Cardiovascular disease is the number one killer of women, claiming the lives of one in three. Yet for decades, women’s hearts have been misdiagnosed, misunderstood, and tragically under-researched.
In this powerful episode of The Dr. Gabrielle Lyon Podcast, Dr. Martha Gulati, a leading voice in women’s cardiology, reveals what most people still get wrong about female heart health and what we must do to fix it.
Whether you’re navigating perimenopause or menopause, feeling unsure about your heart health, or just want to understand your risk, this conversation is a must-listen.
Women Are Not Small Men
For years, medicine assumed men and women shared the same risk factors, symptoms, and treatment responses. But this was due to a historic underrepresentation of women in health research, and the data we have today finally says otherwise.
Dr. Gulati has spent her career correcting those blind spots. She led the groundbreaking “St. James Women Take Heart” study, which showed that fitness has a profound effect on women’s longevity. In fact, every 1-MET increase in cardiorespiratory fitness cuts a woman’s risk of death by 17%. And those with a fitness level below 5 METs? They had three times the risk of dying compared to their fitter peers.
For those who don’t know, a MET, or Metabolic Equivalent of Task, is a unit of measurement used to estimate how much energy your body uses during physical activity compared to rest.
Sitting quietly equals 1 MET. Walking at a brisk pace might be around 4 METs, and jogging could hit 7 METs or more. You can estimate your MET capacity through a clinical exercise stress test, but many wearable fitness trackers and online calculators also provide rough estimates based on your activity data.
The higher your MET capacity, the more resilient and efficient your cardiovascular system is, and for women, that number strongly predicts longevity.
She also proposed the first sex-specific formula for calculating maximum heart rate because the outdated “220 minus age” model simply didn’t work for women: 206 − (0.88 × age).
So, what does this mean for you? It means your “normal” might look very different from a man’s and that’s okay. If your doctor uses generic standards for fitness, heart rate, or even chest pain evaluation, you might be getting the wrong message about your heart health.
Knowing your MET level and using sex-specific benchmarks can help you get a clearer picture of your cardiovascular fitness and, more importantly, how to improve it. Ask your healthcare provider about getting an exercise stress test or using a fitness tracker that estimates METs to establish your baseline.
The Problem With “Atypical” Chest Pain
For years, women who showed up in the ER with chest pain were brushed off. Why? Because they didn’t present like men.
Their symptoms were labeled “atypical.” Their chest pain was often chalked up to anxiety or reflux. As a result, women faced longer ER wait times, fewer EKGs, were less likely to be monitored or admitted, and more often sent home without answers.
That’s why, as chair of the 2021 ACC/AHA guidelines, Dr. Gulati fought to eliminate the term “atypical chest pain.” Instead, she championed a probability-based system to improve diagnostic accuracy and save lives.
Her message is clear: women don’t get heart disease less often, they just get less attention when they do.
If you’ve ever had chest discomfort and were told “it’s probably stress” or sent home without answers, you’re not alone. Women are still less likely to be taken seriously in emergency rooms, which can delay life-saving care. That’s why it’s so important to trust your instincts. If something feels wrong, speak up. And know that today’s guidelines give more weight to your symptoms, not just outdated assumptions about what a heart attack “should” look like. You don’t need to have crushing chest pain to be in danger.
When Your Angiogram Is “Normal” But Your Pain Is Real
Another major blind spot in women’s heart care is INOCA, or Ischemia with No Obstructive Coronary Artery disease.
This condition, which affects up to half of women with chest pain, involves dysfunction of the small vessels that supply blood to the heart. Angiograms may come back clean, but that doesn’t mean the problem isn’t real.
Too often, women are told their chest pain is “just stress” when it’s actually coronary microvascular dysfunction. Dr. Gulati has spent two decades with the NIH-funded WISE study, helping shed light on these invisible forms of ischemia and urging cardiologists to take symptoms seriously, even in the absence of blocked arteries.
This is especially relevant if you’ve had normal angiograms or imaging but still experience chest pain, shortness of breath, or unexplained fatigue. Coronary microvascular dysfunction doesn’t show up on traditional scans, but it can still compromise blood flow to the heart. If this sounds like your story, ask your doctor about advanced testing options for microvascular function.
Menopause: A Critical Risk Window
The menopausal transition (MT) is a major turning point for heart health.
Women often gain visceral fat, develop insulin resistance, and see their blood pressure and cholesterol creep up, sometimes for the first time. Sleep gets disrupted, mood can tank, and vasomotor symptoms (like night sweats) can predict future cardiovascular events.
Dr. Gulati’s recent expert panel review urges clinicians to screen more aggressively during midlife, integrating tools like coronary artery calcium (CAC) scoring and Lp(a) testing.
However, it’s important to note that MHT isn’t right for everyone. The American College of Cardiology stresses that MHT is contraindicated in women with existing cardiovascular disease or who are at a high risk of developing it. And if you are in a good position to initiate MHT, Dr. Gulati reminds us that it is not a replacement for other interventions (like statins).
Menopause is a critical window of change, and it deserves targeted, sex-specific prevention strategies. If you’re in your 40s or 50s and noticing changes in sleep, mood, or energy, don’t brush them off as “just menopause.” This life stage can accelerate your heart disease risk in ways that aren’t visible until it’s too late.
But the good news is: this is also one of the most powerful windows for prevention. Talk to your provider about your cardiovascular risk, and don’t be afraid to ask about tools like CAC scoring, Lp(a) testing, or whether MHT is appropriate for you. If your doctor isn’t trained in menopause care, find one who is. Your heart deserves expert attention.
Exercise Saves Lives, But the Benefits Aren’t the Same for Everyone
Exercise is medicine. And for women, even small doses make a big difference.
Dr. Gulati highlights a recent cohort study showing that just 140 minutes per week of moderate-to-vigorous exercise can reduce all-cause mortality by 24% in women. For men to get the same benefit? They’d need about 300 minutes.
But here’s what’s even more surprising: a meta-analysis of over 60,000 people found that high volumes of endurance exercise increased coronary calcium scores in men but not in women. In women, more exercise was associated with fewer calcified plaques and greater plaque stability.
If you’ve ever wondered, “Am I doing enough?”, here’s your answer: you don’t need to run marathons to protect your heart. In fact, women may benefit more from less exercise than men. Just 140 minutes of brisk walking or other moderate activity per week can drop your risk of death by 24%. And if you’re already active, don’t worry about calcium scores the same way men do, the research shows those plaques are often stable, especially in female athletes. Stay consistent, mix in some strength training, and remember that motion is medicine.
Prevention Is Still the Best Medicine
Despite all the advances, heart disease still kills more women than all cancers combined. But here’s the hopeful part: up to 80% of cardiovascular disease is preventable with early risk assessment and lifestyle change.
That means:
- Moving your body more (and sitting less)
- Prioritizing sleep and stress management
- Managing blood pressure, cholesterol, and blood sugar
- Eating a heart-healthy diet (whole-foods with optimal dietary protein)
- Talking to your doctor about menopause and midlife risk
And perhaps most important of all, being taken seriously when you say something feels wrong.
Final Thoughts: Closing the Research Gap
The FDA banned women of childbearing potential from most clinical trials in 1977 due to concerns about potential harm to a baby. This, combined with other factors, led to a historical pattern of excluding or underrepresenting women in research.
The NIH Revitalization Act of 1993 mandated the inclusion of women in NIH-funded clinical trials, marking a significant turning point. That means we’re still playing catch-up, especially when it comes to female-specific symptoms, diagnostic tools, and treatment options.
Dr. Gulati is one of the pioneers changing that.
Her message? We need to listen to women’s hearts, literally and figuratively. The data is there. Now it’s time for medicine to act.
Action Checklist
Here’s your action checklist for all the women out there.
- Know your numbers. Ask your doctor about LDL cholesterol, Lipoprotein(a) and High-sensitivity C-reactive protein (HS-CRP).
- If you’re over 40 (or younger with risk factors), a coronary calcium scan can detect early plaque buildup, even when you feel fine.
- Take symptoms seriously. Unexplained fatigue, chest pain/discomfort, shortness of breath, jaw or neck pain, or even feelings of anxiety could be signs of heart disease.
- If you’re considering MHT, work with your provider to weigh benefits and risks—it’s not a substitute for statins or lifestyle change.
- Exercise is medicine. Get at least 150 minutes of aerobic activity per week and include resistance training 2-3 times weekly.
- Be your own advocate. If something feels off, pursue answers until you’re heard.
🎧 Listen to the full conversation with Dr. Martha Gulati → Women’s Heart Disease Is Misunderstood—Here’s What You’re Not Hearing | Dr. Martha Gulati
