Smidt Heart Institute cardiologist Janet Wei, MD, is one of the authors of a maternal health report from the National Academies of Sciences, Engineering, and Medicine, a nonprofit organization that reviews published research and provides advice to the U.S. government. Wei, associate professor of Cardiology and Biomedical Sciences, sat down with the Cedars-Sinai Newsroom to explain how pregnancy affects women’s hearts.   

How does pregnancy increase cardiovascular risk?

Pregnancy acts as a stress test for the heart and can uncover, or even worsen, problems like high blood pressure and diabetes. During pregnancy, the heart must work harder to support a growing fetus, and cardiac stress often continues after delivery.

Cardiovascular disease is the leading cause of pregnancy-related death in the U.S., yet most of these deaths are preventable. The National Academies of Sciences, Engineering, and Medicine report on maternal health highlights that although 57% of cardiovascular-related deaths occur between seven days and one year postpartum, preventive care is often focused on the prenatal and immediate postpartum period.

What are two takeaways from the report?

The committee reviewed published medical research and gathered input from a wide range of stakeholders, including clinicians, professional societies, advocacy organizations and patients.

Several takeaways became clear. The report recommends, for example, that clinicians treat pregnant women with chronic hypertension so that their blood pressure is reduced to less than 140/90 millimeters of mercury.  This is because consistently elevated blood pressure during pregnancy can cause pregnancy complications and increase a woman’s risk for developing cardiovascular disease.

The new guidelines also recommended that clinicians caring for patients with postpartum hypertension or other hypertensive disorders give their patients home blood pressure monitors and use a program that allows the patients to report their readings. This way, clinicians can adjust treatment and set clear thresholds for action. 

Cedars-Sinai is already doing this through a postpartum blood pressure monitoring program that sends patients home with a blood pressure cuff and allows them to transmit readings to their care teams. (Kimberly Gregory, MD, MPH, director of the Division of Maternal-Fetal Medicine at Cedars-Sinai, served as an adviser to the National Academies committee that created the maternal health report.)

How often should women visit a doctor in the year after giving birth?

How frequently a woman should see her doctor during the postpartum period depends on her cardiovascular risk. 

Not every woman can easily see a doctor or health specialist—especially in rural areas or when cost is a concern. Therefore, the National Academies report recommends the Health Resources and Services Administration use its telehealth, rural health and maternal health programs to reduce geographic, financial and system barriers to preventive cardiovascular services.

What can pregnant women do to protect heart health?

The National Academies created a resource for women that includes the following advice:

Share your history. Tell your healthcare team your family history of heart disease, especially early heart attacks or strokes, and your pregnancy history, including any past complications.

Keep postpartum follow-up appointments on your calendar. It’s important not to miss these appointments because risk for complications continues through the first year after delivery.

Take warning signs seriously—trust your instincts. If something feels wrong during pregnancy or after birth, seek care right away and tell providers that you’re pregnant or that you gave birth recently.

Read more from Cedars-Sinai Stories and Insights: High Blood Pressure—What Women Need to Know

“Too often, when a young woman has heart disease symptoms, a physician will ignore those symptoms and tell her that she needs to lose weight,” said Bairey Merz, director of the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai. “That’s because heart disease symptoms in women can be very different from what men experience. So it’s crucial that women know what to look for.”

Although heart disease is the leading cause of death among women in the U.S., according to the Centers for Disease Control and Prevention, most heart disease research has been conducted on men. And even though rates of heart disease and heart attacks are increasing among women 35 to 54 years old, they are less likely to receive evidence-based treatments such as statins and more likely to be told they are “too young” to have heart disease, Bairey Merz said.

“These delays and dismissals have had serious consequences,” she said. “The Women’s Ischemia Syndrome Evaluation [WISE] study that I led for the National Heart, Lung, and Blood Institute helped us better understand that heart disease doesn’t always look the same in women. That insight ultimately pushed the field to rethink and improve how we diagnose and treat it.”

Despite these advances, women with heart disease are still more likely to be misdiagnosed, underdiagnosed or undertreated—sometimes delaying care that could save their lives.

“The good news is that heart disease is largely preventable,” Bairey Merz said. “And for women in particular—who may not experience obvious symptoms or whose symptoms are subtle—knowledge is a powerful prevention tool.”

To explain what women should watch for, the Cedars-Sinai Newsroom spoke with Bairey Merz about what women can do to protect their hearts and advocate for the healthcare they need.

What are some of the biggest myths about heart disease?

Many people believe that heart disease primarily affects men, that heart attacks always involve crushing chest pain, or that cancer is the top cause of death. In reality, heart disease kills more women than all cancers combined, yet fewer than half of women recognize it as their greatest health threat.

While men tend to develop cardiovascular disease earlier, women are more likely to experience poorer outcomes.

Why are heart attack rates increasing among younger women?

For decades, heart attack death rates declined sharply, thanks to improved research, standardized treatment guidelines, and widespread use of effective medications and procedures. While heart attack deaths are still much lower than they once were, the increase in heart problems among younger adults is concerning.

Researchers are looking into exact causes for the increase, but we know that contributing factors include low levels of physical activity and prolonged sedentary behavior, rising rates of diabetes and obesity, chronic stress, and environmental exposures such as air pollution.

What does a heart attack feel like for women?

The so-called “Hollywood heart attack”—tingling in the left arm that leads to sudden, crushing chest pain—is common in men and can occur in women as well. But many women experience subtler symptoms, including shortness of breath, nausea, unusual fatigue, back or jaw pain, or chest discomfort that doesn’t feel severe or dramatic.

Because these symptoms don’t match common expectations of a heart attack, they may be overlooked or dismissed. Anyone experiencing them should seek medical care immediately.

What causes heart attacks in women?

An increasing number of heart attacks are occurring in people without significant blockages in the major coronary arteries, a pattern seen more often in women. While men’s heart disease more commonly involves blockage in large arteries, women are more likely to experience dysfunction of the heart’s smaller blood vessels. This condition—called ischemia with no obstructive coronary artery disease [INOCA]—can cause reduced blood flow to the heart even when major arteries appear clear.

Even women who are physically fit can develop INOCA. In the past, if a woman had heart attack symptoms but a “normal” angiogram showing clear major arteries, her condition might not have been recognized. Continued awareness and ongoing education around INOCA are helping clinicians better diagnose and treat these patients.

What is a normal heart rate for women?

A normal resting heart rate for most adults is between 60 and 100 beats per minute, according to the American Heart Association. Because women’s hearts are typically smaller, their resting heart rate may run slightly higher than men’s. Women should consult their doctor if their resting heart rate is below 60 or above 100 beats per minute when not exercising.

How can women protect heart health and prevent heart disease?

Heart disease develops silently over decades. While heart disease can be managed with highly effective treatments, prevention is the most powerful strategy.

An estimated 80% of heart disease cases are preventable with lifestyle modifications. These include staying current with annual screenings and knowing cholesterol, blood pressure and blood sugar levels; exercising at least 30 minutes daily; breaking up prolonged sitting because a sedentary lifestyle is considered as strong a risk factor as smoking; managing stress; getting seven to nine hours of sleep; avoiding smoking; and following a nutritious diet.

A Mediterranean-style, largely plant-based diet rich in fruits, vegetables, nuts, beans, whole grains, olive oil and lean proteins is recommended. Parents are encouraged to help ensure their children make healthy food choices, too.

Heart health isn’t about deprivation. It’s about building lifelong habits that prevent disease before it starts.

Read more on the Cedars-Sinai Blog: High Blood Pressure—What Women Need to Know

The new, five-year grant to examine sex-based differences in multiple age-related diseases supports the Microvascular Aging Effects—Women’s Evaluation of Systemic Aging Tenacity in Heart, Brain and Frailty study, commonly called MAE-WEST HBF. The acronym is a nod to the late actor, who reportedly once said, “You’re never too old to become younger.”

MAE-WEST HBF is funded as a Specialized Center of Research Excellence (SCORE) on Sex Differences through the NIH Office of Research on Women’s Health. It builds on prior research from Cedars-Sinai’s Barbra Streisand Women’s Heart Center that showed small blood vessel disease, chronic inflammation and iron buildup in women are linked to impaired heart, brain and kidney function, and declining physical strength.

“Armed with this funding, we are eager to continue uncovering biological mechanisms behind sex-based differences in aging and heart health,” said C. Noel Bairey Merz, MD, the principal investigator of MAE-WEST HBF and director of the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute. “A better understanding of the causes of common age-related conditions in women could lead to more effective prevention and treatment strategies.”

For more than two decades, Bairey Merz and her team have made landmark discoveries in women’s heart health, particularly in coronary microvascular disease—a condition that occurs more often in women and results from damage to the heart’s smallest blood vessels. Symptoms of the condition, which can be subtle, were previously often dismissed, misdiagnosed or undertreated. But improved diagnostic tools and treatments resulting from Bairey Merz’s discoveries have contributed to significant reductions in cardiovascular deaths among women.

The new study brings together a multidisciplinary team of experts, including Pascal Sati, PhD, director of the Neuroimaging Program in the Department of Neurology at Cedars-Sinai. Collaborators at UCLA will oversee biostatistical analysis, while those at the University of Texas at Arlington will lead frailty research.

“We now have effective treatments for small vessel dysfunction in the heart,” Bairey Merz said. “If we can better understand its effects on the brain and musculoskeletal system, we may be able to find ways to prevent or slow multiple age-related diseases—including declines in cognition and mobility—in both women and men.”

Although women generally live longer than men do, women experience higher rates of chronic conditions and so spend more years in poor health. Ultimately, investigators hope the new study will pave the way for a future in which healthy aging for women includes earlier screenings, advanced technology, and preventive care that identifies risks and stops diseases before they begin.

“After more than 25 years of progress in women’s cardiovascular research, this grant helps advance whole-person care that supports heart health, brain function and physical strength,” said Eduardo Marbán, MD, PhD, executive director of the Smidt Heart Institute. “All three are equally essential to healthy aging.”

Cedars-Sinai Health Sciences University is advancing groundbreaking research and educating future leaders in medicine, biomedical sciences and allied health sciences. Learn more about the university.

Cedars-Sinai maternal-fetal medicine specialists have developed a postpartum blood pressure monitoring program that is receiving high marks from patients and addressing health risks faced by women during and after childbirth.

Hypertensive disorders of pregnancy, including preeclampsia, are a leading cause of serious postpartum complications and hospital readmissions. The risk of serious cardiovascular problems can persist well beyond delivery, making structured follow-up during and after the postpartum period critical.

“The postpartum period is a vulnerable time for patients with pregnancy-related hypertension, and too often it’s when care becomes fragmented,” said program leader Sonya Fabricant, MD, a maternal-fetal medicine fellow at Cedars-Sinai. “This program was designed to provide structure, continuity and support when patients return home and still need close follow-up.”

Support Begins at Home in Postpartum Hypertension Program

Nearly 500 women have enrolled in the Postpartum Hypertension Program and have received blood pressure cuffs to use at home. For two weeks, patients record blood pressure readings through a secure patient portal integrated into their electronic medical record. This allows the care team to review results in a timely manner and respond when readings require attention.

“Our program isn’t just about numbers,” Fabricant said. “It’s about making sure patients understand what their blood pressure readings mean, feel supported and know someone is paying attention and ready to intervene if needed.”

Improving Long-Term Cardiovascular Follow-Up

A central goal of the Postpartum Hypertension Program is to improve follow-up with healthcare providers who can evaluate and manage long-term cardiovascular risk.

Among patients receiving care within the Cedars-Sinai system, 72% had a physician visit within six months after giving birth, and 83% of those enrolled in the program followed up with a specialist by 12 months.

“Hypertensive disorders of pregnancy are not limited to pregnancy itself—they are an early marker of future cardiovascular risk,” said Sarah J. Kilpatrick, MD, PhD, chair of the Department of Obstetrics and Gynecology at Cedars-Sinai, who oversaw the creation of the monitoring initiative. “Programs like this help ensure patients stay connected to care and prioritize their own health after childbirth when mothers are more likely to focus on the newborn and their families.”

High Marks From Patients

Patient surveys consistently highlighted the program’s impact on emotional wellbeing during the postpartum transition, according to Fabricant. Participants frequently reported feeling less anxious after discharge and more confident managing their blood pressure at home.

“What we heard repeatedly from patients was how reassuring it was to know their blood pressure was being closely followed during a stressful time,” Fabricant said. “That reassurance helped many patients stay engaged in their care during early postpartum recovery.”

Read more from Cedars-Sinai Stories and Insights: A High-Risk Pregnancy Lifeline

Although cardiovascular disease is a leading cause of death for women, they remain underrepresented in clinical trials for common heart conditions. These findings, by investigators in the Smidt Heart Institute at Cedars-Sinai, were presented at the 2025 European Society of Cardiology Congress in Madrid.

“Numbers don’t lie,” said Martha Gulati, MD, director of Preventive Cardiology in the Smidt Heart Institute and senior author of the paper. “We hope that keeping track of male-to-female participant ratios will motivate researchers to design trials that reflect the real-world population.”

Gulati presented the findings in an oral abstract at the European Society of Cardiology Congress. The results were simultaneously published in JAMA Network Open.

Gulati and colleagues reviewed data from 1,079 cardiovascular clinical trials registered on ClinicalTrials.gov from 2017 to 2023. Women accounted for 41% of the study participants. Investigators found the proportion of women included in clinical trials for certain conditions was much lower than the proportion of women who have these conditions.

The team applied a ratio called the participation-to-prevalence ratio (PPR) to capture whether the percentage of women in a clinical trial reflected how common the condition is among women. The participation-to-prevalence ratios for women were lowest for trials of coronary heart disease, acute coronary syndrome and stroke. Research on obesity and pulmonary hypertension had much higher female participation.

Investigators also found that younger women, ages 19 to 55, were more likely to participate in clinical trials than women 61 or older, and that women tended to enroll in trials studying lifestyle interventions and not trials studying procedures.

“Some studies might stop enrolling once they reach a certain number of people,” Gulati said. “It would be more equitable to continue enrolling until the number of women in the study reflects the proportion of women with that condition.”

The authors also recommend researchers improve outreach efforts to female patients.

“Although we’ve made progress, critical gaps persist,” said study co-author Susan Cheng, MD, MPH, the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science in the Smidt Heart Institute. “It’s important to ensure that what we learn from research can be applied to women, who represent more than half of the world’s population.”

Frederick Berro Rivera, MD, is first author of the study. Other authors include John Vincent Magalong, MD; Nathan Ross B. Bantayan, BSc; Nicole Tesoro, MD; Mark Jason Milan, MD; Vikramjit Purewal, DO; Polyn Luz S. Pine, MD, MBA; Chieh-Mei Tsai, MD; Ann Marie Navar, MD, PhD; Sharon L. Mulvagh, MD; James Januzzi, MD; C. Michael Gibson, MD; Anuradha Lala-Trindade, MD; Kyla Lara-Breitinger, MD; and Mayra Guerrero, MD.

Funding: This work was supported by contracts from the National Heart, Lung, and Blood Institutes, General Clinical Research Center, National Center for Advancing Translational Sciences, Department of Defense, Gustavus and Louis Pfeiffer Research Foundation, Women’s Guild of Cedars-Sinai Medical Center, Ladies Hospital Aid Society of Western Pennsylvania, QMED, Edythe L. Broad and the Constance Austin Women’s Heart Research Fellowships (Cedars-Sinai Medical Center), Barbra Streisand Women’s Cardiovascular Research and Education Program (Cedars-Sinai Medical Center), Society for Women’s Health Research, Linda Joy Pollin Women’s Heart Health Program, Erika Glazer Women’s Heart Health Project, Adelson Family Foundation (Cedars-Sinai Medical Center), Robert A. Winn Diversity in Clinical Trials Career Development Award, and the Anita Dann Friedman Endowment in Women’s Cardiovascular Medicine & Research.

Read more on the Cedars-Sinai Blog: Why Diversity Matters in Clinical Trials

“To see this level of investment in women’s heart health is remarkable,” said Arthur J. Ochoa, JD, senior vice president of Advancement and chief advancement officer at Cedars-Sinai. “Philanthropists like Erika Glazer are changing the face of healthcare and bringing advanced care to so many of our patients.”

Glazer’s journey into heart care began in 2013, when she established the Erika J. Glazer Chair in Women’s Heart Health. The funds generated by the chair’s endowment supported the work of Jennifer Van Eyk, PhD, an expert in the study of proteins whose research focuses on sex differences in heart disease. Van Eyk is director of Basic Science Research in the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai, director of the Advanced Clinical Biosystems Institute and professor of Cardiology, Biomedical Sciences and Pathology and Laboratory Medicine.

“Science is an uncharted territory,” said Glazer. “I wanted to help ensure that women were not left behind when it comes to heart health and research.”

Glazer further widened her philanthropic focus in 2016 when she established the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science, currently occupied by Susan Cheng, MD, MPH, MMSc, director of the Institute for Research on Healthy Aging and division director of Population Health Sciences in the Smidt Heart Institute at Cedars-Sinai.

Then in 2023, Glazer funded her third chair at Cedars-Sinai—the Erika J. Glazer Chair in Women’s Cardiovascular Research, Education and Innovation. The inaugural chairholder is Janet Wei, MD, FACC, associate medical director of Cedars-Sinai’s Biomedical Imaging Research Institute, director of the Cardiovascular Disease Fellowship program in the Smidt Heart Institute, and associate professor of Cardiology and Biomedical Sciences at Cedars-Sinai. 

Righting a Wrong

Glazer’s philanthropic inspiration was sparked by her growing awareness of the underrepresentation of women in heart research, coupled with the need for greater gender equity in the United States.

“Women’s heart disease impacts everyone, in that all of us have a mother, a sister, a daughter, and/or a wife,” said Glazer, who at age 16 spent time interning at Cedars-Sinai—known then as Cedars of Lebanon—in the cardiology laboratories. “We must do more, we must do better, and we must do it now.”

While she considered a career in healthcare, Glazer opted to join her father, Guilford Glazer, in real estate development.

Glazer has made a name for herself in the male-dominated fields of construction and sports. A successful equity investor, she currently is a co-owner of the NBA’s Golden State Warriors.

“If it’s your passion, nothing should stand in your way,” Glazer said.

In addition to aiding Cedars-Sinai’s mission to attract and retain exceptional investigators, in 2016, Glazer also pledged $7.2 million for the Erika J. Glazer Women’s Heart Research Initiative at the Barbra Streisand Women’s Heart Center to support investigations into heart failure with preserved ejection fraction (HFpEF), a type of heart failure that primarily affects women.

“We are increasingly thankful to Erika Glazer—our colleague, our friend and our partner—for helping us to uncover the secrets of women’s heart health and disease,” said C. Noel Bairey Merz, MD, FACC, director of the Barbra Streisand Women’s Heart Center, and the Irwin and Sheila Allen Chair in Women’s Heart Research. “She is a doer, and she is changing the face of heart disease for women and men.”

A Champion for Women

Wei, the newest chairholder supported by Glazer, is awed by the woman behind its creation.

“I’m honored to join an inspiring group of women leaders who have benefited from the vision and generosity of Erika Glazer,” Wei said. “She is a champion for women’s heart health and is providing opportunities for my colleagues and me to advance the research, education and innovations that will save lives.”

 Read more from Discoveries: Women’s Health and Sex Differences—Research Update

The study is funded by an $8 million grant from the highly respected Leducq Foundation and is one of only four awarded this year as part of the foundation’s 2024 International Networks of Excellence Program, which promotes collaborative global research in cardiovascular and neurovascular diseases.

Karumanchi—an expert on hypertension, or high blood pressure, during pregnancy—is the first Leducq Foundation grant recipient at Cedars-Sinai. He will work with an international network of investigators to identify how problems with the placenta—the organ in the uterus that connects mother and baby during pregnancy—can cause heart defects in newborns and lead to heart and blood vessel issues in the mother. The research team also aims to discover new treatments for these conditions.

“Heart disease is typically studied by looking at the heart, blood vessels, cholesterol and blood pressure,” said Karumanchi, the study’s principal investigator. “Thanks to the generous support of the Leducq Foundation, we can explore the origins of heart disease from a different perspective. Previous studies have linked placenta problems with cardiovascular diseases, including congenital heart disease, but scientists haven’t fully understood why. This new funding will help close that research gap.”

Didier Stainier, PhD, from the Max Planck Institute for Heart and Lung Research in Germany, will co-lead the team of placental and developmental biologists, physician-scientists, cardiovascular biologists and epidemiologists from the University of Pennsylvania, the University of Calgary in Canada, Centro Nacional de Investigaciones Cardiovasculares in Spain and the University of Bristol in England.

“Dr. Karumanchi has assembled an exceptional global investigative team of experts from various fields to tackle this important research and ultimately find new ways to understand and treat placenta-related heart diseases,” said Jeffrey A. Golden, MD, executive vice dean of Research and Education and director of the Burns and Allen Research Institute. “Having Cedars-Sinai at the helm of this collaboration speaks to our leadership in this pioneering field of placenta-related cardiovascular disease.”

Recently, Karumanchi identified a biomarker to help diagnose and predict preeclampsia, a hypertension-related disorder and one of the most common pregnancy complications, which also is thought to occur because of problems with the placenta.

Now, new genetic and molecular research tools are allowing Karumanchi and the international team to study the placenta in far greater detail. Growing collections of human tissue and blood samples from mothers and babies with heart problems will enable scientists to make progress in understanding the role of the placenta in maternal and fetal cardiovascular health and disease.

“What an incredible honor to receive this award from the Leducq Foundation,” Karumanchi said. “It’s recognition that our research team has a promising idea with exciting potential implications. We look forward to uncovering new ways to better understand, prevent and treat certain heart diseases.” 

Read more on the Cedars-Sinai Blog: Five Things We Know About the Placenta—and a Few We Wish We Did

at Cedars-Sinai and colleagues report that women with Type 2 diabetes diagnosed with hypertension before age 50 may benefit from intensive blood pressure treatment.

The findings, published in Diabetes Care, show the risk of developing cardiovascular disease is reduced in women with Type 2 diabetes diagnosed with hypertension in middle age who underwent intensive blood pressure treatment. This risk was not reduced in women diagnosed with hypertension at age 50 or older, or in men.  

“We have known for some time that women with Type 2 diabetes have greater cardiovascular disease risks than men with Type 2 diabetes,” said Susan Cheng, MD, MPH, the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science in the Department of Cardiology in the Smidt Heart Institute, and co-corresponding author of the study.

“We also know blood pressure in women rises faster than in men. Given these two findings, we wanted to find out whether certain women might benefit from more intensive treatments,” added Cheng, who is also director of the Institute for Research on Healthy Aging in the Smidt Heart Institute.

Blood pressure readings measure the force of blood pushing against the walls of the arteries. The readings measure two numbers: The larger number (systolic) is the pressure when your heart beats, and the smaller number (diastolic) represents the pressure between beats.

Experts define intensive blood pressure treatment as aiming to achieve and maintain a blood pressure below 120 mmHg systolic. Standard blood pressure treatment aims to achieve and maintain a reading less than 140 mmHg systolic. Uncontrolled blood pressure can damage the arteries and cause heart attack, stroke and other cardiovascular issues.

Intensive blood pressure treatment typically involves higher doses of antihypertensive drugs but can also involve increasing the number of antihypertensive drugs a patient is taking to achieve the blood pressure target.

The investigators analyzed data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which randomized 4,733 people with Type 2 diabetes to intensive or standard antihypertensive treatment targets. A total of 3,792 participants provided their age at hypertension diagnosis.

Women with Type 2 diabetes and early-onset hypertension who received intensive compared to standard antihypertensive treatment had significantly fewer strokes, heart attacks, and other cardiovascular events over the course of 4 ½ years than women with Type 2 diabetes and hypertension diagnosed at a later age.  

“This study could help clinicians consider situations where more intensive lowering of blood pressure may be beneficial,” said Christine M. Albert, MD, MPH, chair of the Department of Cardiology in the Smidt Heart Institute and the Lee and Harold Kapelovitz Distinguished Chair in Cardiology. “Research findings such as these remind us that we have to consider individual differences, including differences between women and men and between people who developed their conditions earlier or later in life.”

Prospective studies are needed to validate these findings, according to the authors.

“This may be the first study to suggest intensive antihypertensive treatment is a preferred approach for women with Type 2 diabetes and early-onset hypertension,” said Joseph Ebinger, MD, associate professor of Cardiology in the Department of Cardiology in the Smidt Heart Institute and one of the study’s authors. “Our results are in line with the well-known adage that treating hypertension soon after diagnosis prevents many health issues later in life.”

Alan Kwan, MD, assistant professor in the Department of Cardiology at Cedars-Sinai, also worked on the study. Other authors include Hongwei Ji, MD; Karen Reue, PhD; Jennifer C. Sullivan, PhD; and John Shyy, PhD.

This work was funded in part by part by the National Natural Science Foundation of China (82103908), the Natural Science Foundation of Shandong Province (ZR2021QH014), Shuimu Scholar Program of Tsinghua University, National Postdoctoral Innovative Talent Support Program (BX20230189), and National Institutes of Health (grants U54-AG065141, U54-HL170326, and U54-HL169191).

Read more from the Cedars-Sinai Blog: Cedars-Sinai Investigators Exploring the Connection Between the Microbiome and Diabetes

The findings, published in the Journal of the American College of Cardiology (JACC), show that women can exercise less often than men, yet receive greater cardiovascular gains.   

“Women have historically and statistically lagged behind men in engaging in meaningful exercise,” said Martha Gulati, MD, director of Preventive Cardiology in the Department of Cardiology in the Smidt Heart Institute at Cedars-Sinai, the Anita Dann Friedman Chair in Women's Cardiovascular Medicine and Research and co-lead author of the study. “The beauty of this study is learning that women can get more out of each minute of moderate to vigorous activity than men do. It’s an incentivizing notion that we hope women will take to heart.”

Investigators analyzed data from 412,413 U.S. adults utilizing the National Health Interview Survey database. Participants between the time frame of 1997 to 2019—55% of whom were female—provided survey data on leisure-time physical activity. Investigators examined gender-specific outcomes in relation to frequency, duration, intensity and type of physical activity.

“For all adults engaging in any regular physical activity, compared to being inactive, mortality risk was expectedly lower,” said Susan Cheng, MD, MPH, the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science, director of the Institute for Research on Healthy Aging in the Department of Cardiology in the Smidt Heart Institute, and senior author of the study. “Intriguingly, though, mortality risk was reduced by 24% in women and 15% in men.”

The research team then studied moderate to vigorous aerobic physical activity, such as brisk walking or cycling, and found that men reached their maximal survival benefit from doing this level of exercise for about five hours per week, whereas women achieved the same degree of survival benefit from exercising just under about 2 1/2 hours per week.

Similarly, when it came to muscle-strengthening activity, such as weightlifting or core body exercises, men reached their peak benefit from doing three sessions per week and women gained the same amount of benefit from about one session per week.

Cheng said that women had even greater gains if they engaged in more than 2 1/2 hours per week of moderate to vigorous aerobic activity, or in two or more sessions per week of muscle-strengthening activities. The investigators note their findings help to translate a longstanding recognition of sex-specific physiology seen in the exercise lab to a now-expanded view of sex differences in exercise-related clinical outcomes.

With all types of exercise and variables accounted for, Gulati says there’s power in recommendations based on the study’s findings. 

“Men get a maximal survival benefit when performing 300 minutes of moderate to vigorous activity per week, whereas women get the same benefit from 140 minutes per week,” Gulati said. “Nonetheless, women continue to get further benefit for up to 300 minutes a week.”

Christine M. Albert, MD, MPH, chair of the Department of Cardiology in the Smidt Heart Institute and the Lee and Harold Kapelovitz Distinguished Chair in Cardiology, says concrete, novel studies like this don’t happen often.

“I am hopeful that this pioneering research will motivate women who are not currently engaged in regular physical activity to understand that they are in a position to gain tremendous benefit for each increment of regular exercise they are able to invest in their longer-term health,” said Albert, professor of Cardiology.

Other Cedars-Sinai authors include Tzu Yu Huang, MSc; Alan Kwan, MD; David Ouyang, MD; and Joseph Ebinger, MD. Other authors include Hongwei Ji, MD; Kaitlin Casaletto, PhD; Kerrie L. Moreau, PhD; and Hicham Skali, MD, MSc.

Funding: This work was supported in part by NIH grants K23HL153888, K23AG058752, R21HL156132, R01HL142983, R01HL151828, R01HL131532, R01HL143227, R01AG072475, U54AG062319, and U54AG065141, and the Erika J Glazer Family Foundation, National Key R&D Program of China (2022YFC2502800), National Natural Science Foundation of China (82103908), Shandong Provincial Natural Science Foundation (ZR2021QH014), Shuimu Scholar Program of Tsinghua University, and National Postdoctoral Innovative Talent Support Program (BX20230189).

Read more from the Cedars-Sinai Blog: High Blood Pressure: How to Recognize and Treat It

But there is hope, according to Natalie Bello, MD, MPH, director of Hypertension Research in the Department of Cardiology, and colleague Susan Cheng, MD, MPH, the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science, who recently authored a perspective article in the journal Circulation Research.  

The paper reflects on women’s cardiovascular health during the past century and looks ahead to the many advances happening in the field. Bello spoke with the Cedars-Sinai Newsroom to share more.

What do women need to know about their cardiovascular health?

Heart disease is the No. 1 cause of death in women, but surveys show women tend to think they are more likely to die of cancer, particularly breast cancer. The most important thing to remember is that heart disease kills more women than all types of cancer combined.

Are some women at greater risk than others?

Almost 20% of women who get pregnant experience complications, such as high blood pressure, preeclampsia or gestational diabetes, that have important implications for their future heart health. These conditions are associated with a higher incidence of heart disease that often happens early in the lifespan.

What progress has been made?

Thanks to pioneers like C. Noel Bairey Merz, MD, director of the Barbra Streisand Women's Heart Center in the Smidt Heart Institute, the medical community is now actively involved in the advancement of women’s heart disease research and care. Her leadership in this area has broadened visibility to gender differences in things like heart attack symptoms and the diagnosis of small vessel heart disease.

Could you give an example of how increased research into women's cardiovascular health has led to better treatment for women?

There is a now a blood test approved by the U.S. Food and Drug Administration, developed by Cedars-Sinai investigators, that we can use to understand a woman's risk for preeclampsia. It helps tell us when a pregnant woman is safe to go home, or if she needs to stay in the hospital for closer monitoring, treatment or early delivery. We use it very frequently.

This is just one of many examples of how Cedars-Sinai has led in women’s heart health.

When should women think about their cardiovascular health?

At age 20, women should establish care with a primary care physician and have their cardiovascular risk assessed. At minimum, all women should visit a primary care provider annually for a blood pressure check.

What are the best ways to prevent cardiovascular disease?

Learn about your personal risk and ways you can modify the disease. That advice is based on the knowledge that 80% of cardiovascular disease is preventable. By doing things like stopping smoking, eating healthy, maintaining a healthy body weight, exercising and sleeping well, we can prevent or delay the progression of heart disease.

Why is it that women's cardiovascular health has been ignored?

In a paper published in 1912, a researcher named Dr. James Herrick and colleagues described heart disease as something that occurred in men. But they published another paper in 1928 showing that the same thing was happening in women. For whatever reason, the follow-up work never gained traction, and that set the stage for heart disease being seen as a man’s issue.

Early epidemiologic research also demonstrated a delay in the onset of heart disease in women compared with men. Noting that women’s risk seemed to increase after menopause, estrogen was believed to be protective and premenopausal women’s risk for heart disease was thought to be low. We now realize that societal issues and habits at the time also influenced risk: Men were more likely to smoke, and women didn’t start smoking socially until later in the last century. Unfortunately, when smoking became socially acceptable for women, there was an uptick in women's heart disease as a result.

I think one of the main reasons women’s cardiovascular health wasn't really investigated is that there was not as much diversity in science and medicine at the time. If you don't experience things, you don't know what questions to ask. I'm not saying it's impossible, but a bunch of men sitting around a table aren't necessarily going to ask each other, “I wonder how excessive menstrual bleeding impacts heart disease risk?” and decide to examine that in a research study.

What can women who aren’t scientists do to ensure the medical system addresses their needs?

It often takes people outside of the scientific community to remind us that we need to be examining certain issues in women’s health. A lot of times it comes from patients who experienced something in their own pregnancy or in their own heart health journey and either started a foundation or lobbied elected officials to increase funding for research related to women. It’s also important for women to feel empowered to discuss their concerns with their clinicians, and if they feel they aren’t being listened to, they should find another person to listen to their symptoms and work them up appropriately.

Read more from the Cedars-Sinai Blog: High Blood Pressure: How to Recognize and Treat It

The retrospective study was part of the Women’s Ischemia Syndrome Evaluation (WISE), a multiyear, multicenter research project sponsored by the National Heart, Lung, and Blood Institute to study detection and assessment of heart artery disorders in women.

The study’s senior and corresponding author Janet Wei, MD, assistant professor of Cardiology in the Smidt Heart Institute, said that a possible explanation for the findings is that evidence-based, guideline-directed cardiovascular care provided at academic medical centers can help ensure equal health opportunities for Black women, who are at an increased risk of dying from cardiovascular disease compared to non-Black women.

“Our findings suggest that when women with coronary artery disease are treated in an academic setting—as were the women involved in the WISE study—they may experience less racial and ethnic discrimination and receive appropriate guideline-directed therapy,” said Wei, who also is associate medical director of the Biomedical Imaging Research Institute and co-director of the Stress Echocardiography Lab in the Smidt Heart Institute.

While heart disease is the leading cause of death for women in most racial and ethnic groups in the U.S., previous studies have shown striking disparities in heart disease outcomes in Black versus non-Black women, including earlier development of cardiovascular disease and a nearly 20% higher rate of cardiovascular-related death.

But the reasons for these disparities have been unclear, leading Wei and other investigators to explore the factors associated with long-term adverse outcomes in Black women with obstructive coronary artery disease.

Using data from the WISE original cohort of 944 women, investigators studied middle-aged women who had coronary angiograms revealing obstructive coronary artery disease (one-third of the cohort). The women were followed for more than a decade to monitor for heart attack, stroke, hospitalization due to chest pain or heart failure, or any cause of death.

Compared with non-Black women in the group, Black women had higher rates of cardiovascular risk factors, such as obesity (average body mass index was 31 in Black women vs. 28 in non-Black women) and hypertension (90% vs. 64%); lower levels of education (50% vs. 19%) and income (62% of Black women earned less than $20,000 per year vs. 32% of non-Black women); and a higher proportion of public health insurance (51% vs. 39% were on Medicare and 21% vs. 6% were on other public insurance, while 23% vs. 49% had private insurance).

However, Black women had a similar or higher use of guideline-directed treatment, including cholesterol- and blood pressure-lowering medications, for coronary artery disease compared to non-Black women. And their long-term cardiovascular outcomes—including cardiovascular mortality—were similar to that of non-Black women with obstructive coronary artery disease (28% of Black women died vs. 20% in non-Black women).

“Recent studies have attributed social determinants of health and structural racism to disparities in cardiovascular health,” Wei said. “But if racial disparities in cardiovascular treatment are reduced, racial disparities in cardiovascular outcomes may be lessened or even eliminated.”

In a separate, recent study, Cedars-Sinai investigators found that Black women with signs and symptoms of ischemia with no obstructive coronary artery disease (INOCA) have increased long-term risk of heart attack, stroke or death.

In addition, they reported that women with INOCA are less likely to be prescribed cardiac medications compared to women with obstructive coronary artery disease, in part because traditional cardiology training advises physicians to look for blockages in coronary arteries when diagnosing coronary artery disease, making INOCA a commonly overlooked cardiac condition.

“Increasing understanding and awareness of how cardiac conditions affect women is so important,” said C. Noel Bairey Merz, MD, principal investigator of the WISE clinical trial, director of the Barbra Streisand Women’s Heart Center, director of the Linda Joy Pollin Women’s Heart Health Program, and the Irwin and Sheila Allen Chair in Women’s Heart Research at the Smidt Heart Institute. “Also critical is the need for appropriate guideline-directed care for all women, regardless of where they go for treatment.”

Bairey Merz, Wei and other investigators in the WISE study into more equitable outcomes for Black women recommended that physician and community education campaigns aimed at evidence-based and guideline-directed care be used in community healthcare settings to help mitigate structural racism.

Other Cedars-Sinai investigators involved in the study include Galen Cook-Wiens, MS, biostatistician.

Read more on the Cedars-Sinai Blog: Women’s Health and Sex Differences: Research Update