Picture a heart attack. Did an image of an older man, clutching his chest, and dropping to the floor come to mind? Stacey E. Rosen, MD, has a name for that reflex visual: the “Hollywood heart attack.” That image of “a man in a suit with a briefcase and a cigarette and a pastrami sandwich, clutching his chest,” she says, has cost women decades of misdiagnoses, dismissed symptoms, and lost lives.
Heart disease is the number one killer of women, more deadly than every form of cancer combined, yet only 44 percent of women know it’s their biggest health risk, a number that drops even lower for Black and Hispanic women. On this episode of Next Question, Katie sits down with Dr. Rosen, the executive director of Northwell’s Katz Institute for Women’s Health and the former volunteer president of the American Heart Association, to unpack why.
Heart attack symptoms in women don’t always look like what you've seen in movies
For decades, heart disease research focused almost entirely on men, shaping our understanding of what a heart attack “should” look like. As a result, the symptoms we’ve been taught to recognize are often based on the male experience.
“It may not be the elephant sitting on my chest,” says Dr. Rosen, “but most will have chest pain.” The key difference, she explains, is what accompanies it. Women, as opposed to men, will often have other symptoms at the same time — breathlessness, back pain, jaw discomfort, or a foggy head.
These signs were historically lumped under the “atypical” label. But as Dr. Rosen points out to Katie, that label doesn’t make sense when women make up 51 percent of the U.S. population. If half of us experience heart attacks differently, are those symptoms really out of the norm?
“We didn’t learn about it, and we dismissed it,” Dr. Rosen tells Katie of the generation of doctors trained to see heart disease as a man’s condition.
Why heart disease is still misdiagnosed as a “man’s disease”
In their conversation, Katie and Dr. Rosen trace how this bias took root: Women were largely excluded from major cardiovascular trials well into recent decades, in part because researchers assumed heart disease was a male problem and women’s health began and ended with reproduction. The result is a system where women’s symptoms are still more likely to be minimized, misattributed to stress, or discharged without answers. Dr. Rosen had her own women’s-only cardiology practice dismissed as a “niche” specialty. With women making up more than half of the population, Dr. Rosen says to Katie, “we really can’t call that niche.”
How pregnancy and menopause raise your heart disease risk
“It’s a stress test, basically,” Dr. Rosen says of pregnancy, explaining that “fewer than 50 percent of women who become pregnant are at optimal heart health” to begin with. Anywhere from “ten to 20 percent of women will have some form of high blood pressure during pregnancy,” says Dr. Rosen, “and about five to 10 percent will have gestational diabetes.” But even when those conditions resolve after childbirth, the elevated risk doesn’t. She calls these adverse pregnancy outcomes, or APOs, and says what happens during pregnancy needs to be a part of your medical history, since it’s a window into future cardiac risk.
Then there’s menopause. As estrogen, which helps keep cholesterol, blood pressure, and inflammation in check, disappears, “our weight goes up, our blood pressure goes up, our good cholesterol drops, and our bad cholesterol goes up,” Dr. Rosen says. And the shift doesn’t wait for your last period: while the average age of menopause in the U.S. is 50 or 51, “things start to change for a decade or more before that” — exactly why she wants women watching their numbers in their 30s and 40s, not waiting for hot flashes to appear first.
When to see a cardiologist and what tests to ask for
Dr. Rosen points to the PREVENT calculator, a free online risk tool that considers age, cholesterol, blood pressure, and kidney function to “spit out a risk assessment for you.” The number she wants most people to aim for is an LDL of less than 100, but she’s clear that prevention needs to start well before numbers are considered too high to ignore. Updated ACC/AHA guidelines for managing lipids and blood pressure both emphasize early intervention as the key to reducing cardiovascular risk, a point Dr. Rosen echoes. For some patients, Dr. Rosen also recommends a coronary artery calcium score — “ a simple test with very little radiation,” she explains — that can catch early plaque buildup years before symptoms start.
Katie and Dr. Rosen also discuss heart conditions many people, including some doctors, have never heard of: microvascular disease, which can “cause all the damage of heart attacks without obstruction or a blockage,” says Dr. Rosen; and MINOCA, a type of microvascular disease that happens without any blockage at all. For years, women with these conditions had normal-looking angiograms and were sent home with a diagnosis of stress. “We didn’t think that maybe women could get heart attacks differently,” Dr. Rosen shares.
Her bottom-line advice for any woman who feels brushed off by her doctor is simple: “Find a doctor who will take you seriously.”
Katie calls this one an enlightening conversation — the kind that makes you want to book a doctor’s appointment before you even finish listening. Catch the full episode of Next Question to hear it all.
This interview has been condensed and edited for length and clarity.
