Latest / Heart Health, Reimagined with Dr. Mona Shah, MD / Why Heart Disease Is Still Missed in Women

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Why Heart Disease Is Still Missed in Women · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: One of my patients was a runner.
• 0:02
  SPEAKER_00: She did not have crushing chest pain.
• 0:05
  SPEAKER_00: She simply noticed that running suddenly felt harder and that she was becoming unusually tired.
• 0:11
  SPEAKER_00: Her coronary calcium score was zero, which sounds reassuring.
• 0:15
  SPEAKER_00: But because this was a new change for her, we looked further with a coronary CT angiogram.
• 0:23
  SPEAKER_00: That test revealed non-calcified or soft plaque, causing 90% narrowing in her proximal left anterior descending artery, one of the most important arteries supplying her heart.
• 0:37
  SPEAKER_00: And this video is not only for women.
• 0:40
  SPEAKER_00: If you're a husband, partner, son, brother, or friend, you need to hear this too.
• 0:48
  SPEAKER_00: You may be the person who recognizes that something has changed.
• 0:52
  SPEAKER_00: You may be the person who encourages a woman you love to stop dismissing a symptom and get evaluated.
• 1:00
  SPEAKER_00: Because recognizing heart disease in women should not be a responsibility that women carry alone.
• 1:07
  SPEAKER_00: Heart disease remains the leading cause of death in American women, causing approximately one out of every five female deaths.
• 1:17
  SPEAKER_00: In a typical recent year, heart disease killed roughly seven times as many American women as breast cancer.
• 1:25
  SPEAKER_00: Breast cancer awareness is incredibly important, but women also need to understand that their greatest health threat is still heart disease.
• 1:36
  SPEAKER_00: And yet, in a National American Heart Association survey, fewer than half of women recognize heart disease as their leading cause of death.
• 1:45
  SPEAKER_00: That lack of awareness matters.
• 1:48
  SPEAKER_00: If women underestimate their own risk and the people around them and the medical system underestimate it too, prevention begins later.
• 1:57
  SPEAKER_00: Symptoms may be dismissed, and important diagnosis can be missed.
• 2:03
  SPEAKER_00: Let's correct one of the biggest misconceptions about women and heart attacks.
• 2:08
  SPEAKER_00: Chest pain or chest discomfort is still the most common heart attack symptom in women.
• 2:16
  SPEAKER_00: But chest discomfort does not always mean dramatic crushing pain.
• 2:21
  SPEAKER_00: It may feel like pressure, tightness, squeezing, heaviness, burning, or simply an uncomfortable sensation in the chest.
• 2:31
  SPEAKER_00: Women may also experience shortness of breath, nausea, sweating, lightheadedness, unusual fatigue, or discomfort in the jaw, neck, back, shoulder, arm, or even the upper abdomen.
• 2:48
  SPEAKER_00: These symptoms can occur with chest discomfort, and sometimes they may be even more noticeable than the chest symptoms themselves.
• 2:57
  SPEAKER_00: This is why I don't like calling women's symptoms atypical.
• 3:02
  SPEAKER_00: If women commonly experience them, they are not atypical.
• 3:06
  SPEAKER_00: They are simply symptoms we need to recognize.
• 3:10
  SPEAKER_00: I once cared for a woman who went to the emergency room with abdominal pain.
• 3:16
  SPEAKER_00: She did not have an EKG until almost 24 hours later, when someone finally evaluated her heart, they discovered she had been having a heart attack.
• 3:25
  SPEAKER_00: That does not mean abdominal pain automatically means a heart attack.
• 3:29
  SPEAKER_00: Most abdominal pain has nothing to do with the heart.
• 3:33
  SPEAKER_00: The lesson is that a possible cardiac cause was not considered early enough.
• 3:40
  SPEAKER_00: When a woman has a new unexplained symptom, especially when it occurs with exertion or alongside shortness of breath, sweating, nausea, or chest discomfort, we have to consider the complete picture.
• 3:56
  SPEAKER_00: The most important question is often not, is this a classic symptom?
• 4:01
  SPEAKER_00: It is what has changed?
• 4:04
  SPEAKER_00: If you have always felt tired after a stressful week, that is very different from suddenly becoming exhausted during a walk, you usually complete easily.
• 4:14
  SPEAKER_00: If you have always experienced indigestion after certain foods, that is different from new upper abdominal pressure that appears when you climb stairs.
• 4:23
  SPEAKER_00: A change in your normal pattern matters.
• 4:27
  SPEAKER_00: And if you're having new chest pressure, significant shortness of breath, sweating, fainting, or symptoms that could represent a heart attack or heart disease, seek emergency care.
• 4:40
  SPEAKER_00: Don't use a YouTube video to diagnose yourself.
• 4:44
  SPEAKER_00: Current cardiology guidance continues to recognize differences in how women are diagnosed and treated during a heart attack.
• 4:52
  SPEAKER_00: Women can experience longer delays before receiving a diagnosis.
• 4:56
  SPEAKER_00: They are less likely to receive some recommended medications and procedures, and they may be less likely to undergo an angiography exam or treatment to restore blood flow when it is indicated.
• 5:09
  SPEAKER_00: The reasons are complicated.
• 5:11
  SPEAKER_00: Women with heart attacks are often older and may have more medical conditions by the time they present.
• 5:17
  SPEAKER_00: Women can also have different patterns of coronary disease.
• 5:21
  SPEAKER_00: Healthcare system delays, communication differences, and unconscious bias may all contribute.
• 5:29
  SPEAKER_00: So I'm not saying every difference is caused by bias, but the disparities are real, and some remain even after researches account for age, health conditions, geography, education, and income.
• 5:43
  SPEAKER_00: When a heart attack is suspected, an ECG should be considered immediately.
• 5:48
  SPEAKER_00: A woman should not have to look like the stereotypical male heart attack patient before her heart is evaluated.
• 5:55
  SPEAKER_00: And women are not simply smaller versions of men.
• 5:59
  SPEAKER_00: Their traditional risks still matter enormously in women.
• 6:04
  SPEAKER_00: High blood pressure, smoking, diabetes, high APOB, and elevated lipoprotein A, inflammation, and insulin resistance all matter, but there are meaningful differences.
• 6:17
  SPEAKER_00: On average, women's coronary arteries are smaller than men's, even after accounting for body size.
• 6:25
  SPEAKER_00: Women are also more likely to experience problems involving the smaller blood vessels, more diffuse plaque, and abnormal coronary artery constriction.
• 6:39
  SPEAKER_00: There are also important conditions called in OCO, INOCA, and SCAD, SCAD, that disproportionately affect women and can be missed when we look only for a traditional cholesterol blockage.
• 6:54
  SPEAKER_00: I'm going to explain exactly what those terms mean later in this video, because every woman and every person who loves one should know about them.
• 7:03
  SPEAKER_00: Hormonal transitions, menopause, certain inflammatory and autoimmune diseases, and pregnancy complications can also affect a woman's lifetime cardiovascular risk.
• 7:15
  SPEAKER_00: At the same time, women have historically been underrepresented in cardiovascular research.
• 7:22
  SPEAKER_00: Some of our tests, risk calculations, and treatment recommendations were developed from studies that included disproportionately more men.
• 7:31
  SPEAKER_00: That does not make those tools useless in women.
• 7:34
  SPEAKER_00: It just means that we have to interpret them within the context of the woman sitting in front of us.
• 7:39
  SPEAKER_00: If you like videos like this, where we talk about early detection, prevention, and a more holistic, precision-based approach to heart health, please subscribe to the channel and like this video.
• 7:51
  SPEAKER_00: It helps more people find this information and allows me to continue making detailed videos that go beyond the usual advice.
• 7:59
  SPEAKER_00: Women are not missed only after symptoms begin.
• 8:03
  SPEAKER_00: Risk can also be missed years earlier.
• 8:06
  SPEAKER_00: A study published in the New England Journal of Medicine followed almost 30,000 initially healthy American women for 30 years, tracking three blood markers, LDL cholesterol, lipoprotein A, and high sensitivity CRP, a marker of inflammation.
• 8:25
  SPEAKER_00: Women in the highest fifth of HSCRP had about a 70% higher risk of a major cardiovascular event compared to the lowest fifth.
• 8:37
  SPEAKER_00: For LDL, about 36% higher.
• 8:40
  SPEAKER_00: For lipoprotein A, about 33% higher.
• 8:44
  SPEAKER_00: And women with all three markers elevated had roughly more than two and a half times the risk of women with none of them elevated.
• 8:53
  SPEAKER_00: So no single number told the whole story.
• 8:56
  SPEAKER_00: Together, they predicted risk decades out.
• 8:59
  SPEAKER_00: In my own practice, I lean more heavily on APOB than LDO, and I checked several additional labs beyond the standard panel, including lipoprotein A and high sensitivity CRP, which is HSCRP.
• 9:13
  SPEAKER_00: I have full videos on APOB and on the complete list of labs I check, so I won't reteach all of them here.
• 9:20
  SPEAKER_00: I'll link them below in the comments.
• 9:23
  SPEAKER_00: Let's return to my patient who was a runner.
• 9:26
  SPEAKER_00: A coronary calcium score looks for calcified hard plaque.
• 9:31
  SPEAKER_00: A score of zero is reassuring for many people, but it only means no calcified plaque was detected.
• 9:40
  SPEAKER_00: Not that there's no plaque at all.
• 9:43
  SPEAKER_00: Non-calcified or soft plaque doesn't show up on a calcium score.
• 9:48
  SPEAKER_00: Because my patient had a new symptom with exertion, we needed a test that could see that soft plaque too.
• 9:55
  SPEAKER_00: A coronary CT angiogram or CCTA shows both calcified and non-calcified plaque, and that's how we found her severe narrowing.
• 10:07
  SPEAKER_00: I'm not saying everyone with a zero calcium score needs a coronary CT angiogram.
• 10:13
  SPEAKER_00: The right test depends on your symptoms, risk, and the specific questions we're trying to answer.
• 10:19
  SPEAKER_00: I have full videos on what a calcium score measures and on what CCTA can show.
• 10:25
  SPEAKER_00: So I'll link those below rather than repeat them here.
• 10:29
  SPEAKER_00: And I do have a dedicated video comparing the two coming out soon, since it's a question I get constantly.
• 10:37
  SPEAKER_00: Another important condition, especially in women, is called inoco INOCA, ischemia with non-obstructive coronary arteries.
• 10:47
  SPEAKER_00: Ischemia means the heart muscle isn't getting enough oxygen-rich blood.
• 10:53
  SPEAKER_00: Non-obstructive means there's no major blockage in the large coronary arteries.
• 10:58
  SPEAKER_00: When women with concerning symptoms are sent for a coronary angiogram, approximately 50 to 70% are found not to have a major obstructive blockage.
• 11:10
  SPEAKER_00: That doesn't mean 50 to 70% of all women have ENOCA.
• 11:14
  SPEAKER_00: It means the problem is usually in the tiny vessels that distribute blood throughout the heart muscle, something we called coronary microvascular dysfunction, or in a coronary artery that temporarily constricts called coronary spasm.
• 11:32
  SPEAKER_00: Some women have more than one of these.
• 11:35
  SPEAKER_00: Think of the large coronary arteries as highways and the microvessels as a smaller neighborhood street.
• 11:42
  SPEAKER_00: The highways can look completely open while the smaller streets aren't functioning properly, which is why no major blockage does not always mean nothing is wrong.
• 11:55
  SPEAKER_00: There are real treatment options for ENOCA from medications to lifestyle measures like natural vasodilators.
• 12:03
  SPEAKER_00: Vasodilators mean something that'll expand the vessels, including nitrate-rich foods such as beets, match to whether the underlying problem is microvascular dysfunction or coronary spasm, since they aren't identical conditions.
• 12:20
  SPEAKER_00: It's enough of its own topic for a dedicated video, but for today, a clean angiogram is not the end of the conversation if your symptoms are real.
• 12:30
  SPEAKER_00: There's one more condition women should know about called SCAD, SCAD, spontaneous coronary artery dissection.
• 12:38
  SPEAKER_00: Unlike the usual heart attack caused by cholesterol plaque and blockage and a blood clot, SCAD happens when bleeding or separation develops within the wall of the coronary artery itself, which can compress the channel and reduce blood flow to the heart.
• 12:56
  SPEAKER_00: SCAD causes roughly 1 to 4% of heart attacks overall.
• 13:02
  SPEAKER_00: But among women younger than 50 who have a heart attack, it may account for a quarter to a third of cases.
• 13:09
  SPEAKER_00: That doesn't mean a quarter of young women will have SCAD.
• 13:13
  SPEAKER_00: It means that among the relatively small number who do have a heart attack at a young age, SCAD is definitely an important possible cause.
• 13:22
  SPEAKER_00: And it's most consistently linked to a condition called fibromuscular dysplasia or FMD, which makes artery walls more vulnerable to a tear.
• 13:33
  SPEAKER_00: I want to say this directly.
• 13:35
  SPEAKER_00: Please don't stop exercising because you heard about SCAD.
• 13:39
  SPEAKER_00: Some people recall intense physical or emotional stress right before the event, but that's a trigger in someone with an underlying vulnerability, not a cause in a healthy artery.
• 13:52
  SPEAKER_00: And many people who develop SCAD can't identify any trigger at all.
• 13:57
  SPEAKER_00: Exercise remains overwhelmingly good for your heart.
• 14:01
  SPEAKER_00: There's no validated screening test to predict a first SCAD in an otherwise healthy woman.
• 14:07
  SPEAKER_00: And this isn't primarily a cholesterol plaque disease, so our usual risk calculators don't even apply to it the same way.
• 14:16
  SPEAKER_00: Just know that SCAD exists and that a heart attack in a young, healthy, seeming woman is not something to dismiss.
• 14:24
  SPEAKER_00: A woman's history is part of her heart history too.
• 14:27
  SPEAKER_00: Pregnancy complications like preeclampsia can also be an early clue to future cardiovascular risk.
• 14:35
  SPEAKER_00: Menopause matters most of all here.
• 14:38
  SPEAKER_00: It is one of the single biggest turning points in a woman's cardiovascular risk.
• 14:43
  SPEAKER_00: The hormonal transition can affect cholesterol particles, body fat distribution, insulin sensitivity, blood pressure, and blood vessel function, often all at once.
• 14:54
  SPEAKER_00: I have a dedicated menopause and heart health video coming soon on this.
• 14:59
  SPEAKER_00: And a separate one on hormone therapy for men and women coming after that.
• 15:06
  SPEAKER_00: Heart disease in women is not one single disease with one single presentation.
• 15:11
  SPEAKER_00: A woman may have calcified hard plaque, non-calcified soft plaque, a major blockage, disease involving the tiny blood vessels, coronary spasm, or much less commonly SCAD.
• 15:26
  SPEAKER_00: And sometimes she may have more than one problem.
• 15:29
  SPEAKER_00: We don't want to frighten women or order every possible test.
• 15:33
  SPEAKER_00: We need to stop underestimating them.
• 15:36
  SPEAKER_00: Pay attention to change.
• 15:39
  SPEAKER_00: Know your numbers, including APOB and lipoprotein A.
• 15:43
  SPEAKER_00: Understand what your test actually evaluated and make sure the test answered the clinical question being asked.
• 15:51
  SPEAKER_00: A normal result can be reassuring, but no single test answers every cardiovascular question.
• 15:59
  SPEAKER_00: If something feels meaningfully different, especially during exertion, don't dismiss it simply because you're a woman, or because you're young, or because you exercise, or because one previous test was normal.
• 16:13
  SPEAKER_00: And if you're a man watching this, take that message to the woman in your life.
• 16:18
  SPEAKER_00: Listen when she says something has changed.
• 16:20
  SPEAKER_00: Encourage her to seek care.
• 16:22
  SPEAKER_00: And don't assume that being tired, fit, young, or having a calcium score of zero means her heart cannot be the problem.
• 16:31
  SPEAKER_00: I'm Dr.
• 16:32
  SPEAKER_00: Mona Shaw, triple board certified in cardiology, holistic medicine, and cardiac CT.
• 16:38
  SPEAKER_00: If you found this helpful, please like this video, subscribe to the channel, and share it with a woman or a man who loves one who needs to hear it.
• 16:46
  SPEAKER_00: Next up, I'm digging into a silent risk factor almost nobody gets checked for until it's already done damage.
• 16:53
  SPEAKER_00: Insulin resistance.
• 16:55
  SPEAKER_00: I'll see you in the next one.