of calls involving women compared with 91.6% involving men. That difference partly explained why women received less bystander CPR.
A woman who collapses may be assumed to have fainted, had a panic attack, used drugs or become intoxicated. Those assumptions waste time.
If she is unresponsive and not breathing normally, begin CPR.
Women have some different heart-health risk factors
Many cardiovascular risk factors affect everyone:
Smoking
High blood pressure
High cholesterol
Diabetes
Kidney disease
Physical inactivity
Poor sleep
Chronic stress
Increasing age
Women can also face risks connected to reproductive and hormonal health, including:
High blood pressure during pregnancy
Preeclampsia
Gestational diabetes
Premature or early menopause
Polycystic ovary syndrome
Some autoimmune diseases
Changes associated with menopause
Pregnancy complications do not always end when the pregnancy does. Preeclampsia, pregnancy-related high blood pressure and gestational diabetes can be warnings of increased cardiovascular risk later in life.
Premature menopause, before age 40, is also recognized as a cardiovascular risk-enhancing factor.
Menopause and heart health
Cardiovascular risk rises across and after the menopause transition. Declining estrogen is one part of that change, but it is not the only cause.
Menopause may occur alongside changes in:
Blood pressure
LDL cholesterol and triglycerides
Blood-sugar regulation
Body-fat distribution
Sleep
Physical activity
Weight
Heart & Stroke reports that postmenopausal women are disproportionately affected by high blood pressure, atrial fibrillation and depression.
Some menopause symptoms can also overlap with heart attack warnings. Sweating, palpitations, disrupted sleep, anxiety and fatigue may feel familiar during perimenopause. That does not make every new episode harmless.
Symptoms deserve urgent attention when they are new, unusually intense, triggered by activity or combined with chest discomfort, breathlessness, nausea, dizziness or fainting.
Hormone therapy is not one single treatment
Menopausal hormone therapy is often discussed as though every product has the same benefits and risks. It does not.
The route matters.
Oral estrogen passes through the liver before reaching the wider circulation. This can affect the proteins involved in blood clotting. A review comparing oral and transdermal estrogen found that oral estrogen was associated with a 63% higher risk of a first venous blood clot than transdermal estrogen.
Transdermal estrogen is delivered through a patch or gel. It bypasses this first pass through the liver and has a substantially lower blood-clot risk profile. Observational studies generally have not found an increased risk of venous blood clots with transdermal estrogen, although individual risk still matters.
Low-dose local vaginal estrogen is different again. Very little reaches the bloodstream, and it has not been associated with the blood-clot risk seen with oral systemic estrogen. It is mainly used for vaginal, vulval and urinary symptoms. It does not provide enough systemic estrogen to treat symptoms such as hot flashes.
Not every vaginal product is local. Some vaginal rings deliver estrogen throughout the body, so the exact product matters.
Dr. Jen Gunter explains in The Menopause Manifesto that menopause begins a series of biological changes associated with increased cardiovascular and osteoporosis risk.
Hormone therapy is effective for several menopause symptoms and can prevent bone loss in appropriate patients.
Blanket fear has caused some women to avoid useful treatment. Blanket claims that estrogen prevents every age-related illness are equally unhelpful. Women need accurate, individualized advice.
Diverse CPR training equipment matters
CPR is performed in the same location on everyone: the centre of the chest.
However, practising only on lean, flat-chested manikins can leave students unprepared to perform CPR on someone with breasts. They may understand the steps in theory but hesitate when clothing must be opened, breast tissue moved or AED pads placed.
A 2024 study examined adult CPR manikins available from major manufacturers. Nineteen of the 20 models—95%—did not have breasts.
A later international study surveyed 133 training organizations across 43 countries and collected information on more than 5,000 manikins. Only about one in five organizations owned a female manikin. Around one-quarter used makeshift adaptations, such as putting a bra on a flat-chested manikin.
Training equipment cannot solve every cause of unequal care. It can, however, make responding to different bodies more familiar.
Students should practise:
Finding the centre of the chest on someone with breasts
Moving breast tissue when necessary
Opening or cutting clothing
Moving or removing a bra if it blocks AED pad placement
Applying AED pads directly to bare skin
Preserving dignity without delaying care
Diverse manikins with female anatomical features are not a gimmick. They give students the chance to face practical questions in a classroom instead of confronting them for the first time during a real cardiac arrest.
Training saves lives at home as well as in public
Most cardiac arrests do not happen in dramatic public settings. Many happen at home.
That means the person who needs CPR may be someone you live with, work with or know well. Waiting for a trained stranger to appear is not an emergency plan.
In Canada, bystander CPR rates have historically ranged from about 36% to 49% between communities. Too many people receive no CPR before professional responders arrive.
Approximately 60,000 out-of-hospital cardiac arrests occur in Canada each year. Nine out of ten are fatal, but immediate CPR and AED use can double a person’s chance of survival.
Training helps people:
Recognize heart attack and cardiac arrest
Challenge myths about women’s symptoms
Take unfamiliar or subtle symptoms seriously
Call 911 without waiting for certainty
Perform CPR on different body types
Use an AED without fear
Act before professional help arrives
Women do not need a different version of CPR. They need their risk to be recognized, their symptoms to be taken seriously and bystanders who are ready to respond.
Do not wait for dramatic chest pain.
Do not assume it is anxiety.
Do not let modesty delay an AED.
If she is unresponsive and not breathing normally, start CPR.
References
Blewer AL, McGovern SK, Schmicker RH, et al. Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public. Circulation: Cardiovascular Quality and Outcomes. 2018;11(8).
Blewer AL, Dai D, Chan PS, et al. Sex Differences in Receipt of Bystander Cardiopulmonary Resuscitation by Neighborhood Racial and Ethnic Composition. Journal of the American Heart Association. 2024;13.
Chen C, et al. Global Sex Disparities in Bystander Cardiopulmonary Resuscitation Following Out-of-Hospital Cardiac Arrest: A Scoping Review. Journal of the American Heart Association. 2024.
Munot S, et al. Bystander Cardiopulmonary Resuscitation Differences by Sex: The Role of Cardiac Arrest Recognition. Resuscitation. 2024.
Perman SM, Shelton SK, Knoepke C, et al. Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest. Circulation. 2019;139(8):1060–1068.
Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-Based Differences in Early Mortality After Myocardial Infarction. New England Journal of Medicine. 1999;341:217–225.
Schulte KJ, et al. Myocardial Infarction Signs and Symptoms: Females vs. Males. Cureus. 2023.
Heart & Stroke Foundation of Canada. Signs of a Heart Attack.
Heart & Stroke Foundation of Canada. Cardiac Arrest.
Heart & Stroke Foundation of Canada. 2020 Spotlight on Women.
Heart & Stroke Foundation of Canada. Menopause.
Gunter J. The Menopause Manifesto: Own Your Health with Facts and Feminism. Random House Canada; 2021.
The North American Menopause Society Advisory Panel. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767–794.
Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs Transdermal Estrogen Therapy and Vascular Events: A Systematic Review and Meta-Analysis. Journal of Clinical Endocrinology & Metabolism. 2015;100(11):4012–4020.
Canonico M, Plu-Bureau G, Lowe GDO, Scarabin PY. Hormone Replacement Therapy and Risk of Venous Thromboembolism in Postmenopausal Women: Systematic Review and Meta-Analysis. BMJ. 2008;336:1227–1231.
Szabo RA, et al. CPR Training as a Gender and Rights-Based Healthcare Issue. Health Promotion International. 2024;39(6).
Veigl C, et al. Diversity of CPR Manikins for Basic Life Support Education. Resuscitation Plus. 2025.
Canadian Red Cross. Why Are People with Breasts Less Likely to Receive CPR?.
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