Prevention, Diagnosis, and Treatment of Heart Disease in Women

Stanford is committed to improving the cardiovascular health of women. Our team offers evidence-based, sex-specific, personalized, and comprehensive care including primary, secondary, and tertiary prevention, diagnosis, and treatment of cardiovascular disease.

Women's Heart Health at Boswell Building
300 Pasteur Drive
Stanford, CA 94305
Phone: 650-723-6459 Getting Here

Our Doctors

Care and Treatment of Heart Disease in Women


I've always had the feeling that cardiovascular disease is more of a man's disease. Why is there now such an emphasis on women?

Cardiovascular disease has been the leading cause of death in women for decades, but only recently is it getting the attention it deserves. In fact, since 1984, more women than men have died from cardiovascular disease every year. There are several important reasons that we have learned to associate cardiovascular disease with men and these should not be overlooked.

First, cardiovascular disease is also the leading cause of death in men. Second, cardiovascular disease is actually more common in men than women. Third, because of the higher rates of disease in men, most of the research in cardiovascular disease has been done on men. Consequently, death rates from CVD have been steadily declining for men over the past two decades, while rates have been relatively stable in women.

This has resulted in a growing sex gap and has prompted more scientific research studies about women and cardiovascular disease, as well as campaigns to raise awareness of heart disease in women. In turn, there has been an increase in public information and education about women and heart disease and this is why you now so commonly hear about it.


  • One out of every two women in the U.S. dies from cardiovascular disease 
  • One out of every four women in the U.S. dies from coronary heart disease 
  • Cardiovascular disease kills almost twice as many women as all forms of cancer combined 
  • Still, only 21% of women perceive heart disease as their greatest health threat
How can I determine if I'm at risk? How is my risk different from a man's risk?

It is important that you know your risk of heart disease. The risk factors for heart disease are the same in women and men, but their relative importance varies between the sexes. For example, diabetes and impaired fasting glucose (an elevated blood sugar level between 100 mg/dl to 125 mg/dl) have been shown to confer an even greater risk in women than in men. Likewise, smoking is felt to be worse for women than men.

While an elevated triglyceride level and low HDL (good cholesterol) are independent predictors of heart disease in both women and men, they appear to have greater predictive potential in women. On the other hand, an elevated LDL (bad cholesterol) is more predictive of coronary risk in men. Not only is high blood pressure (hypertension) a risk factor in women, but even prehypertension (blood pressure between 120-139/80-89) is associated with an increased risk for heart attack, stroke, heart failure, and cardiovascular death.

Finally, both obesity and a sedentary lifestyle are risk factors for heart disease, but more women than men carry excess weight and do not engage in physical activity. Given the above findings, women need to be particularly careful not to develop metabolic syndrome. Metabolic syndrome is a clustering of risk factors that increases a person's risk of developing cardiovascular disease. In addition to the traditional risk factors, it may be helpful to know if you have other markers of risk, such as an elevated C-reactive protein (CRP) or lipoprotein (a). Also, mental stress and depression are more common in women and can have an adverse effect on your heart. You can assess your risk online.

Are there any other blood tests besides my cholesterol that can help determine my cardiovascular risk?

Yes. High-sensitivity C-reactive protein (hs-CRP) is a marker of inflammation found in the blood that may independently predict future vascular events regardless of cholesterol levels. A recent study, the Jupiter study enrolled men > 50 years old and women > 60 years old who had no history of cardiovascular disease or diabetes, and who had a normal LDL cholesterol (< 130 mg/dL) and mildly elevated hs-CRP (≥ 2.0 mg/L).

In randomized fashion, half of the participants were given a statin, a medication to lower LDL, while the other half were given a placebo. Those receiving the statin had a decrease in their risk of heart attack, stroke, or needing a stent by more that half, and decrease their risk of death by 20%. The trial was stopped early, after just under 2 years, because of the strong benefit seen in the statin group. Similar benefits were seen for both women and men.

At what age should I start worrying about my risk of heart disease?

Women (and girls) of all ages should be concerned about their risk of heart disease. Healthy habits start early, and neglecting risks leads to an accumulation of your total risk over time. Staying physically active and maintaining a healthy weight should be goals for everyone. Childhood obesity and diabetes are on the rise and may soon have a significant impact on heart disease rates in young people. Having your blood pressure periodically checked is important, even for children and adolescents.

It is recommended that everyone have their cholesterol checked at the age of 20 and at least every five years after that. If there is someone in your immediate family (parent, sibling, or child) with premature heart disease (a male relative < 55 or a female relative < 65) then you need to be particularly concerned about your risk and may want to have your cholesterol checked sooner. While we consider post-menopausal women to be at an increased risk of heart disease, your risk increases steadily over time from an early age. You may be surprised to learn that heart disease is the third-leading cause of death for women age 25 to 44 years and the second-leading cause of death for women 45 to 64 years.

What can I do to reduce my risk of heart disease?

Exercise, eat well, don't smoke, and know your family's heart health history. We encourage you to take an active role in managing any conditions you have that increase your risk for heart disease, such as high blood pressure, diabetes, and high cholesterol. In addition to following a healthy diet, exercising regularly, and maintaining a normal weight, it is also very important that you take your prescribed medications appropriately.

How much exercise is enough?

Women with higher fitness and activity levels have less heart disease and stroke, and live longer than women who are sedentary. It is recommended that you get at least 30 minutes of moderate-intensity physical activity on most, if not all, days of the week. Moderate intensity means that you're breathing hard, but can still carry on a conversation. For weight loss it is recommended that you exercise 60-90 minutes on most, if not all, days of the week. Remember that "being busy" isn't the same as exercise. If you don't like doing organized exercise, consider obtaining a pedometer and aim to achieve 10,000 steps in a day.

What should I be eating?

In general, most people know what constitutes a healthy diet, but they don't always make the best choices. Women with a higher intake of fruits, vegetable, legumes, fish, poultry, and whole grains and a lower intake of red and processed meats, sweets, fried foods, and refined grains have a significantly lower risk of cardiovascular disease. In terms of how much to eat, two simple rules of thumb are to not eat when you aren't hungry and to stop eating before you are full. Also, eating six smaller meals throughout the day is better for regulating blood sugar and metabolism than eating three large meals.

To achieve and maintain a heart-healthy diet, the following guidelines are recommended:

Recommendations for omega-3 fatty acid intake from AHA

What is a normal weight?

Achieving a body mass index (BMI) of 18.5 to 25kg/m2 and a waist circumference < 35inches is an optimum guide to obtaining a healthy weight in women. BMI can be calculated by dividing your weight in kilograms by your height in meters squared. You can also use a BMI calculator. Measurement of your waist circumference should be at the level of your belly button. Having a BMI greater than 25 is associated with an increased risk of heart disease. Carrying fat around your waist (apple shape) increases your risk of heart disease more than carrying fat in your hips and thighs (pear shape).

What symptoms should I be concerned about? How do these symptoms differ from men's?

The most common symptom of coronary artery disease in both women and men is chest pain during exertion. Remember, though, that while doctors use the term chest "pain", it doesn't always feel like pain. It may actually feel like a pressure, tightness, or squeezing. There is often accompanying shortness of breath, and the discomfort may radiate down the arms or into the jaw.

While women will generally have symptoms similar to men, they often report more symptoms, including abdominal pain, neck pain, or fatigue. Women are also more likely than men to get their symptoms with rest or during emotional stress, or during their menstrual period if they are pre-menopausal. Women's symptoms are often considered "atypical", but they are only atypical when compared with men. Women's symptoms are actually quite "typical" when compared with other women. Because women are less aware of the symptoms they should be concerned about, or because they think that heart disease couldn't happen to them, they often present for medical care later than men. This may explain, in part, why women have worse outcomes than men.

What should I do if I'm having symptoms but I don't know if the symptoms from my heart?

It is always better to be safe than sorry. If you are periodically having symptoms that you think are coming from your heart, you should consult with your physician. Your physician may order a stress test just to be sure and may also consider other possibilities such as asthma, acid reflux, or a pulled muscle.

These diagnoses should only be considered after heart disease has been ruled out. Unfortunately, women are less likely to receive testing for heart disease, perhaps because they are considered to be at lower risk or because their symptoms sound "atypical". This is another possible explanation for why women have worse outcomes than men. If your doctor hears about your symptoms, but doesn't mention heart disease, it never hurts to specifically ask him or her if heart disease is a possibility. We encourage women (and men) to be pro-active about their healthcare. If you are having severe symptoms that aren't going away, you may be having a heart attack and should call for emergency medical help immediately.

My doctor has recommended a coronary catheterization (angiogram). What risks do I need to be concerned about?

There are several potential risks when undergoing an invasive procedure, but most are very rare. The most common risk is bleeding, which usually involves minor bruising, but infrequently can be severe and even life-threatening. When the catheterization is done through the femoral artery (groin), women have 2-3x the risk of bleeding and vascular complications compared with men. At Stanford we offer a lower risk alternative, utilizing the radial artery (wrist), which is known to lessen bleeding complications in both women and men. It also allows patients to be ambulatory soon after their procedure, increasing comfort and oftentimes decreasing the length of their hospital stay.

Learn more about an angiogram.

I have been told that my arteries are normal, but I still have chest discomfort and shortness of breath. What should I do?

Some women continue to have their symptoms even though it appears that heart disease (and often many other diagnoses) have been ruled out. While our current testing (stress testing and angiography) is good for ruling out narrowings or blockages in the coronary arteries, it does not always rule out functional problems of the coronary arteries. These functional problems include endothelial dysfunction and microvascular disease.

Endothelial dysfunction occurs when the cells lining the coronary arteries become damaged and start to constrict when they should dilate. Microvascular disease is when the small vessels that we can't see on angiography become dysfunctional or plugged and don't easily allow blood to the heart muscle. This is an area in which Stanford is currently doing research. It has been found that women with symptoms of heart disease, but normal-appearing coronary arteries, often have endothelial dysfunction, microvascular disease, or diffuse non-obstructive plaque. What we don't know is if these findings are actually more common in women than men.

At Stanford, we are testing both women and men to determine if there is a difference in vascular functional abnormalities between the sexes. The testing is specialized and requires an invasive procedure so it is only performed on patients who are felt to need a cardiac catheterization (angiogram). In patients who don't want/need invasive testing, we often try empiric treatment to see if it helps. In addition to medications that can help with the symptoms, lifestyle modification (diet, exercise, and weight loss) are key components in the treatment plan.

How is going to a women's cardiovascular health clinic different from going to a general cardiology clinic?

Women have traditionally been treated based on research that has been done on men. While men have had an improvement in their outcomes over the decades, women have not fared as well. We have a growing body of research showing that there are sex differences throughout cardiovascular disease, from risk factors to symptoms and from testing to treatment and outcomes.

Unfortunately, many physicians continue to care for women and men similarly, and many physicians continue to treat women less aggressively. It has been shown that women get less diagnostic testing than men, are not always prescribed proven medications, and are often not achieving the minimum recommendations of prevention guidelines. In our women's cardiovascular health clinic we aim to treat a woman like a woman, using the most up-to-date, evidence-based data on women's cardiovascular disease.

We take this information into consideration when defining your risks, listening to your symptoms, ordering your tests, and treating your problems. We also try to take in the whole patient, recognizing that social and psychological factors can play a large role in your symptoms and cardiovascular health. Our hope is that caring for women in this way will ultimately lead to an improvement in their outcomes.

I am getting close to menopause. What changes should I watch for that might increase my risk of heart disease?

As women go through menopause, many changes take place. Women tend to put on weight and have a decrease in their exercise tolerance. In addition, their cholesterol profile often changes. HDL (good cholesterol) tends to go down, while triglycerides and LDL (bad cholesterol) tend to go up. Along with that, the LDL phenotype often changes so that women develop more small, dense LDL (more atherogenic), replacing their large, buoyant LDL (less atherogenic).

Women also experience many symptoms during menopause that can be confusing to both them and their health care provider. They often feel more fatigue, don't sleep as well, have hot sweats, may notice more palpitations, or even chest pain. They may also notice more emotional problems such as anxiety, depression, or irritability. Menopause is as important a time as any to persist with healthy lifestyle behaviors such as maintaining weight and getting regular physical activity.

I have heard that hormone therapy is bad for your heart, but I'm having terrible hot flashes and can't sleep. What do you recommend?

It was originally thought that hormone therapy would be good for women's hearts because estrogen has many beneficial effects on the cardiovascular system and also positively affects certain cardiac risk factors, such as cholesterol. However, studies have shown that hormone therapy does not protect the heart and may be harmful. Women over the age of 70 or greater than 20 years from menopause, in particular, have increased rates of cardiac events (within the first year of taking hormone therapy). There does not appear to be quite the same risk in younger women, but they also have an increased risk of stroke, blood clots, and breast cancer.

It is important to be screened and treated for risk factors of stroke before starting hormone therapy. The decision to start hormone therapy is best done in conjunction with both your cardiologist and gynecologist, who can together help you weigh the risks and benefits. The current recommendation is that women only take hormone therapy for moderate to severe vasomotor symptoms (hot flashes, night sweats, etc), and that when doing so, they take the smallest effective dose for the shortest possible time.

Does stress and depression affect my heart?

Depression is a common condition in patients with cardiovascular disease, particularly among women. Women especially young women are uniquely prone to depression during and after a cardiovascular event, with a prevalence of depression almost twice that of men. Mild to moderate depression can more than double the chance that a woman with heart disease will die within a few years.

Depression needs to be identified and addressed because untreated depression makes it difficult to maintain a healthy lifestyle and follow recommended treatments. Additional psychosocial factors can increase risk and worsen prognosis in coronary disease. For example, marital stress has been found to increase cardiovascular risk more strongly than job stress in women, whereas marriage has been shown to largely reduce risk in men.

One study found women with heart disease who received stress management interventions had almost 3 times the survival rate of women who simply received usual care. Women benefit from long-term group-based interventions that promote social bonding and support and encourage reciprocal positive social interactions. Identifying and treating depression and stress reduction are important components of your comprehensive cardiac care. This is why Women’s Heart Health at Stanford offers a weekly Women’s Heart Health Support Group for our patients, as well as periodic instruction on Mindfulness-based Stress Reduction.

Should I be taking aspirin?

Women's Heart Health at Stanford provides a cardiac risk assessment for women without existing heart conditions or symptoms of heart disease. A risk assessment alerts you to your risk factors and helps you manage those risks to prevent heart disease. Your one-hour risk assessment visit is conducted by our nurse practitioner, Mary Nejedly, and includes a full history and physical exam, as well as blood cholesterol and glucose testing. Mary and Dr. Jennifer Tremmel work as a team, so if Mary finds something that is concerning, she will consult with Dr. Tremmel or may even have you come in to see Dr. Tremmel for a full evaluation.

Additional diagnostic testing may also be ordered if indicated, or we may recommend that you see one of the doctors in our Internal Referral Network. All of these doctors are committed to providing the same evidence-based, sex-specific care that we are. Finally, we will make our recommendations, which you may pursue on your own or with your regular doctor, or if you wish, you may continue to see Mary for ongoing risk factor modification counseling. In addition, once you are a patient in our clinic, Dr. Tremmel will always be available to you should you need to see a cardiologist. At the end of the visit, you will be given access to a computerized, personalized cardiac risk assessment with customized recommendations that you can update as your risk profile changes.

I don't have an existing heart condition or any symptoms of heart disease. How can Women's Heart Health at Stanford benefit me?

Achieving a body mass index (BMI) of 18.5 to 25kg/m2 and a waist circumference < 35inches is an optimum guide to obtaining a healthy weight in women. BMI can be calculated by dividing your weight in kilograms by your height in meters squared. You can also use a BMI calculator. Measurement of your waist circumference should be at the level of your belly button. Having a BMI greater than 25 is associated with an increased risk of heart disease. Carrying fat around your waist (apple shape) increases your risk of heart disease more than carrying fat in your hips and thighs (pear shape).

I have an existing heart condition or symptoms of heart disease. How can Women's Heart Health at Stanford benefit me?

Women's Heart Health at Stanford provides cardiology consultations and ongoing care for women with existing heart conditions or symptoms of heart disease. Your cardiology consultation may provide a diagnosis of your condition and/or recommend a course of treatment. When you first call in, we will decide if you should see Dr. Tremmel or if you have a special need that would be better served by one of the physicians in our Internal Referral Network.

Dr. Tremmel sees women who either have known coronary artery disease or who have symptoms consistent with coronary artery disease. You will meet with Dr. Tremmel for a one-hour visit, and she will do a complete history and physical exam in order to determine what kind of care you need. Additional diagnostic testing may be ordered if indicated. A copy of your consultation will be sent to your primary healthcare provider, unless you indicate otherwise. Women with an established local cardiologist are accepted on a case-by-case basis for a second opinion. Once you are established in our clinic, Mary and Dr. Tremmel will work together to treat your symptoms and optimize your risk factors.

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  • New patients, bring your completed new patient questionnaire and new patient lifestyle and risk factor questionnaire.
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Phone: 1-866-742-4811
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