It is the leading cause of death in women, and yet, the same prevention that is emphasized in the case of men is overlooked when it comes to women. "Obviously, there is no awareness of the cardiovascular risk that women face. Traditionally, prevention has been limited to what is known as 'bikini medicine', that is, gynecological check-ups, and this is a tremendous mistake because cardiovascular disease is the leading cause of mortality in the female population," says Antonia Sambola, a cardiologist and one of the leading experts in the prevention and treatment of heart disease in women. In her new book, "El corazón de las mujeres" (The Heart of Women), Sambola explains how hormones influence cardiovascular health, how to take care of ourselves at each stage of our lives, or how to lead a healthy lifestyle built on the pillars of nutrition, exercise, rest, and stress management.
Question. Due to the attention given to prevention in the case of both, one would not say that more women die from heart problems than men...
Answer. More women die each year from cardiovascular disease than men in both Europe and the United States. What happens? There are more men suffering from cardiovascular diseases than women. In other words, the incidence is higher in men, but the risk is more severe in women.
Q. Nor is there talk about the differences between men's and women's hearts...
A. Indeed. Our heart is not only smaller, but the caliber of the coronary arteries that supply blood to the heart muscle is also smaller. There are also a series of characteristics that make it different. For example, women's hearts respond differently than men's in cases of hypertension or heart attacks. Additionally, an important point to consider is that the way drugs are metabolized is not the same. Absorption and elimination vary, and therefore, medication doses should also be different. In fact, due to this reason, women experience a much higher number of adverse drug effects than men. The major issue here is that clinical trials are mainly conducted with men. In most cases (including cardiovascular diseases), women make up less than 30% of the subjects studied. However, the results are extrapolated to females with the same doses, which should not be the case.
Q. And, until now, little or nothing has been said about the influence of hormones on our heart health. Isn't that right?
A. That's correct. Beyond the life cycle, I would say something more: hormonal influence varies in each woman. The fact that hormones not only have reproductive effects but also play a key role systemically should not be overlooked. How do we see this? This is seen very clearly, for example, in women going through menopause who, beyond the cessation of menstruation, experience sweating disturbances, increased tendency to accumulate fat or retain fluids, elevated cholesterol, blood pressure...
Q. Speaking of hormones, how do you interpret this 'boom' in menopause?
A. I believe hormones have generated a huge business. There is a lot of money involved. Hormone therapy has shifted from being prohibited to being prescribed to everyone, and this should not be the case. Its benefits in selected patients are undeniable, but caution is necessary. In individuals over 60 years old, it is contraindicated, as well as in people with a history of breast cancer or cardiovascular risk. It also does not provide any benefit to women who have been in menopause for over a decade.
Q. In your book, you state that pregnancy is a stress test for our heart...
A. Yes, that's true. Pregnancy is not a disease. It is a physiological condition, but it is a stress test. Why? Because it increases heart rate, raises blood pressure, in general.
Q. Tobacco, alcohol, stress... Which is the biggest enemy of our heart?
A. All of them are significant enemies of our heart. Tobacco is the number one, as it is scientifically proven to be associated with the development of multiple diseases: cancer and cardiovascular conditions. Moreover, it has a much more detrimental effect on women, through mechanisms still unknown. It is very concerning to know that Spain is among the countries with the highest number of smokers in the EU, especially in the consumption of fewer than 20 cigarettes per day. Smoking among Spanish women has increased, especially in girls aged between 14 and 18 years and in middle-aged women (45-54 years). Excessive alcohol consumption among women is a largely unknown reality; it is a taboo subject. Stress is inherent in our daily life, but what matters is how it is managed, how we set limits to prevent it from overwhelming us.
Q. You emphasize the beneficial power of lifestyle. Could you provide some dietary guidelines?
A. In my book, I provide guidelines for each age group, from puberty to old age. Nutrition varies for each life stage in women. We cannot eat the same way when we were 30, 40 years old as we do at 50 or 60 years old. Dietary patterns need to change because physical activity is not the same, and metabolism also undergoes changes. In general, these recommendations are based on the Mediterranean diet, which, according to scientific evidence, provides the most health benefits. Unfortunately, in our country, it has gradually been abandoned by young families due to various reasons, including the high cost of fresh foods, lack of time to cook, and the media influence of less beneficial dietary cultures.
Q. What about physical activity? Some cardiologists still say that just walking would be enough... What is your opinion? What are your recommendations?
A. Physical activity has been largely neglected in women's daily lives. Many women stop exercising after secondary education. Then, when they start a family, exercising is not a priority and tends to be put aside due to economic reasons or lack of time. This is a serious mistake. Walking is not enough; strength and toning exercises are necessary to stay fit and release endorphins. The choice of physical activity depends on each woman's preferences. There are many free online applications for physical exercise.
Q. What is worse for the heart: strenuous exercise or sedentary lifestyle?
A. As always, the best approach is not in the extremes. It is ideal to recommend regular exercise according to each woman's preferences.
Q. Is sleeping too little as bad as they say?
A. It depends on each individual's needs. This topic is highly debated, but generally, it is recommended to sleep between seven and eight hours a day to feel well. However, some people require less sleep time and are still healthy.
Q. Let's talk about supplementation. How does this 'bombardment' of supplements affect our heart?
A. The 'bombardment' of supplements for women does not protect the heart. Most do not have cardiovascular evidence, and some may even be harmful. Not all natural products are harmless to the cardiovascular system. Excessive intake of calcium, iron, or vitamins increases vascular risk. 'Natural hormonal supplements' are neither neutral nor safe. Collagen is not absorbed, and vitamin C is minimally absorbed. If following a balanced diet, magnesium supplementation is unnecessary. There is a significant placebo effect in all this. The female heart needs science, personalization, and healthy habits, not marketing.
Q. Lastly, what can you tell us about melatonin and its potential effect — in high doses — on the heart?
A. Melatonin is not cardiotoxic in usual doses (0.5-5 mg). In high doses, it can lower blood pressure and heart rate, with a risk of dizziness or syncope. It may interfere with blood pressure control and antihypertensive medications. The evidence on cardiovascular benefits is limited and inconclusive. There is no solid long-term safety data with mega-doses. The data presented at the American Heart Association Congress 2025 on the potential cardiotoxicity of melatonin has not yet been confirmed in a scientific article.