How to Reduce Your Risk of a Heart Attack

Feel like saving a life this week? If you read and share this article with all the women you know, you just might.  

Your mission is simple, no paramedic training or medical school required. All we need you to do is to take in the information we’re about to share about women and cardiovascular disease, then pass it on. Send it to the group chat, bring it up at book club, forward it to friends and family—you never know who might need to hear it, but considering the statistic that by age 45, one in nine women will have heart disease, increasing to one in three by age 65, the odds are good that someone you care about will be grateful for the information.

We need all the messengers we can get, since heart disease remains the number one cause of death for adults in the United States and affects more than 60 million women, but only about 44% of women today recognize their risks (which, as we have written elsewhere, increase after menopause).

That means more than half of American women are missing out on critical information about how heart disease presents in women, what our unique risk factors are, why heart disease risks increase after menopause, and how to self-advocate for essential care.

That’s not going to be you.  

Today we’re sharing insights from a conversation between Gennev’s Chief Medical Officer, Dr. Rebecca Dunsmoor-Su, and cardiologist Dr. Sarah Speck, Director of Cardiac Rehabilitation at Swedish Medical Center in Seattle. They shared invaluable tips about what women over 40 need to know about heart disease and lowering the risk of a cardiovascular event.

While there are different types of cardiovascular disease and different interventions to address them, in this article we’ll focus on the following: 1. risk factors for common types of heart disease in women, 2. presentation (e.g., the signs and symptoms of acute events like heart attacks), 3. what to ask your doctor about your health history and risks, and 4. what kinds of lifestyle and clinical adjustments you can make for a healthier heart, before and after menopause.

Women’s risk factors for heart disease:

In healthcare terms, a risk factor is something that may signal a higher likelihood of developing a disease. Risk factors can be modifiable (for instance, habits that can be changed, like smoking) or non-modifiable (like age or genes). They don’t necessarily cause diseases, but can be a red flag that conditions are in place for future illness or dysfunction.

Some risk factors for common types of heart disease are well known because they affect men and women, have plenty of research behind them, and are widely publicized. These include:

• Diabetes

• Smoking

• High blood pressure

• Excess weight

• High and/or abnormal cholesterol and lipid levels (which can be genetic)

All of these factors can contribute to inflammation and damage to the endothelium, or the layer of cells that line blood vessels and help them expand and contract for optimal blood flow. Damage to these cells can make veins and arteries less flexible and encourage plaque made of cholesterol, fat, calcium, and other substances to form along blood vessel walls. Too much plaque buildup causes those blood vessels to narrow (a condition called atherosclerosis) which can reduce and even block blood flow to the heart, brain, and other organs.  

These “big 5” factors, says Dr. Speck, are just as common in women as they are in men, and just as preventable. They’re the ones you’re likely to encounter when you first start looking into taking care of your heart health. However! There’s a massive knowledge gap when it comes to heart disease causes, prevention, presentation, and treatment specifically in women. Though there’s been medical and scientific progress on that front in the past few decades, awareness of women’s unique risk factors hasn’t kept pace. We can change that.  

Below is a list of other factors that can increase a woman’s risk of developing cardiovascular disease or having a cardiovascular event. Knowing more about them is a great first step toward understanding your options for prevention and treatment, even—or especially—if you have no obvious symptoms.

Other cardiovascular risk factors in women:

• Autoimmune diseases like rheumatoid arthritis, psoriatic arthritis, and lupus  

• A history of pre-eclampsia or gestational diabetes during pregnancy

• Early onset of menopause (before age 40-45)

• Vasomotor symptoms like hot flashes and night sweats (some studies show that severity, rather than frequency, of these symptoms is associated with higher risk of cardiovascular disease)

• Acute psychosocial stress (from grief, fear, or a sudden shock) that causes a surge in stress hormones and temporarily reduces the heart and blood vessels’ ability to pump blood sufficiently

• Coronary microvascular disease, which leads to plaque buildup and reduced blood flow through the small blood vessels in the heart instead of the major coronary arteries (this condition affects women more often than men, and may not be detected by standard tests for other forms of heart disease)

It’s particularly important to keep these factors in mind during menopause. While some heart disease risk factors can affect women well before midlife and plaque can begin developing as early as our twenties and thirties, we do know that estrogen has an anti-inflammatory effect on blood vessels. It helps to keep them flexible, functional, and less likely to accumulate plaque. This may explain why women’s cardiovascular disease risks go up after menopause; we lose estrogen’s protective effect on our arteries as well as its influence over metabolic functions that help manage inflammation and process substances like LDL cholesterol and triglycerides, which accelerate plaque buildup.

Now that you're aware of these risk factors, what can you do with that information? Well, the more you know, the faster and earlier you can act if you think you or someone you love is at risk of a cardiovascular event. And that brings us to our next point: cardiovascular disease can look different in women.

Signs of heart attack and cardiovascular issues in women:

We’re not about to ask you to forget everything you know about typical heart attack symptoms, but we now know that women in cardiovascular distress often experience it differently than men. This can lead to missed diagnoses and care delays if women, their loved ones, and healthcare providers don’t know what to look for.

Dr. Speck explains that while women can have the crushing, elephant-on-the-chest type of pain that might be the first thing we think of when we imagine a heart attack, they may also (or instead) experience:

• Unusual shortness of breath

• Radiating pain or discomfort in the arm, jaw, upper back, neck, or abdomen

• Unusual nausea or vomiting

• Unusual dizziness or lightheadedness

• Breaking out in a cold sweat

• Unusual fatigue

• Heart palpitations, especially accompanied by any of the symptoms above

It can be difficult to connect the dots about women’s heart disease symptoms, because they may only have one or a few of the symptoms above. Even if they do feel classic chest pain, it may not be as severe as it is in men, or it may present more as indigestion. Dr. Speck has seen this before: “I've met women in the emergency room who swear that if they just burp, they would feel better and they're having inferior myocardial infarction (heart attack).” Point taken: don’t wait for the crushing chest pain before seeking care for a potential heart attack.

If you’re reading the list above thinking, “Wait, I've had heart palpitations...” or “How would I know if my fatigue was unusual?! I’m going through menopause!” there's good news and, uh, less-good news.  

The less-good news is that menopause symptoms and heart disease symptoms can sometimes overlap. This doesn’t mean that one condition is causing the other or that the same mechanism is necessarily behind them, but it does add another layer of concern and confusion to this time of transition. It’s a really good reason to know what’s normal for your body, understand your family history, and have a healthcare provider you trust. If you’re experiencing concerning symptoms, it’s worth keeping track and mentioning them to your doctor.  

The actual good news is that we can manage many risk factors for heart disease, and knowledge is power when it comes to taking care of your body.  

Here’s what you need to know to be an active, informed participant in your cardiovascular healthcare at any age.

What doctors look for to learn about your cardiovascular health:

As a cardiologist, Dr. Speck investigates several markers of cardiovascular health, family history, and lifestyle. She particularly wants to know about:

• A family history of heart disease, especially early-onset heart disease, early cardiac death, or inherited disorders like genetically high cholesterol or lipids

• Exercise habits

• Eating habits

As for the tests women over 40 should consider to understand their cardiovascular risks, she suggests starting with the following:

• Blood pressure readings: If your blood pressure is higher than 120/80 when you visit the doctor but normal at home (a condition called white coat syndrome), it could be a good idea to take your blood pressure at home routinely and update your doctor if it changes. If you buy a blood pressure cuff for home use, you can have it calibrated and learn to use it at the doctor’s office or pharmacy.

• LDL cholesterol profile: It’s never too early to get familiar with your cholesterol numbers and what they mean. Need a tip for remembering the cholesterol types? LDL is your “Lousy” cholesterol, the type that calcifies into plaque, and HDL is your “Healthy” cholesterol, which is thought to help prevent plaque buildup. The optimal level of LDL cholesterol for heart health is 100 milligrams or less, if you haven’t had a previous cardiovascular event.  

• A high sensitivity C reactive protein test: High levels of this protein in a blood test can indicate inflammation in the endothelium and suggest an increased risk of a future heart attack.

If you have a family history of heart disease or other risk factors like diabetes, Dr. Speck advises diving even deeper to understand your cardiovascular health profile. The tests she might recommend to higher-risk patients include:

• Screening for genetic markers that can be risk factors for heart disease, like:

• The APOE e4 gene, which is linked to higher LDL cholesterol levels and an increased risk of cardiovascular disease.

• High levels of lipoprotein(a), a particle of fat and protein that moves cholesterol through the bloodstream. High levels of Lp(a) are genetic and can make LDL cholesterol more likely to build up in the arteries.

• A cardiac calcium score test: This test measures the amount of calcified, or hardened, plaque in the coronary arteries that deliver blood to the heart.

• A carotid IMT ultrasound: This type of imaging is useful to see how much and what kind of plaque (soft or calcified) may have accumulated in the carotid artery, and whether there is thickening of the artery wall, which is a sign of inflammation.

What you should do with all the information from these tests is something to discuss with your doctor. They should help you assess your risks and advise how to lower them, whether through diet, exercise, medication, or a combination. In her practice, Dr. Speck works with a nutritionist and an exercise physiologist who can counsel patients about the many ways to incorporate heart-healthy lifestyle habits.  

Of course, if you’re eager to make heart-healthy tweaks to your nutrition and exercise habits, no matter the state of your cardiovascular health or risk factors, it's always a good time to start. Gennev’s team of Registered Dietitian Nutritionists are a fantastic resource for menopause-specific nutrition, fitness, and lifestyle guidance (including sleep and stress management, both important for heart health), tailored for your individual needs, health history, and goals. No referrals necessary—you can sign up and book with a Gennev RDN directly.  

What you can ask your doctor about your risk of a cardiovascular event:

Want a quick cheat sheet for talking to your doctor? If you’ve never asked these questions, it’s worth jotting them down for your next appointment.

• What tests do I need to get a clear picture of my cardiovascular health, and when?

• Could anything about my health history or lifestyle put me at higher risk for a cardiovascular event?

• What do my numbers (blood pressure, lipid profile, and other blood tests) mean for my health and risk factors?

• Am I a candidate for blood pressure or cholesterol medications?

• (If you’re curious about or already using hormones to manage menopause symptoms) Can menopause hormone therapy lower my cardiovascular risks? Are they appropriate based on my health history and do they work with other medications?  

Be your own heart hero:

So, you know the risk factors for heart disease. You know the signs and symptoms. You know what tests you might need. What else can you do right now to minimize your risk of a cardiovascular event after menopause and be your own best advocate?

Understand the misconceptions

You’re already savvy about some of these, like how women may not have chest pain as their first sign of a heart attack. You should also know that women are less likely to be prescribed statins to lower cholesterol or blood thinners to address blood clots or some types of abnormal heart rhythms. There’s a misconception that statins don’t work as well in women as they do in men, but Dr. Speck and Dr. Dunsmoor-Su confirm that this is false. If your situation calls for a statin, know that it can be a safe and effective way to lower your cholesterol.

When it comes to menopausal hormone therapy and cardiovascular disease, be aware that just as hormones are not an automatic no-go, they’re also not an automatic must-try for everyone. There is strong evidence that MHT can be protective against heart disease during and after menopause for some women, in some forms, under the appropriate conditions—but not as a first line of defense. And for some women, especially those with a history of estrogen-provoked blood clots, hormones are not a safe option when it comes to cardiovascular health. Whatever your situation, your doctor can help you weigh the risks and benefits of using hormones during and after menopause.

Know your numbers and your history

Even if you haven’t had a blood test in a long time, the use of electronic medical records makes it easy to track down past results. If you can access old test results through your online patient profile, jot down the numbers from your lipid panel and nudge your doctor about getting another one if it’s been a few years.

As for your health history, if you have vague memories of a relative who died much too young of a heart attack or know a parent has struggled with their blood pressure (or was it their cholesterol?), get to chattin’! Ask family members how old they were when they started getting abnormal markers, what medications they’ve tried and for how long, and what they can share about other relatives’ cardiovascular conditions. This information can help you know what to watch for and plan your own approach to cardiovascular health.

Change the factors in your control

You can’t change your age, your genes, or the fact that you’ll lose your natural estrogen after menopause, but there are plenty of things you can do to reduce other cardiovascular risk factors. Dr. Speck advises patients to “try to be vegetarian twice a day and eat the Mediterranean diet,” which she likes because it has anti-inflammatory benefits, offers a low saturated fat-to-protein ratio while offering plenty of protein, and champions at least 10 servings of fruits and vegetables a day for heart-healthy fiber.

In terms of exercise, she says, “anything that moves the big muscles between your waist and your knees for 150 minutes a week is beneficial for reducing inflammation and reducing your cardiovascular risk.” Exercise is key for keeping the heart strong and improving metabolic function, so it’s absolutely worth finding a few moderate-to-vigorous workout routines you like to do and can follow consistently.

Find a provider who takes you seriously

Finally, we know that seeking healthcare as a woman can be a frustrating, sometimes even demoralizing, experience. There are gaps in research, lack of awareness about women’s health concerns, fewer opportunities for patient education, and sadly even medical biases standing between many women and quality healthcare. As common as cardiovascular disease has become, it’s of the utmost importance to keep pushing for care if you feel like something’s wrong. You deserve to have your concerns taken seriously, and if you find yourself feeling dismissed or unheard, you deserve to find another provider—one who will listen, ask questions, and help you understand what’s going on with your health.