Midlife and menopausal women still lag well behind men in cardiac awareness and care. Here’s how to make heart health a top priority. 

By Selene Yeager

I’ve been writing this same story for years: millions of women are dying unnecessarily from heart disease. We don’t receive the same preventative care. We don’t receive the same emergency care. We don’t always recognize our symptoms. Hell, just over half of us even realize that heart disease is our number one killer. And despite 20 years of the American Heart Association’s Go Red for Women Campaign designed to raise awareness of these issues, two recent studies show we are still faring far worse in cardiac care than men.

As Martha Gulati, MD, President of the American Society for Preventive Cardiology and the author of the best-seller, “Saving Women’s Hearts” put it so succinctly in Episode 94 of Hit Play Not Pause, “The only thing that women do better than men after a heart attack is die.”

Our Cardiac Care is Worse All the Way Around

To recap what we’ve covered before in this space, women start out with a disadvantage in the medical system, as we do not receive the same preventative care as men. A meta-analysis of 43 studies including 2,264,000 women and men ages 56 to 71 published in the Journal of the American Heart Association reported that women were significantly less likely to be prescribed aspirin, statins (for cholesterol management), and ACE inhibitors (a type of blood pressure medicine) compared to men.

We’ve known for decades that women don’t always present with classic heart attack symptoms like crushing chest pain. But doctors don’t always readily catch symptoms like shortness of breath, cold sweats, bone-crushing fatigue, and jaw, neck, and shoulder pain that are common in women. Plus, research shows their doctors are more likely to diagnose their symptoms as non-cardiovascular related.

Past research has shown that when we come to the hospital with classic symptoms, we’re still not treated as seriously and expediently as men. That’s not gotten better. A study published this month in the Journal of the American College of Cardiology found that women showing up in the emergency medical system with chest pain were less likely to receive guideline-directed care across most care measures including transport to the hospital, prehospital aspirin or analgesia administration, 12-lead electrocardiogram, intravenous cannula insertion, and off-load from EMS or review by emergency department clinicians within target times. In other words, all the stuff that is standard of care for someone who might be having a heart attack. Similarly, women with acute coronary syndrome (i.e., sudden reduced blood flow to the heart) were less likely to undergo angiography or be admitted to a cardiac or intensive care unit. 

A second study published this month in JAMA Surgery found that women were significantly more likely to die and have adverse outcomes after undergoing coronary artery bypass (the most common surgical treatment for coronary artery disease, designed to improve blood flow to the heart) than men. Worse, we've seen no significant improvement here over the past decade.

Make Heart Health Priority #1

Maybe it’s because we can see our breasts and have a literal intimate connection to them and cancer is a scary diagnosis, but women’s knowledge of breast cancer risk far outweighs our knowledge of heart disease risk. We need to know both. About 42,000 women die from breast cancer each year. About 7 ½ times as many women die from heart disease. In 2020 alone, 314,186 women died from heart disease. Millions of us are living with heart disease and don’t even know it.

“Heart disease is the number one killer of women, but lack of awareness is a close second,” Gulati said on the show. “So get your risk assessment. And don’t always believe that just because you’re athletic that you’re protected. You’re helping your heart for sure, but there are some components of our genes that we don’t control.”

The good news here is that an estimated 80% of cardiovascular disease, including heart disease and stroke, is preventable, according to the World Heart Federation. As a woman, that means being an advocate for yourself and making heart health priority number one. Along with eating a nourishing diet and exercising (which is preaching to the choir here), the following steps will put you on the right path.

Know your general risk

The first step to prioritizing heart health is knowing how healthy your cardiovascular system is right now (and that has nothing to do with how fast you can run a mile or your PR in the gym). That means making an appointment with your doc and asking specifically, “What’s my risk for heart disease?”

At a minimum, you should see your doctor for a basic workup that includes blood pressure, fasting glucose, triglyceride, and cholesterol levels, family risk, lifestyle factors, and other risk factors such as waist-to-hip ratio, if applicable. For a more thorough workup, you can get a coronary calcium scan, which measures the amount of plaque buildup in the arteries around your heart. You can also get a more thorough lipid panel that provides more detailed information about your cholesterol, including particle size, shape, and composition. This can include a test for lipoprotein (a), or Lp(a), which is a form of LDL that increases your risk for heart attack or stroke, especially if you have familial hypercholesterolemia. Unfortunately, since these more detailed tests aren’t part of routine testing, you may end up paying out of pocket for them. But that’s a rant for a future blog…

Just as you check in on your breasts every year or so, depending on your mammogram schedule, you should also be checking in on your heart health.

Know your unique risk

There are many risk factors for heart disease that are universal, such as family history, age, unhealthy lipid levels, high triglycerides, metabolic syndrome, diabetes, and high blood pressure. (Though these don’t all affect women and men evenly, which we’ll talk about in a minute). But there are also risk factors that are unique to women. 

Pregnancy issues such as preeclampsia, gestational diabetes, preterm delivery, having a small for gestational age baby, or multiple miscarriages all increase your 10-year risk. “Pregnancy is mother nature’s cardiovascular stress test,” Gulati says. 

Polycystic ovarian syndrome may increase your risk for heart disease. Premature menopause, whether naturally or surgically, raises your risk. Autoimmune diseases (which are more common in women), such as rheumatoid arthritis and lupus increase risk. Breast cancer, as well as breast cancer therapy, can increase risk of heart disease. “Women who have had breast cancer are often most worried about whether it will recur. But they should also be talking with their doctor about managing their risk for heart disease,” Gulati says.

Menopause can raise some of your cardiovascular risk factors. There’s a shift to become more insulin resistant and to gain more deep visceral body fat. Cortisol and cholesterol levels can rise. The shift in hormones is driving these changes, but the full mechanism isn’t fully understood, says Gulati. 

Though hormone therapy appears to help lower the risk in some women, it doesn’t clearly reverse these changes, research is not yet conclusive, and is still not recommended for primary prevention of cardiovascular disease. That said, recent research has found that frequent or persistent vasomotor symptoms were associated with a 50 to 77 percent increased risk for future cardiovascular events like heart attack and stroke. So if you are suffering from severe hot flashes and/or night sweats, it’s well worth pursuing treatment.

Research also shows blood pressure starts rising earlier and advances faster in women than men. It is also more dangerous in women than men. That’s why some in the medical community believe the systolic blood pressure threshold of risk in women should be 110 mmHg rather than the standard 120 mmHg used for both women and men currently.

Take Preventative Measures

A general heart-healthy lifestyle includes a whole-foods diet including lots of vegetables, fruits, and fiber-rich foods, avoiding smoking and vaping, minimizing alcohol intake, exercising, and managing stress. Even if you do “all the right things” you may still find yourself with some risk factors that can’t be managed through lifestyle alone. 

This is where it’s important to work with an athlete-friendly physician to get a prescription that works for you. Medical science has made huge progress in the treatment of cholesterol and blood pressure and there are numerous medications that you can try. If you find that you don’t feel well on one or that it is interfering with your training, ask your doctor for another. “We’re living in an era with a lot of choices. Communicate with your doctor on a regular basis and tell them what you’re experiencing. Don’t suffer or don’t just stop taking something. Work with us and we’ll find something that works for you,” Gulati says.

That’s especially important for women to hear, since women refuse these medications more often than men do. In fact, women at high risk of developing cardiovascular disease were about 20 percent more likely to say no to statin therapy when their doctors first suggested it, and 50 percent more likely to never accept the recommendation, according to a Harvard Study published last month.

Seek Care and Advocate for Yourself

Do NOT hesitate to seek care if you feel classic symptoms of a cardiac emergency, including chest pain, breathlessness, radiating pain or discomfort, or breaking out in a cold sweat (as opposed to a hot flash). For a complete list of signs of a cardiovascular emergency, including those more common in women, such as dizziness, nausea, and unexplained fatigue, check out my blog on 5 Live Saving Heart Health Steps Menopausal Women Should Know.

If you’re in the hospital, be a relentless advocate for yourself and tell them to check your heart. Say you think you’re having a heart attack. Don’t let someone just tell you that it’s “just stress.” It completely sucks that we have to fight like this, but as I’ve written before, my mom almost died from a massive heart attack, because her doctors wrote off classic symptoms of heart trouble as “stress” and gave her “nerve pills.” We want you around for decades to come, living your strongest, healthiest, feistiest lives.