Imagine having symptoms of a heart attack — chest pressure, shortness of breath, fatigue — going to the hospital, getting an angiogram, and being told your arteries look fine. So you should go home.
With these symptoms present, it’s likely that something did happen here, even if it can’t be seen by traditional tests. And for many women, this is our reality, because women’s heart attacks don’t always follow the rulebooks, one written largely around a different kind of heart disease, in a different kind of patient.
🧠 The takeaway
Up to a third of women who have symptoms of a heart attack show no major blockage on standard imaging.
Standard cardiac tests were built to find plaque. They miss what's happening in the microvasculature.
Knowing these conditions exist is the first step to asking the right questions.
❤️🩹 Did you know about the statin treatment gap for women? Here's how it connects.
What you should know about your heart health
This conversation continues at the Livelong Women's Health Summit on April 17–18 in San Francisco. Dr. Leslie Cho, Director of the Women's Cardiovascular Center at Cleveland Clinic, will be on the main stage on Saturday, covering what women need to know about heart health: risk detection, early intervention, and why prevention looks different for us. Remaining tickets are limited, and you won’t want to miss this session to learn about your own cardiac picture.
Use the code TIFFANY to get $50 off.
When the angiogram comes back "clear"
INOCA (ischemia with no obstructive coronary arteries) describes women who experience chest pain and signs of reduced blood flow without a blocked artery in sight. MINOCA goes one step further: It's a true heart attack, with measurable muscle injury, and still no significant blockage on angiogram. It's three times more common in women than men. And it disproportionately impacts Black or Hispanic/Latino women.
Among women referred for coronary angiography for suspected ischemic heart disease, more than half show no significant arterial obstruction.
The question is why women’s heart attacks aren’t always recognized. The answer starts with the tools we're using.
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How concerned are you about your heart health?
Why standard tests miss this
Dr. C. Noel Bairey Merz, Director of the Barbra Streisand Women's Heart Center at Cedars-Sinai, has spent decades studying this gap and she says this isn't a failure of medicine so much as a mismatch between tools and the problem being looked for.
Coronary calcium scoring (CAC) measures calcified plaque in large vessels. Stress tests are designed to detect large-vessel obstruction. Angiograms show the main coronary arteries. None of these is designed to see microvascular function, spasm, or arterial wall tears. The reason comes down to anatomy.
The large arteries on the outside of the heart get plaque, Bairey Merz says.
"But the arterials have a very thin wall, and the capillaries have no wall. They can't develop plaque. But they can become dysfunctional."
When those small vessels fail to dilate, or constrict instead, the heart muscle doesn't get what it needs. That's ischemia, and it won't appear on a standard test.
There's also coronary vasospasm (an artery that suddenly tightens in response to stress, cold, or exertion), something else that won't show up on a standard angiogram. Then there's SCAD: a tear in the arterial wall that has nothing to do with plaque. Among women under 50 with acute coronary syndrome, SCAD may account for nearly a quarter of all heart attack cases, and 88.5% of SCAD patients are women. It requires different treatment than atherosclerosis. Conflating the two can cause harm.
But, what you've experienced in your body over a lifetime is part of this picture too.
Your history is part of your heart story
One of the most important points from Bairey Merz is that adverse pregnancy outcomes are early cardiovascular signals for women. "Gestational hypertension is just an early window to hypertension. Gestational diabetes is an early window to insulin resistance," she says.
There is also currently no mandatory reproductive history field in most electronic health records. But "there should be," Bairey Merz says. "Because then you could use it."
A history of preeclampsia, a baby born too small, or gestational diabetes may not feel relevant to a cardiologist appointment decades later. But it should, says Bairey Merz.
The same is true for autoimmune disease, which is more common in women and raises cardiovascular risk. If you have rheumatoid arthritis, lupus, or another autoimmune condition, it belongs in any serious cardiovascular risk conversation.
What to do with this knowledge
You don't need to memorize the acronyms or be scared of the stats. But you do need to know that:
Chest pressure, shortness of breath, unusual fatigue, jaw pain, or shoulder discomfort above the belly button that feels different (and keeps coming back) are worth investigating, even if a standard test comes back clear.
A "clear angiogram" is not the same as a "clear bill of health."
Women's heart symptoms have long been labeled as atypical or anxiety, but the guidelines have changed. "There's no such thing as atypical chest pain," Bairey Merz says. "If you think there’s cardiac chest pain, investigate it."
If symptoms persist after a normal workup, ask specifically about coronary function testing, cardiac MRI, or a referral to a cardiologist who specializes in women's ischemia.
The science is catching up to what many women have known intuitively: something was wrong, even when the test said otherwise. The goal now is to close the distance between what women experience and what the system is equipped to find.
Join the Livelong Women’s Circle.
We’d love to have you join the conversation in the Livelong Women's Circle, our private community where women share what they're navigating, what they've learned, and what's actually helped.
If you’re looking for a smart, supportive space to ask questions and learn alongside other women who care about long-term health, you’re welcome here.
Get involved in the Livelong Women’s Health Summit
👉If you're passionate about women's health, we'd love to have you join our Ambassador program for the Summit — see the details here.
👉If your work supports women's long-term health, we're welcoming vendors and partners for the Summit — view the media kit.
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Poll response
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We asked: How would you describe your sleep right now?
More than half of us are waking frequently during the night. 😩Hopefully, some of the tips we shared can help you get a better night’s rest in the coming days.
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The information provided about wellness and health is for general informational and educational purposes only. We are not licensed medical professionals, and the content here should not be considered medical advice. Talk to a doctor before trying any of these suggestions.
