Women’s Heart Disease Is Misunderstood—Here’s What You’re Not Hearing | Dr. Martha Gulati

Gulati relayed the advice of her colleague Paul Ridker: the three most informative cardiac biomarkers are LDL, Lp(a), and hs‑CRP. Despite the existence of risk calculators, these three numbers provide a baseline that can uncover hidden risk, especially in younger women whose short‑term scores would read ‘low’ despite a high lifetime or near‑term risk due to Lp(a) or inflammation. She noted that women’s risk changes over time because of pregnancy, menopause, weight fluctuations, and stress, so periodic reassessment is crucial. The new PREVENT risk score will soon incorporate additional variables like zip code and kidney function, but these three tests remain immediately actionable. She highlighted that Lp(a) and hs‑CRP are still underutilized — physicians rarely screen for them, and women may need to advocate for themselves.

Gulati distinguishes ‘primary‑and‑a‑half’ prevention — patients with atherosclerosis who have not yet had an event. She explained that calcified plaque on a calcium scan is merely a marker of long‑standing disease; the real danger is the soft, non‑calcified plaque that can rupture. When patients see their own CT images, they become highly motivated to take medication and adopt lifestyle changes. She addressed the misinformation around statins, noting that large, long‑term trials consistently show safety and that the brain‑protection data are strong. For those who develop side effects, the landscape has completely changed: ezetimibe, PCSK9 inhibitors, twice‑yearly inclisiran, and bempedoic acid provide multiple effective alternatives to a statin. She stressed that the decision always involves shared decision‑making, and she never forces a patient on a medication they hate. However, the stakes are high, and plaque visualization often aligns patient and physician goals.

Gulati referenced several studies, including the VIRGO study (women under 55 with heart attacks) and the AIRMES study that used cardio‑linguistic AI to analyze doctor‑patient conversations. These studies confirmed that 90% of both men and women report chest pain, but women also describe more accompanying symptoms like shortness of breath, jaw pain, back pain, and profound fatigue — and are much more descriptive, which can inadvertently lead clinicians to attribute the presentation to anxiety. The persistent bias means that even when women say ‘chest pain,’ it is less likely to trigger a full cardiac protocol. She told the audience that if their heart has not been evaluated, they should not leave without explicitly asking that question, because the default often remains ‘it’s stress’ unless forced to confront the possibility of a heart attack.

Gulati championed the emerging field of cardio‑obstetrics, where cardiologists and obstetricians jointly identify and follow high‑risk women. She noted that women remember their reproductive history far better than any doctor asks about it, yet it is rarely elicited. If a woman had hypertension during pregnancy that resolved, the standard postpartum discharge often overlooks future cardiovascular risk. Studies show that such women have a markedly elevated 10‑year risk of heart attack, stroke, or heart failure. Gulati urged women to know their numbers and ensure their primary care provider or internist is aware of these reproductive red flags, because early intervention can be life‑saving.

Gulati’s study, published in 2024, examined survey data on aerobic and resistance activity and linked it to mortality outcomes. Women who performed the same amount of exercise as men had a significantly greater reduction in cardiovascular death and death from any cause. The difference held for both aerobic activity and resistance training. Gulati speculated that physiological differences — such as muscle mass, hemoglobin, or vascular function — might explain why women extract more benefit from a given exercise stimulus. She stressed that despite this advantage, women at every age are less likely than men to exercise regularly, and their activity levels decline further with aging. She also noted that women tend to favor aerobic exercise and neglect resistance training, whereas both are essential. While it is too early to rewrite guidelines, these results could eventually lead to sex‑specific recommendations that are more encouraging for women who struggle to meet the current targets.

Gulati described the pivotal small study that found a statistically significant reduction in carotid intimal‑medial thickness with MHT, but the absolute difference in plaque was minuscule and clinically meaningless. She stressed that intermediate endpoints like plaque thickness are never sufficient to change guidelines; large randomized trials testing hard outcomes (heart attack, death) are required, and those have not shown benefit for primary prevention. She warned that some practitioners are actively telling women to replace their statins with MHT — an extremely dangerous advice, especially for women with established heart disease, for whom MHT is contraindicated. For women without heart disease who suffer from significant vasomotor symptoms, MHT can be considered after shared decision‑making with a gynecologist, but it will not lower their future heart disease risk. She also cautioned against bioidentical pellet implants, which deliver unregulated doses that cannot be adjusted or removed, and for which safety data are lacking.