Hello everyone,
Today I have the pleasure of introducing you to Dr Lily Kruse, a cardiac surgeon with a Yale medical degree and a deep passion for prevention. We discuss the risk of cardiovascular disease in women and how it differs from men, why women are twice as likely to die of a heart attack compared to men (it’s not what you think) and why women with PCOS have a higher risk of CVD.
A deep conversation that will show you how to take care of your heart early so we can live a long, fulfilling life. We answer:
What are the differences between men and women in CVD?
Women are twice as likely to die of a heart attack compared to man. Why is that?
What symptoms should I take seriously as a women?
How does each hormonal stage in a women’s life impact our CVD risk?
How can I protect my cardiovascular health?
What is your view on PCOS in relation to CVD?
Lily is also the founder of HealthCaters, where she has dedicated the past 4 years to building preventive health check-ups to help people avoid coming to her operating table.
This conversation is available to listen to on: Apple and Spotify.
If you prefer reading, I have summarised the most important parts below:
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What are the differences between men and women in CVD?
The first difference is anatomical.
When I was in medical school, we were taught that a heart is a heart, whether it belongs to a man or a woman. In practice, that’s not really true. Women’s hearts are physically smaller, even when you account for body size, and the coronary arteries that supply blood to the heart are also narrower. This matters because the same amount of plaque or the same degree of constriction will limit blood flow more in a smaller vessel. So disease can present differently in women, and it’s also one of the reasons why it can be harder to see on scans, because women often have involvement of smaller vessels rather than the large, obvious blockages we tend to look for first.
The second difference is hormonal.
Hormones, and particularly estrogen, play a very important role in cardiovascular health. Estrogen acts as a protective factor for the blood vessels: it helps keep them flexible, it influences inflammation, and it even affects how cholesterol interacts with the vessel wall. That’s one of the reasons why, before menopause, women tend to have a lower cardiovascular risk compared to men. Men’s risk is more stable across life, whereas women’s risk is much more shaped by hormonal changes. As estrogen levels start to decline, especially in the years leading up to menopause, that protective effect fades, and women begin to catch up to men in terms of cardiovascular risk.
Women are twice as likely to die of a heart attack compared to man.
Yes, women do tend to have worse outcomes after cardiovascular events, even though the overall risk of having one can be similar. They are twice as likely to die of a heart attack compared to man. This is why:
If you look at the data globally, women still have heart attacks and other cardiovascular events, and when they do, their outcomes are often worse compared to men. This pattern holds even when you account for age and even when women receive the same interventions.
There are several reasons for this. One is that women tend to present later. By the time they come into the healthcare system, they often already have more accompanying conditions, such as high blood pressure or diabetes, alongside the acute cardiovascular event. That combination makes recovery more complex.
Another reason is how cardiovascular events present in women. Symptoms are often less typical, more vague, and easier to dismiss. In women, heart attacks frequently don’t look like the classic picture most people have in mind. Instead of severe chest pain and left arm pain, symptoms can include shortness of breath, nausea, vomiting, jaw tightness, unusual fatigue, or a general sense that something is wrong.
Because of this, heart attacks in women are very often confused with panic attacks. If you see a woman who is sweaty, clammy, breathing quickly and distressed, the first assumption — by bystanders and sometimes by healthcare professionals — is often anxiety rather than a cardiac event. That assumption creates the first delay. A second delay can happen because women are then less likely to arrive by ambulance. If you think you’re having a panic attack, you’re more likely to wait, try to calm yourself, or come to the emergency room later and under your own steam.
And even once women are in the emergency department, delays can continue. If a woman is still sitting upright, talking, and appears relatively stable, it can be easier to underestimate the seriousness of what is happening. On top of that, diagnostic tests can be less straightforward in women, because the disease often affects smaller vessels or involves constriction rather than a clear blockage, which is not always obvious on initial scans.
All of this means that women are more likely to receive care later in the course of the event, when the situation is already more complex. This is a major reason why outcomes tend to be worse — not because women are inherently at higher risk, but because recognition and timing are different.
Even once women are in the system, diagnosis can be more challenging. Women are more likely to have disease affecting smaller blood vessels, or vessel constriction rather than a clear blockage, which may not show up as obviously on scans. As a result, disease can be underestimated or recognised later than it should be.
So when we see worse outcomes in women, it’s not because women are inherently at higher risk or weaker. It’s a combination of biology, presentation, and how the healthcare system is currently structured and trained to recognise cardiovascular disease.
What symptoms should I take seriously as a women?
The most important thing to understand is that cardiovascular symptoms in women are often subtle and non-specific. That means they’re easy to explain away as stress, anxiety, exhaustion, or “just one of those days”.
Symptoms that deserve to be taken seriously are not necessarily dramatic, but unusual for you, persistent, or out of proportion to what’s happening around you.
That can include:
A feeling of shortness of breath that comes on without a clear reason, especially if it feels different from anxiety or exertion.
A sense of pressure, tightness, or discomfort in the chest that doesn’t quite feel like pain, but also doesn’t feel normal.
Pain or discomfort in places you might not associate with the heart, such as the jaw, neck, upper back, shoulders, or between the shoulder blades.
Unusual nausea, vomiting, light-headedness, or breaking out in a cold sweat, particularly if it comes on suddenly.
A sudden, overwhelming fatigue — the kind where something feels “off”, rather than just tiredness after a long day.
How does each hormonal stage in a women’s life impact our CVD risk?
Each major hormonal stage in a woman’s life changes how the cardiovascular system behaves, and those changes matter for long-term health.
Adolescence is where a lot of the groundwork is laid.
This is a period of major hormonal shifts, and those shifts affect many systems at once. Fat distribution changes, insulin sensitivity changes, lipid profiles start to evolve. For some women, this is also when PCOS first becomes apparent.
At the same time, adolescence is when habits begin to form — how someone eats, moves, sleeps, copes with stress. Those patterns often track into adulthood. From a cardiovascular perspective, this stage can already give us early signals about future risk, even though the person is young and generally considered “healthy”.
The problem is that we tend to underestimate this stage. There’s often very little education or early prevention offered, even though this period is actually very influential for long-term cardiovascular health.
Pregnancy is one of the most demanding stages for the cardiovascular system.
Physiologically, pregnancy places a significant load on the heart. Blood volume increases, cardiac output rises, the heart works harder, and blood vessels have to adapt quickly.
Because of this, pregnancy can unmask risks that were already present but silent. Conditions such as gestational diabetes, high blood pressure in pregnancy, or pre-eclampsia are now recognised as important signals for future cardiovascular risk — even if everything appears to return to normal after delivery.
I don’t see pregnancy complications as isolated events. I see them as information. They tell us how the cardiovascular system responds under stress, and that information is valuable if it’s followed up properly.
Menopause represents a major shift because of estrogen.
Estrogen has a protective role in cardiovascular health. It helps maintain flexibility of blood vessels, influences inflammation, and affects how cholesterol interacts with the vessel wall.
For much of a woman’s life, this protection is present in the background. As estrogen levels decline — and this starts years before menopause itself — that protective effect gradually fades. This is why women tend to “catch up” to men in terms of cardiovascular risk later in life.
What’s important to understand is that this change doesn’t happen overnight. It’s gradual, which means there is time to respond. But it does mean that menopause is a key transition point where cardiovascular health deserves more attention, not less.
Overall, I see hormonal stages as windows of insight, not moments of danger.
Adolescence, pregnancy and menopause are not problems in themselves. They are periods where the body is adapting, and those adaptations tell us something about long-term cardiovascular health.
The earlier we pay attention to those signals, the more calmly and effectively we can support the system over time.
How can I protect my cardiovascular health?
When I think about preventing cardiovascular disease, I think much less about doing something extreme, and much more about doing simple things consistently over time.
From a clinical perspective, most cardiovascular disease does not appear suddenly. It develops quietly, over many years. That’s why prevention works best when it starts early and stays relatively unremarkable.
The foundations matter most. Regular movement is one of the strongest protective factors we have. This doesn’t need to mean intense exercise. In fact, consistent, moderate activity — something like walking regularly over long periods of time — is often more protective than sporadic bursts of high-intensity exercise that aren’t sustained.
Sleep is another core pillar. Chronic sleep deprivation affects blood pressure, insulin sensitivity and inflammation, all of which feed into cardiovascular risk. Good sleep is not a luxury for heart health; it’s part of the baseline.
Nutrition matters too, but not in an extreme or restrictive way. From a cardiovascular perspective, what I look for is whether someone’s diet supports stable blood sugar, healthy lipid levels and overall metabolic health over time. It’s not about perfection, supplements or trends, but about patterns that the body can maintain.
One marker I pay particular attention to is blood pressure. Blood pressure is powerful precisely because it’s simple. It’s easy to measure, accessible, and gives us a lot of information about how the cardiovascular system is responding over time. You don’t need very sophisticated tools to notice early shifts and noticing those shifts early makes a real difference.
What I try to emphasise is that prevention is not something you start once symptoms appear. By then, the process has often been unfolding for a long time. The earlier you begin supporting the system — ideally in adolescence, early adulthood, or after key life stages like pregnancy — the better the long-term outcomes tend to be.
And finally, prevention should not feel like fear management. It should feel like care. Cardiovascular health responds well to steady, consistent support. Most of the time, it doesn’t require doing more, it requires doing less, but doing it for longer.
What is your view on PCOS in relation to CVD?
PCOS is often discussed as a reproductive condition — about periods, fertility, hair growth — but from a cardiovascular perspective, that’s only a small part of the picture.
What matters more to me is that PCOS affects multiple systems at the same time. Women with PCOS, on average, tend to have higher blood pressure, less favourable lipid profiles, and higher rates of insulin resistance and diabetes. All of these are established cardiovascular risk factors, and over time they interact with each other.
Because of this, women with PCOS do have a higher long-term risk of cardiovascular disease compared to women without PCOS. That can include conditions such as heart attacks, strokes, and also rhythm disturbances. But I think it’s very important how this information is framed.
PCOS is not a single cause of cardiovascular disease. It creates a different metabolic and hormonal environment over time, and that environment can increase risk if it’s not recognised and supported properly.
What I find reassuring — and what I think is often under-emphasised — is that this risk is not fixed. Studies show that when PCOS is well managed, cardiovascular risk can reduce significantly, in some cases approaching that of women without PCOS. From a clinical perspective, this is a key point.
So my view is not that PCOS should be seen as something frightening in relation to the heart, but as something informative. It gives us an earlier signal that cardiovascular prevention may need to start sooner and be taken a bit more seriously. And when that happens, outcomes can be very good.
PCOS, in that sense, is not a prediction, it’s an opportunity for earlier, calmer prevention.
My main closing thought is that cardiovascular health is a long-term process.
It’s not something you should only start thinking about once symptoms appear. By that point, a lot of the process has already been unfolding quietly in the background.
The earlier you start paying attention, the better the outcome tends to be. And I don’t say that to scare anyone. I think it’s actually reassuring, because it means there is a lot we can do ourselves, outside of the medical system.
Most of what protects the heart is very straightforward. It’s about consistent movement, sleep, nutrition, and paying attention to simple signals over time. When you know that you have a certain risk — whether because of PCOS or other factors — that knowledge doesn’t have to be heavy. It can simply guide you to take care of yourself a bit earlier and a bit more intentionally.
So my hope is that women with PCOS are aware that this risk exists, but also confident that they can meaningfully reduce it. A lot of it really is in our own hands.
See you next Sunday,
Francesca
