shown to present with the expected symptoms, as well as unusual and not expected symptoms of cvd in comparison to men. the traditional, or common, symptoms seen in both men and women include: chest pain or feeling of crushing pain in the chest radiating pain in the arms or shoulder heartburn however, some studies have shown that chest pain is not as common a symptom in women. thus, its absence cannot rule out the likeliness of cvd. for the atypical symptoms, there are numerous that are commonly vague and seem to be unattached to specific diagnoses. women generally develop angina and are less likely to present with myocardial infarction at the onset of cardiovascular diseases. the other symptoms to account for include: pain or discomfort in neck, jaw, upper back, or abdomen shortness of breath nausea/vomiting sudden and random sweating fatigue lightheadedness or dizziness overall, these symptoms seem to be more present at rest than any other time of day for women, and at times of emotional distress. women also tend to report milder symptoms, while also experiencing a combination of more symptoms than men. to ensure that practitioners are able to catch all cases and forms presented to them, it is crucial to ensure that women's diagnostic tests are adjusted to include all of these symptoms appropriately. causes as there are a variety of cvds and causes for cvd, there is no one specific mechanism that can cause cvd. however, there are general components shown to promote cvd development which can be found in a few pathways. reactive oxygen species (ros): ros are produced through numerous processes in our cells, including the induction of oxidative enzymes. the notable species involved in human cells include superoxide anion (o2−), hydroxyl radicals (oh), and hydrogen peroxide (h2o2). not only does ros physiologically have a role in controlling the vasculature through tone and endothelial and cardiac function, but it also is a vital player in inflammation, promoting apoptosis, angiogenesis and much more. additionally, ros causes oxidative stress within the body which, although may not be the sole proprietor, exacerbates the various factors that contribute to developing cvd, especially hypertension. finally, ros also act as signaling molecules to induce the body's inflammatory response to prevent any further damage from happening, which can lead to cell and tissue damage of the vasculature if not moderated appropriately. induction of oxidative enzymes: cytosolic oxidases are another critical component in ros production. these enzymes transfer electrons to create radicals or superoxide, and increase oxidative stress. these enzymes have also shown to be present in various physiological stressful situations, which is associated with hypertension and other traditional risk factors negatively impacting cvd. xanthine oxidase (xo): xo, under normal circumstances, is an important enzyme in producing uric acid, released from the kidneys. these are typically located in the liver, however under times of stress from ros, can increase its activity. this elevates vascular tone and even ros production in the form of superoxide, thus contributing to higher oxidative stress. nitric oxide synthase: nitric oxide synthases are known for producing nitric oxide, which has numerous functions in the body including vasodilation – i.e. widening of the vessels. nitric oxide reacts with other forms of ros to create potent oxidants, consequently causing other pathologic conditions, including heart failure and myocardial infarction. moreover, this family of enzymes are crucial signaling molecules in regulating vascular tone and multiple other functions. thus, any disruption in regular functioning impacts the vascular tone regulation. nadh/nadph oxidase: these enzymes contribute significantly to the amount of ros present in the body. if in cardiac distress, an individual may induce excessive production, which may in turn lead to the pathogenesis of varying forms of tissue damage and cellular dysfunction in cardiac muscles. uncoupling of mitochondrial electron transport chain: the mitochondria is a contributor to the levels of ros we see within our body. not only does it produce it, but is also vulnerable to the damage caused by ros. it also is a key player of cell function in the cardiovascular system. with this damage to the mitochondria, the cell's function may be altered as not enough energy is being produced as needed, thus hindering the cell's ability to function optimally. these events create a disastrous feedback loop where further mitochondrial damage results in increased ros production, which furthers the damage and contributes to the risk of developing cvd. immune cell infiltration and cytokines: a large contributing risk factor to the development of cvd is the production of plaque, also known as atherogenesis or atherosclerosis. this condition is known to involve multiple inflammatory cascades from the immune system responding to varying pathogens. elevated inflammatory cytokines, including interleukin-6 and tumor necrosis factor-⍺, initiate a cascade conducive to plaque production. risk factors there are numerous risk factors that have been found to be associated with developing cvd. a number of them are considered traditional, as they are found in men and women with cvd at high rates. however, there are also unique risk factors found only in women that are commonly associated with this group developing cvd. the following list includes the predominant ones found in many cases of cvd in women. smoking smoking has been well established as risk factor for plaque formation which can lead to developing different forms of cvd. previous studies have shown that 4-5 cigarettes per day almost doubled the risk of cvd and 20 cigarettes per day increased the risk of cvd by 6 times. women who smoke face up to a 25% increased risk of developing cad compared to their male counterparts, with studies showing that reduction in smoking decreased the incidence of cad in women by 13%. furthermore, second-hand smoking may increase the risk of cvd by 25%. obesity obesity has been shown to be associated with several other factors that can cause cvd, such as dyslipidemias. with increasing body mass, the risk of developing various cvds, such as ischemic stroke and coronary artery disease grows as the unhealthy lifestyle maintained prevents the cardiovascular system from functioning optimally. women make up about 40% of obese adults over the age of 20. postmenopausal women are also more likely to experience fat redistribution to the abdomen and develop metabolic syndrome, resulting in increased susceptibility to obesity. hypertension chronic high blood pressure (hypertension) alters the structure of vessels overtime, such as narrowing or complete blockage of blood flow through. this can subsequently lead to cvds, including stroke. the prevalence of certain disorders such as fibromuscular dysplasia is increased in premenopausal women and can lead to secondary hypertension. these factors, including others such as preeclampsia, have been shown to contribute to the risk of developing hypertension, and thus, consequently, cvds from the resulting damage. lipids cholesterol, is a type of lipid that has diverse function in the body. there are several types of cholesterol but the main two are high-density lipoprotein (hdl) and low-density lipoprotein (ldl). then levels of these cholesterols can be determined by a blood test. hdl cholesterol is known as "the good cholesterol" and ideally it is recommended to have a high level of this cholesterol. hdl cholesterol works by removing ldl from the blood stream and returning it back to liver where it can not cause cardiovascular damage. ldl cholesterol is known as "the bad cholesterol" and it is recommended to have a low level (130 mg/dl or less) anything higher can lead to a higher cvd risk. when there is a high level of ldl cholesterol in the blood it is up-taken by inflammatory cells known as macrophages. the high burden of ldl cholesterol inside macrophages leads to an inflammatory response, which ultimately damages the inner lining of the blood vessels. due to this damage, macrophages invade the cell wall of the blood vessels and cause the formation of a plaque. a plaque can lead to obstruction of the blood vessel and if this were to occur in a coronary artery it could increase the risk of a myocardial infarction (heart attack). diabetes mellitus the high blood sugar levels associated with diabetes mellitus is also an important cardiovascular risk factor to consider. data suggests that women with diabetes are at five times greater risk than those without for developing cvd. uncontrolled levels of glucose can cause damage to the vessels and nerves alike, increasing the risk of developing other conditions, including cvd. women with type i diabetes were found to be twice as likely to experience adverse cardiovascular events when compared to men with the same disease, but were less likely to receive aggressive treatment to control modifiable risk factors. women with type ii diabetes are also at greater risk than men with the same condition despite similar glycemic control. gestational diabetes mellitus similar to hypertensive disease of pregnancy, the already prevalent risk factor of diabetes mellitus combined with pregnancy puts women at increased risk of developing cvd. women diagnosed with gestational diabetes are at a higher risk of developing traditional risk factors for cvd, such as type 2 diabetes mellitus, and hypertension. the irreversible changes made during pregnancy may make these women prone to cvds in the long term. additionally, women diagnosed with gestational diabetes remain at higher risk of developing type 2 diabetes mellitus and cvd, despite blood sugar metabolism returning to normal post-pregnancy. preeclampsia hypertension can be severely damaging to vessels and the heart and cause cvd to develop. hypertensive disorders in pregnancy such as pre-eclampsia can be seen in 10% of pregnancies and has been recognized as a risk factor for developing new-onset hypertension after pregnancy. other pregnancy-associated conditions pregnancy offers numerous vascular and metabolic changes that, although may seem temporary, result in long-term effects on the cardiovascular system. women who deliver prior to 37 weeks gestation are at increased risk of developing cvd, with additional risk depending on the number and timing of preterm births. data suggests that women with a history of preterm births have two times the risk of cvd-related deaths than women with regular-term births. this may be due to the complications associated with preterm birth and its effect on the mothers. additionally, intrauterine growth restriction (iugr), which affect up to 10% of all births, in prior pregnancies is associated with an increase in maternal cvd risk for both the mother and the baby. finally, prior pregnancy loss, including miscarriage and stillbirth, also contributed to a two-fold increase in risk of maternal cvd. menopause estrogen has several cardioprotective effects on women, thus during the age of fertility – i.e. puberty to menopause – females are at a lower risk of developing cvd. however, menopause is associated with a decrease in estrogen production. this allows for typical cardiovascular issues to implement their effects with little protection from the women's body. in rare cases, early menopause is correlated with increased cvd risk, although the relationship between the two is complex. premature menopause is defined as menopause prior to the age of 40. although the relationship between the two is complex, it seems to be due to the prevalence of atherosclerosis in perimenopause. physical activity lower levels of fitness are commonly associated with blockages and obstructed blood flow found in cvds. as exercise promotes the use of the heart and improves oxygen affinity for muscles, this can help relieve stress from the heart and allow for it to pump at a normal pace while providing more nutrients and oxygen to the body. an observational study found that those with limited physical activity in their day were at a 4.7 times increased risk for stroke and other forms of cvd. ethnicity and race the prevalence of cvd has been shown to vary greatly amongst different ethnic and racial groups. overall, ethnic minority women exhibit greater risk factors for cvd than white women. black women are at the highest rate of cvd-related death. the cause for these gaps is still unclear, however, this may be related to genetics, socioeconomic status, education status, or inequitable health resources access. socioeconomic status lower socioeconomic status has been shown to be largely associated with an increased risk of cvd development. this may be due to a combination of psychosocial risk factors affecting those in these groups. additionally, inequitable access to much-needed resources to appropriately identify and treat these conditions may lead to delayed diagnosis and inability to treat appropriately. age the risk