A Yale cardiologist explains how women’s life stages shape heart disease risk — and what to ask your doctor.

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Heart disease is the leading cause of death in women in the United States — and yet, for most women, it barely registers as a personal concern. The cultural image of a heart attack belongs to a middle-aged man, not a new mother, a woman navigating menopause, or a 35-year-old with no obvious risk factors. The gap between perception and reality is an opportunity to bring awareness and advocacy to this critical issue, focusing on the importance of how sex matters in cardiac care.

Dr. Erica Spatz is a cardiologist at Yale School of Medicine who focuses her clinical work and research on preventive care including the intersection of women's health and cardiovascular risk. I sat down with her to cover the questions every woman — and every woman's doctor — should be asking.

Dr. Eve Cunningham: What drew you to focus on women's heart health — was there a moment or a patient that changed the way you thought about it?

Dr. Erica Spatz: It actually goes back to my grandmother, who struggled with high cholesterol in the days before statins were available. Watching her navigate that — the dietary restrictions, the uncertainty — planted an early seed of interest. But the main thing that brought me to focus on the unique biology of women was my work on the VIRGO study at Yale when I was a cardiology fellow.

The VIRGO study compared men and women under the age of 55 who presented to the hospital with heart attacks. The study validated a counterintuitive and concerning trend previously seen: young women experiencing heart attacks had worse outcomes than their male peers. Compounding the issue, women with classic heart attack symptoms were often sent home without a diagnosis after diagnostic studies showed no blockages.

We now know that women don't always have the same type of heart attack as men and don’t always present with the same symptoms. We have better diagnostic testing today in which we can infer that many of those women were experiencing some sort of cardiac event, but traditional diagnostic testing at that time did not do a good job of detection. That experience — watching women go undiagnosed and then seeing medicine finally catch up — is what really drew me into this field.

Cunningham: A lot of women are surprised to learn that what happens during pregnancy can affect their heart health decades later. Can you explain that connection?

Spatz: High blood pressure during pregnancy — which includes serious conditions like preeclampsia — affects about 1 in 6 women, so if you haven't experienced it yourself, you very likely know someone who has. And one of the most persistent myths around it is that once the baby is delivered, the problem is resolved. That's simply not true.

First, it's important to know that about half of preeclampsia in pregnancy actually occurs after delivery, in the six weeks postpartum — and if blood pressure isn't being monitored during that period, it can go undetected with serious consequences, including heart attack or stroke.

But beyond the immediate postpartum period, having preeclampsia significantly raises a woman's cardiovascular risk for decades. The pregnancy is essentially a stress test — and preeclampsia is the body telling us that the cardiovascular system showed a vulnerability under that stress.

Cunningham: There's often a gap between when a woman leaves her OB after delivery and when she might see a cardiologist or primary care doctor. What needs to change about that handoff?

Spatz: This is one of the most important structural problems in women's cardiovascular care. The postpartum period is completely overwhelming — and the idea that a woman is going to independently arrange follow-up with a cardiologist or primary care provider after their episode of preeclampsia is not realistic.

What we've done at Yale is give blood pressure cuffs to women who had preeclampsia or elevated blood pressure during pregnancy through our MITEY program, so they can monitor at home during that critical six-week postpartum window with the support of a remote clinical team. We know that everything during that period is rightly focused on the baby — so we bring the care to the patient rather than expecting her to navigate an appointment.

Then, ideally around six months to a year after delivery — once some of the physiologic changes from pregnancy have settled back to baseline — we bring her in for a comprehensive cardiovascular health visit. That visit is an opportunity to understand her full picture: risk factors, family history, cholesterol, blood pressure. And to put a plan in place that addresses not just today, but the decades ahead.

Cunningham: Many women think of menopause as hot flashes and mood changes. How does it actually affect the heart?

Spatz: Women have a biological advantage when it comes to heart disease — our natural estrogen is protective. That's why, on average, heart disease presents about 10 years later in women than in men. But menopause is the transition where we lose that protection, and it's not a single moment — it's a journey that can span up to eight years.

As estrogen levels decline, we start to see shifts in cardiometabolic health. Blood pressure that was previously normal can begin to rise. Cholesterol levels can climb. Weight distribution tends to shift toward more visceral fat — fat that accumulates around the organs rather than just under the skin — which carries its own cardiovascular risk. None of this happens in every woman, and there's a wide spectrum of experiences. But for some women, menopause is when risk factors emerge or accelerate.

We also see certain types of chest pain syndromes emerge more frequently during the perimenopausal period — including arterial spasm, which is thought to be related to the same vascular instability that produces hot flashes. Any new cardiac symptoms during this transition deserve a thorough evaluation, not a dismissal as "just menopause."

Cunningham: Hormone therapy has had a complicated history. What does the latest science actually say about HRT and heart health?

Spatz: The story of hormone therapy and heart disease is a good lesson in how medicine can overcorrect when a study is misunderstood. The original Women’s Health Initiative study alarmed physicians and patients about cardiovascular risk, but when we look more carefully, the average age of women in that study was 64, and they were more than a decade past menopause. Their arteries had been without estrogen for a long time. The findings really reflected what happens when you introduce hormone therapy late, not what happens when it's prescribed appropriately.

What we've learned since then is that when hormone therapy is initiated within 10 years of menopause, using more bioidentical estrogens and often a transdermal patch (which doesn't pass through the liver and therefore doesn't increase clotting factors), the cardiovascular risk profile is very low.

The more recent WHI re-analysis, along with other studies, confirms that hormone therapy does not raise atherosclerotic cardiovascular disease risk in women aged 50 to 59 who are experiencing vasomotor symptoms — hot flashes, night sweats — and who are appropriately screened. There are even signals from studies like ELITE that HRT may slow the progression of plaque buildup in the arteries, though we’re not yet at the point where we prescribe it for heart health. That’s still an emerging area of science.

Cunningham: What specific changes to cardiology fellowship training would have the greatest impact on women's cardiovascular care?

Spatz: Two things: start early, and embed it everywhere.

The sex-based biology of cardiovascular disease shouldn't be introduced for the first time in fellowship. It should be woven through the medical school curriculum — because that's when the foundational mental models of disease are being built. If those models are built on male reference cases, they stay male-biased throughout a physician's career.

At the fellowship and residency level, the message I’d want to reinforce is curiosity. When a patient has persistent symptoms that don’t fit, when the tests seem normal but the clinical picture doesn't add up, look harder. Reach out to colleagues. Consider that our diagnostic frameworks may not be capturing the full picture.

I've lived this in my own practice. There were women I couldn't give a diagnosis to, because the tools didn't exist yet. Now the tools are there. We need to train the next generation of cardiologists to use them — and to never stop looking until they find an answer for their patient.

“The conversation has been edited and condensed for clarity.”