February is American Heart Month, and I want to spend the second half of it talking specifically about heart disease in women, because it is one of the most underrecognized health threats out there. Most people still think of heart disease as a men's issue. It isn't. It's the leading cause of death in women in the United States, responsible for about one in five female deaths. And yet women are more likely to have their cardiac symptoms dismissed, less likely to be referred for testing, and more likely to die from a first heart attack than men.
A big part of why this happens is that heart disease in women often doesn't look like the classic picture. And if providers aren't looking for the right things, they miss it.
The "Classic" Heart Attack That Isn't
Most people, including a lot of healthcare providers, have a mental image of a heart attack: crushing chest pain radiating down the left arm, breaking out in a cold sweat, dramatic and unmistakable. That presentation is real, but it's more common in men. Women having heart attacks often experience a different and more subtle set of symptoms.
Women are more likely to report nausea, fatigue, jaw or neck pain, back pain, shortness of breath, and a vague feeling that something is wrong, sometimes without significant chest pain at all. These symptoms are easier to attribute to stress, anxiety, indigestion, or just being tired, and that's exactly what happens. Women are more likely to wait longer before going to the emergency room, and when they do, they are statistically more likely to be sent home without a cardiac workup.
This is not a small gap in care. Women who are discharged from the ER after presenting with what turns out to be a cardiac event have significantly worse outcomes than men in the same situation. The delay in diagnosis and treatment costs lives.
Why Women's Hearts Are Different
Part of what makes this complicated is that the biology of heart disease in women actually differs from men in ways that weren't well understood until relatively recently, largely because most early cardiovascular research was conducted almost exclusively on men.
Women tend to develop heart disease about ten years later than men on average, often after menopause, when the protective effects of estrogen decline. The drop in estrogen at menopause is associated with increased LDL cholesterol, decreased HDL cholesterol, increased blood pressure, and greater abdominal fat accumulation, all cardiovascular risk factors that can shift significantly in a short period of time.
Women are also more likely than men to have what's called microvascular disease, where the small arteries of the heart become diseased or dysfunctional rather than the large coronary arteries. Standard cardiac testing, including the traditional stress test, is better at detecting large-artery disease and can miss microvascular disease entirely, meaning women can have a normal stress test and still have significant cardiac risk.
Unique Risk Factors in Women
There are several cardiovascular risk factors that are either unique to women or affect women differently than men, and they don't always get the attention they deserve in a routine checkup.
Pregnancy complications are one of the most underappreciated. A history of preeclampsia, gestational diabetes, or preterm birth is associated with significantly increased cardiovascular risk later in life. These aren't just things that happened during pregnancy and resolved. They're signals about how the cardiovascular system responds under stress, and they matter for long-term risk assessment.
Autoimmune conditions like lupus and rheumatoid arthritis, which disproportionately affect women, carry elevated cardiovascular risk due to systemic inflammation. Polycystic ovary syndrome (PCOS) is associated with insulin resistance, elevated androgens, and increased cardiovascular risk. And mental health conditions, including depression and anxiety, which are more prevalent in women, are independently associated with worse cardiovascular outcomes.
If you've had any of these and your provider has never connected them to your heart health, that's a conversation worth having.
What to Actually Screen For
Standard cardiovascular screening catches some of the picture but not all of it, especially in women. Here's what I think is worth looking at and why.
| Test | Why It Matters for Women | Staywell Member Price |
|---|---|---|
| Lipid panel | Baseline; watch for shifts around menopause | $4 (included for Complete members) |
| High-sensitivity CRP | Inflammation marker; more predictive of risk in women than in men | $10 |
| Fasting glucose / A1c | Diabetes doubles cardiovascular risk in women vs 1.5x in men | Included for Complete members |
| Blood pressure | Hypertension risk increases significantly after menopause | Included |
| Apolipoprotein B | More predictive of cardiovascular risk than LDL alone | $10 |
| NMR Lipoprofile | Detailed particle analysis; catches risk standard panels miss | $35 |
| Lipoprotein(a) | Genetic risk factor; elevated in many women with early heart disease | $15 |
Prices reflect negotiated rates for Staywell Health members and are subject to change.
Lipoprotein(a), or Lp(a), is worth a specific mention. It's a genetic lipid marker that is not affected by diet or exercise and is not included in standard cholesterol panels. Elevated Lp(a) is an independent and significant cardiovascular risk factor, and many women with early or unexpected heart disease have never had it checked. It only needs to be tested once in most cases, but if it's elevated it changes how aggressively other risk factors need to be managed.
What to Do About It
If you want to dig deeper or connect with others who've navigated this, WomenHeart is a patient-led organization specifically focused on women living with heart disease, with resources, community support, and a strong advocacy voice around exactly the issues covered in this post. And given that Black women face compounding disparities at the intersection of race and gender in heart health, the Black Women's Health Imperative is another organization doing important work worth knowing about.
The lifestyle factors that protect heart health are well established and apply equally to women: not smoking, regular physical activity, a diet that supports stable blood sugar and healthy lipids, quality sleep, and stress management. None of that is new information. What's often missing is a provider who connects all of these dots for a specific person and helps them understand their actual risk, not just a generic checklist.
If you're a woman over 40, or younger with significant risk factors, it's worth having a real cardiovascular conversation, not just a blood pressure check and a "looks good, see you next year." Know your numbers. Know your history. Know whether your specific risks are actually being addressed.
If you've been brushed off about cardiac symptoms, or you've never had a provider sit down with you and actually go through your cardiovascular risk, that's exactly the kind of thing I have time for at Staywell. It matters, and it's worth doing right.
Daniel Corbin, DNP, APRN, FNP-C
Board-certified Family Nurse Practitioner and founder of Staywell Health, a direct primary care practice in Raleigh, NC specializing in whole-person care, LGBTQ+ health, and lifestyle medicine.