As a cardiologist and researcher, Elizabeth Nabel has been highlighting for years that heart diseases are the leading cause of death among women – and are still too often overlooked. The reason is not only biology but also a blind spot in diagnostic pathways, the body of research, and communication. Those who want high performance need a precise early warning system. This begins with the understanding that women’s hearts often communicate differently – quieter, more diffuse, but by no means harmless.

A heart attack is not just a heart attack. In women, in addition to the classic pressure behind the breastbone, "atypical" signs are more common: pain in the back, neck, jaw, or shoulder, nausea, unusual fatigue, shortness of breath. "Atypical" does not mean rare – it means distributed differently. Women also more frequently show dysfunction in the smaller heart vessels, referred to as microvascular dysfunctioncirculatory disturbance of the small heart vessels without major constrictions and MINOCAheart attack without narrowed major coronary arteries. Moreover, vasospasmspasm of the heart vessels with temporary reduced blood flow and SCADspontaneous tear of a coronary artery play a larger role in women. Risk emerges in a phase-specific manner: pregnancy complications, preeclampsiapregnancy-related hypertension with organ damage, PCOSpolycystic ovary syndrome, autoimmune diseases, and menopause shift the risk curve. This makes standard risk scores, which heavily depend on age, often too coarse for women – the clinical picture counts more.

Underestimated symptoms cost time – and time is myocardium. Data from German chest pain units show that women more often present with atypical complaints and experience longer pre-hospital and hospital delays until treatment; therefore, knowledge of symptoms and broader diagnostics are essential ^[1]. In STEMI studies, women less frequently had classic chest pain and interpreted their complaints as "cardiac" less often – a core reason for dangerous delays ^[2]. Concurrently, psychosocial burdens such as stress, anxiety, or depression exacerbate autonomous dysregulation, promote vascular spasms, inflammation, and ischemia – particularly relevant for women and in angina without stenosis ^{[3] [4]}. Additionally, menopause contributes: the hormonal shift worsens endothelial function, lipid profiles, insulin resistance, and fat distribution – a multiple lever for increased cardiovascular risk ^{[5] [6]}.

First: reality of care. A large evaluation of certified chest pain units in Germany found that women more frequently report atypical symptoms, have longer pre- and intra-hospital delays, and receive non-coronary diagnoses more often. Conclusion: increasing awareness of symptoms and broader diagnostics in women improves the detection of acute coronary syndromes ^[1]. Second: symptom profile in STEMI. In a multicenter observational study, women less frequently experienced chest pain, but more often shoulder, neck/back pain, and nausea; women interpreted their concerns as less cardiac – a direct path to delayed assistance ^[2]. Third: mechanisms beyond the "blocked" artery. Reviews indicate that women more frequently present with microvascular ischemia, MINOCA, vasospasm, SCAD, and Takotsubo. These phenotypes require different strategies than merely searching for blockages – for instance, cardiac MRI, intracoronary imaging, or coronary function tests – and take into account female risk modulators such as early menopause, pregnancy histories, and autoimmunity ^[7]. Fourth: life course and menopause. Reviews emphasize that the hormonal decline during menopause is associated with worsened endothelial function, stiffer arteries, and unfavorable metabolism; holistic prevention, including early risk factor assessment and careful consideration of hormone therapy, is indicated since study data on this is heterogeneous ^{[5] [6]}.

- Know your warning signs and act immediately: If you experience pressure/tightness in the chest or atypical symptoms like back, neck, jaw, or shoulder pain, sudden shortness of breath, nausea, cold sweat – call 112, do not drive yourself. Women more often have atypical presentations and longer delays; early action saves myocardium ^{[1] [2]}.
- Mental checklist for performance days: If you experience exercise-dependent chest discomfort or "unexplained exhaustion," plan an evaluation today instead of a meeting. Women are more often misinterpreted as having non-obstructive ischemia; request, if needed, an ECG, troponin, and – depending on the picture – further diagnostics ^{[7] [1]}.
- Nutritional levers: eat a plant-dominant diet (large amounts of vegetables/fruits, whole grains, nuts), use unsaturated fats, reduce red/ultra-processed meat. Overall, a heart-healthy diet significantly lowers cardiovascular risk; combined with other measures, a risk reduction of 70–90% is possible ^{[8] [9]}.
- Exercise as a daily dose of vascular care: at least 150 minutes/week of moderate to vigorous exercise, plus two days of strength training. This improves blood pressure, insulin sensitivity, and endothelial function, often outperforming medications in preventive effectiveness ^{[8] [9]}.
- Micro-breaks against macro-risk: stress triggers ischemia, especially in women and in INOCA. Install 2–3 "breathing anchors" daily (e.g., 4-6 breaths of box breathing), a 10-minute brisk walk after stressful calls, and use wearables for HRV feedback. Goal: lower stress reactivity, better vascular function ^{[3] [4]}.
- Track emotions like LDL: recognize patterns from anger/grief and symptoms. Integrate short, reliable screenings for anxiety/depression into the annual check-up; psychocardiological interventions reduce residual risk alongside lipid control ^{[4] [10]}.
- Consciously manage menopause: know your individual risk profile (blood pressure, lipids, fasting glucose/HbA1c, waist circumference/visceral fat). Discuss the pros and cons of hormone therapy individually; focus on endothelial function, arterial stiffness, and metabolism, as the hormonal shift influences these axes ^{[5] [6]}.
- Reproductive history as a risk compass: history of preeclampsia, gestational diabetes, preterm birth, or PCOS increases future heart risk – screen earlier and more closely, prioritize lifestyle and prevention programs ^[7].

Women’s hearts send signals – often differently but never less importantly. Know your warning signs, minimize stress, strengthen your vessels through nutrition and movement, and actively incorporate menopause and reproductive history into your prevention. Implement today, benefit tomorrow: high performance begins with precise heart health.