Heart disease is the number one cause of death for women, and yet far too many of us still think of it as a man’s disease. We get our routine cholesterol panel, see a few numbers that do not look terrifying, and assume we are fine. But that is not always the whole story.
In this conversation, Dr. Thais Aliabadi and Mary Alice Haney sit down with cardiologist and longevity specialist Dr. Mohammad Ghalichi to talk about the slow, quiet development of cardiovascular disease, the tests that can reveal risk earlier, and the practical actions that can help protect both heart and brain health over decades.
Table of Contents
- Why Women Need a More Proactive Approach to Heart Health
- The Advanced Lipid Tests We Should Know About
- Risk Starts Earlier Than Most of Us Think
- What Imaging Can Show Beyond Blood Work
- Heart Attack Symptoms in Women
- Blood Pressure Is a Major Longevity Marker
- Exercise, Nutrition, Sleep, and Metabolic Health
- Medication Is Not Failure
- Heart Health and Brain Health Are Connected
- A Practical Heart Health Checklist
Why Women Need a More Proactive Approach to Heart Health
Why is heart disease such an urgent issue for women?
Dr. Ghalichi: Cardiovascular disease is the leading cause of death globally for both men and women, but women have historically been underdiagnosed and undertreated. There has been a long-standing tendency to assume women are at lower risk or that their symptoms are less concerning. That is simply not true.
Atherosclerotic cardiovascular disease is the process most people mean when they refer to heart disease. It is the gradual buildup of plaque inside arteries. It can lead to heart attacks, strokes, kidney disease, and sudden death. For women, this is not a problem that begins at retirement. Microscopic evidence of plaque development is common by age 40, and one-third of women will experience a cardiac event before age 65.
That is why the conversation cannot begin only once someone has chest pain or a clearly abnormal standard cholesterol panel. We need to understand individual risk early enough to change its trajectory.
What exactly is plaque, and how does it create a heart attack?
Dr. Ghalichi: Cholesterol is essential for the body. Nearly every cell can make it, and the body needs to move it around. But cholesterol does not dissolve in blood. Think of cholesterol as oil and blood as water. They do not mix.
So cholesterol travels through the bloodstream inside carrier particles called lipoproteins. HDL and LDL are examples of lipoproteins. These particles can enter and get trapped in the walls of arteries. Once trapped, they trigger inflammation. The immune system tries to clean them up, and over years or decades, plaque forms.
As plaque gets larger, it narrows the vessel and can restrict blood flow. The real catastrophe often occurs when plaque ruptures. The body recognizes that rupture as an injury and creates a clot. That clot can abruptly block blood flow to the heart, causing a heart attack, or to the brain, causing a stroke.
We are very good at treating a heart attack in an emergency. Cardiologists can open blocked arteries quickly with catheter procedures and stents. But the disease process that led to that event likely began decades before. The real opportunity is to intervene long before the emergency.
The Advanced Lipid Tests We Should Know About
Why is a standard lipid panel not always enough?
Dr. Ghalichi: A standard lipid panel can be helpful, but it may not show the full picture of a person’s atherosclerotic risk. LDL cholesterol is often calculated rather than directly measured, and LDL alone does not account for every particle that can contribute to plaque formation.
There are two advanced tests I would strongly consider for every person at least once, ideally by age 18:
- Apolipoprotein B, or ApoB
- Lipoprotein(a), or Lp(a)
These are not exotic tests reserved only for people already diagnosed with heart disease. Many major laboratories can perform them. They are a practical way to look beyond a routine cholesterol panel and understand the particles actually driving plaque formation.
What does ApoB tell us?
Dr. Ghalichi: If I had to choose one blood test to assess atherosclerotic risk, ApoB would be the test. ApoB is essentially a collective count of the atherogenic particles circulating in the blood, meaning particles capable of getting trapped in arteries and contributing to plaque.
The important concept is particle number. The more particles moving through the bloodstream, the more opportunities there are for particles to enter artery walls and begin the plaque process. LDL is part of that story, but ApoB captures more of the total burden.
In my view, an ApoB level below 60 is good. A more aggressive longevity-focused goal is roughly 20 to 40, which reflects levels commonly seen when people are very young. That said, these are more aggressive targets than standard guidelines, which often rely on LDL cholesterol and 10-year risk calculators.
The limitation of a 10-year risk calculation is obvious. A young person can have a low predicted 10-year risk while still accumulating exposure to harmful lipoproteins for decades. Risk is cumulative. It is not only about what happens this year. It is about the area under the curve: how high the particle levels are and how long they remain elevated.
Why is Lp(a) so important?
Dr. Ghalichi: Lipoprotein(a), or Lp(a), is a largely genetic lipoprotein that is not typically included in a standard cholesterol test. About 15 percent of people have elevated levels.
It matters because it is pro-atherogenic, pro-inflammatory, and pro-thrombotic. In other words, it can accelerate plaque buildup, inflammation, and clot formation. Someone can look healthy, exercise regularly, have normal blood pressure, and still have elevated Lp(a) because genetics plays a major role.
The good news is that Lp(a) usually needs to be checked only once. It is genetically determined, so we are generally identifying whether it is present rather than monitoring dramatic fluctuations over time. If it is negative, most people do not need to repeat it.
For someone interested in cardiovascular longevity, an Lp(a) below 20 would be considered an optimal result. A positive result does not mean a heart attack is inevitable. It means we should take the rest of the risk profile more seriously and work aggressively on the modifiable factors.
For a fuller conversation about women’s heart risk, including symptoms that can be missed, see our guide on why heart attacks are more likely in the early morning.
Risk Starts Earlier Than Most of Us Think
When does atherosclerosis begin?
Dr. Ghalichi: We now understand that plaque formation can start at birth, and possibly even in utero. It is a slow, silent process. When people in their late twenties or early thirties die from an unrelated cause, such as an accident, microscopic examination can already reveal early disease in their arteries.
This is why waiting for symptoms is not an effective prevention strategy. By the time a person has angina, a heart attack, or a stroke, the underlying process has often been in motion for decades.
Family history matters. If close relatives had heart attacks, stents, bypass surgery, stroke, sudden death, dementia, or significant vascular disease at young ages, that information should change the conversation. We need to ask when it happened, what the circumstances were, and how closely related that family member is.
Should young adults be treated if their levels are high?
Dr. Ghalichi: It depends on the degree of elevation, the family history, genetic factors, and the person’s goals. But age alone should not be a reason to ignore severe risk.
If someone has markedly elevated lipoproteins, especially with familial hypercholesterolemia or a strong family history, there may be a case for treatment early. The principle is similar to smoking. We would never tell someone to continue smoking until a scan shows lung damage. We understand the cause and effect, so we work to reduce exposure as early as possible.
A small improvement made early can compound over time. That is the entire point of a longevity approach. We are not waiting for the disease to announce itself.
What Imaging Can Show Beyond Blood Work
When should someone consider seeing a cardiologist for proactive testing?
Dr. Ghalichi: For many people, age 40 is when a detailed cardiovascular assessment has the greatest payoff. That does not mean younger adults should ignore their risk. Advanced lipids, especially ApoB and Lp(a), can be checked much earlier. But around 40, imaging is more likely to provide useful additional information.
An initial evaluation should include symptoms, a cardiovascular exam, an EKG, blood pressure, a detailed family history, and appropriate blood work. For people who want a proactive assessment, there are three imaging approaches that can be very useful.
What are the three imaging tests?
Dr. Ghalichi: The first is a CT coronary calcium score. It is a focused CT scan of the heart that detects calcium in the coronary arteries. We can think of it as a mammogram for the heart. A zero score is encouraging, but it does not completely rule out cardiovascular disease because early plaque can be non-calcified.
The second is a CT coronary angiogram. This test uses IV contrast and more radiation, but it maps the coronary arteries in detail. It can identify non-calcified plaque and show the degree of blockage in a specific artery.
The third is a carotid artery ultrasound with intima-media thickness evaluation. The carotid arteries in the neck are close to the skin and can be assessed with ultrasound. With high-quality equipment and skilled technique, this test can show early non-calcified plaque without radiation exposure.
Each test has tradeoffs. Not everyone needs all of them. The right approach depends on symptoms, family history, blood work, age, and how aggressively someone wants to investigate their risk.
Heart Attack Symptoms in Women
Are heart attack symptoms different in women?
Dr. Ghalichi: Women can present differently. The textbook symptom is pressure-like chest pain that can radiate to the left arm, neck, or jaw. But women may have shortness of breath as the main symptom rather than classic chest pain.
Other warning signs can include nausea, sweating, chest pressure, pain in the neck or jaw, sudden fatigue, or a general feeling that something is seriously wrong. Symptoms vary in everyone, not only women.
We should not rationalize away concerning symptoms because we are busy, young, fit, or convinced it is anxiety. Sudden symptoms, especially with shortness of breath, pressure, sweating, nausea, fainting, or pain spreading to the arm, neck, or jaw, require urgent medical evaluation.
Blood Pressure Is a Major Longevity Marker
What should we know about high blood pressure?
Dr. Ghalichi: High blood pressure becomes more common with age because arteries become less elastic and less compliant. But in younger women, there can be many additional contributors, including stress, insomnia, untreated sleep apnea, obesity, stimulant medications, and other prescription medicines.
Leaving blood pressure elevated for years puts stress on the heart, kidneys, small blood vessels, and brain. It increases the risk of heart attack, stroke, and overall mortality. This is a risk factor we should take seriously, not just something to recheck at the next annual appointment.
Sometimes lifestyle changes can make a meaningful difference. Cardiovascular exercise, better sleep, reducing stress, addressing sleep apnea, reviewing medication effects, and improving metabolic health can help. In other circumstances, medication is absolutely appropriate. The decision depends on the full clinical picture and the severity of the elevation.
How should we measure blood pressure accurately at home?
Dr. Ghalichi: Use an arm cuff rather than a wrist cuff. Sit quietly for at least five minutes before checking. Keep both feet on the floor, do not cross your legs, and keep the cuff at heart level.
A useful protocol is:
- Check twice in the morning and twice in the evening.
- Record the readings and heart rate in a log.
- Continue for at least two weeks, or ideally a month.
- Bring the log to your clinician rather than relying on one reading from a stressful appointment.
Pregnancy also deserves special attention. Gestational hypertension and preeclampsia are important cardiovascular signals. Blood pressure changes can emerge later in pregnancy and can remain a concern for up to six weeks postpartum. These are not issues to manage alone.
Exercise, Nutrition, Sleep, and Metabolic Health
What lifestyle changes have the greatest impact?
Dr. Ghalichi: Exercise is one of the most powerful interventions available. Cardiovascular exercise is profoundly protective for the heart and brain. Resistance training is equally valuable for women because maintaining muscle mass and bone health protects against frailty as we age.
We do not have to train like elite athletes. The goal is to build and maintain physical reserves. Muscle mass declines with age, so strength training early helps flatten that decline. Cardiovascular fitness supports heart health, metabolic health, and cognitive health.
For longevity, the core levers are:
- Exercise: cardiovascular training plus resistance training.
- Nutrition: limiting dietary fat when appropriate and reducing refined, starchy carbohydrates.
- Sleep: prioritizing both sufficient hours and a consistent schedule.
- Metabolic health: addressing insulin resistance, diabetes, visceral fat, and blood pressure.
- Stress and emotional health: recognizing that chronic stress and poor sleep can affect blood pressure and overall health.
- Personalized medications or hormones: when clinically appropriate.
Nutrition can improve lipoprotein levels, but the degree of reduction may be limited, especially when genetics are driving very high levels. For someone with marked elevations, lifestyle should never be framed as a substitute for medications that could substantially lower risk.
Women in perimenopause and menopause deserve even more attention to metabolic and cardiovascular factors. As estradiol falls, LDL, triglycerides, insulin resistance, and visceral fat can worsen. This makes individualized cardiovascular care particularly important during this transition. Our discussion of early menopause and heart disease risk offers additional context on why menopause timing can matter.
Medication Is Not Failure
When do medications make sense for high ApoB or Lp(a)?
Dr. Ghalichi: When lipoprotein levels are very elevated, particularly at a young age or in the setting of strong family history, medications may offer benefits that far outweigh the risks. No one loves taking medication. But it is important not to see medication as failure when it is being used to prevent disease.
Statins remain a foundational treatment. They reduce cholesterol synthesis and have strong evidence for improving cardiovascular outcomes. They can cause side effects in some people, such as muscle aches, liver enzyme elevation, worsening insulin resistance in a small percentage, or temporary brain fog. Those effects are generally reversible, and statins are inexpensive.
Other options include:
- Ezetimibe: blocks cholesterol reabsorption in the gut and can lower lipoprotein levels modestly.
- Bempedoic acid: works primarily in the liver and may be helpful for some people who cannot tolerate statins.
- PCSK9 inhibitors: can substantially lower LDL-related risk and may lower Lp(a) as well.
There are also emerging therapies specifically targeting Lp(a), but lowering a laboratory level is not enough. We need outcome data showing that a therapy reduces heart attacks, strokes, and death. That is why individual decision-making with a knowledgeable clinician matters.
Heart Health and Brain Health Are Connected
How does cardiovascular prevention overlap with dementia prevention?
Dr. Ghalichi: What is good for the heart is often good for the brain. The brain needs a reliable delivery of oxygen and fuel. A healthier cardiovascular system supports that delivery.
For people with a family history of Alzheimer’s disease or dementia, testing for the APOE gene may provide useful context. APOE comes in several forms: E2, E3, and E4. Having one or two copies of APOE4 raises risk, but it is not destiny. Genetic risk should be a reason to become more proactive, not to become hopeless.
The strongest preventive measures include cardiovascular exercise, consistent sleep, good metabolic health, avoiding type 2 diabetes and insulin resistance, and managing lipoproteins to reduce vascular plaque. Avoiding repeated head trauma also matters.
It is also important to distinguish vascular plaque from the amyloid and tau plaques associated with Alzheimer’s disease. They are not the same thing. But vascular disease in the brain can affect blood flow and can contribute to cognitive risk.
What about metformin for longevity?
Dr. Ghalichi: Metformin can be very helpful for people with high blood sugar, insulin resistance, or diabetes. It reduces glucose production in the liver and may have anti-inflammatory and antioxidant effects.
For otherwise healthy people with normal glucose and insulin metabolism, I am not convinced it should automatically be used as a universal longevity drug. There is considerable individual variation. It can be reasonable to discuss with a clinician in the right context, particularly for postmenopausal women with insulin resistance or a strong family history of diabetes.
A Practical Heart Health Checklist
If we want to take action now, what should we ask our doctor about?
Dr. Ghalichi: We should approach heart health as an ongoing prevention plan, not a once-a-year cholesterol check. These are meaningful questions to bring to a clinician:
- Can we check ApoB and Lp(a) at least once?
- Do we have a family history of early heart disease, stroke, dementia, or sudden death?
- Is our blood pressure truly normal based on properly collected home readings?
- Should we assess insulin resistance, glucose control, and metabolic health?
- At age 40 or with elevated risk, is coronary calcium scoring or another imaging test appropriate?
- Are medications or supplements contributing to elevated blood pressure?
- Are we getting enough cardio exercise, strength training, sleep, and stress recovery?
- If there is a family history of dementia, would APOE testing be useful in our individual situation?
The message is not to panic over a single number. It is to understand our actual risk, ask better questions, and make changes early enough for them to matter. Our annual well-woman care should be part of that bigger prevention strategy, which is why we encourage reviewing comprehensive women’s preventive health guidance alongside cardiovascular screening.
Concerned About Your Health? Talk to Dr. Aliabadi
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Frequently Asked Questions About Heart Attack Prevention and Advanced Lipid Testing
Should women get ApoB and Lp(a) tested?
Dr. Ghalichi’s broad recommendation is that every person have ApoB and Lp(a) measured at least once, ideally by age 18. Lp(a) is largely genetic and usually does not need repeated testing if it is negative.
Is a normal LDL cholesterol level enough to rule out heart disease risk?
No. LDL cholesterol is useful, but it does not capture every atherogenic particle. ApoB provides a more complete estimate of particles that can contribute to plaque formation.
What are common heart attack symptoms in women?
Women may have chest pressure, pain radiating to the arm, neck, or jaw, nausea, sweating, sudden shortness of breath, fatigue, or a severe sense that something is wrong. Sudden or concerning symptoms require urgent medical evaluation.
Does a zero coronary calcium score mean there is no plaque?
No. A zero score is reassuring, but it does not rule out early non-calcified plaque. Blood work, symptoms, family history, and other imaging can still be important.
What is the most powerful lifestyle habit for heart and brain health?
Cardiovascular exercise is one of the most protective interventions for both heart and brain health. Resistance training, sleep consistency, blood pressure control, and metabolic health are also essential.
