Martha Gulati, MD, MS, FACC, is the division chief of cardiology for the UA College of Medicine – Pheonix, and physician executive director for the Banner – University Medicine Heart Institute. She is also the best-selling author of Saving Women's Hearts and editor-in-chief of ACC's CardioSmart.

For her extensive work as an advocate for women's heart health, Gulati is the recipient of ACC's 2019 Bernadine Healy Women's Cardiovascular Disease Award. In the second part of this two-part interview, Gulati reflects on her experiences and shares advice for Fellows in Training. Click here for part one.

Representation is extremely important – especially when we think about women's heart health – as female patients are not always represented and their concerns may be put to the side due to their "atypical" presentation. As someone who has chaired women's cardiovascular health centers, how has your work changed that focus?

It was actually women that drove us to look at the differences in care regarding women, starting with Bernadine P. Healy, MD, FACC; Nanette K. Wenger, MD, MACC; and C. Noel Bairey Merz, MD, FACC. Men have also contributed to recognizing sex differences, including Carl J. Pepine, MD, MACC, but the focus in the last ten years or so has especially been driven by female cardiologists.

In the past, we were making great strides in reducing deaths and improving outcomes from cardiovascular disease in men, but were not seeing that in women. People were asking why we were not making the same strides and it was related to our lack of female-specific data as well as a bias that cardiovascular disease only affected men.

We have come so far!

Now, women's heart centers have opened across the country, with the focus on providing sex-specific care in this disease state where we had often ignored women. While we are still behind in understanding women's hearts, we are making progress. Compared to men, we have more inclusion of women in research, focus on sex differences in cardiovascular disease and clinical respect for the differences in female outcomes.

I do not know if women present entirely different. According to data from the VIRGO study, we saw that 90 percent of younger women had chest pain, which was the same as men. The difference was simply that these younger women often had more "other" symptoms with the chest pain or chest pressure.

I am cautious to say women present differently because I wonder if we just hear them differently, or if we do not always ask women the right questions. I also wonder if because they give additional symptoms, we become focused on the other symptoms and not on the chest discomfort they are experiencing.

As a public health message, we need to inform women that heart disease is their number one killer, the symptoms of chest pain or pressure can mean heart disease and to call 9-1-1 if they think they are having a heart attack.

We should also inform them about the less common symptoms that can occur, reminding them there are various symptoms for a heart attack in women.

When I was a cardiology fellow at the University Chicago, there were no women's heart centers. However, I knew that I wanted to focus on women's cardiovascular health from both a clinical and research standpoint. There were many reasons for this focus, one being that I could see women being treated differently but also that the pathophysiology was different in women.

We all saw this difference when we would Cath a woman with an abnormal stress test or after an infarct, and then it was more common to not see an obstructive lesion. No one knew what to tell the woman when you had that scenario and instead would call the stress test false positive, or reassure them after a myocardial infarct that their heart was fine.

There was no knowledge about how to treat them and if they were really "fine."

I left knowing this is what I wanted to do – I wanted to work with women and find out what was going on. So, that became my goal: how can I start a women's center and focus on women? I created this at Northwestern University, Ohio State University and the University of Arizona.

When people call to ask me for help setting up a women's cardiovascular health center, I tell them to come up with a plan for what they can achieve with no money, with money and with a lot of money. For every institution, you may have to prove to them the value or they may not have the resources.

There are many ways to set this up. When I was at Northwestern, it was more of a virtual clinic. We were in the general cardiology clinic, but our goals were to have a presence and let women know that we had cardiologists who were focused exclusively on them. We did a lot of outreach in the community and worked with our colleagues who cared for women to assist them in care for the whole woman.

The dream women's center, like Merz has at Cedar Sinai (The Barbra Streisand Women's Heart Center), is one that is very well-funded, has great resources and a comprehensive team. If given the chance, it is worth going to see center and take ideas to implement at your institution with your funding level.

Sometimes, it is worth going to a center that is very well run and taking your hospital executives, leadership and donors so that they can see what the potential is, along with what they can do realistically with the budget and people that they have.

Know what your resources are and then start creating things. Begin simple with creating a website with your hospital, university or clinic to create a presence. The next step is to decide how you integrate yourself, how you do things differently, ways to advertise and how to get involved. Every place has different stepping stones.

You must get involved in your community and invite yourself to anything related to women. Recently, a friend was having an event and we placed our cards in their swag bags. I have hung hearts from trees around my hospital to create awareness, as well as created and placed posters across the halls.

One of our clinics is focused on adverse pregnancy outcomes and prevention of heart disease, so we created a poster to place outside of our OB-GYN clinics and hallways with information from CardioSmart and a referral to our clinic. Work with your colleagues who care for women: internists, OB-GYN, rheumatologists, dermatologists, plastic surgeons and oncologists. They will gladly collaborate and work with you. They just need to know you exist!

Some women's heart centers can become part of the Women Heart National Hospital Alliance, an organization that has a group of hospitals and allows women with heart disease find your hospital, clinic or center.

Talk to people who have done this successfully – we are not competitors. It is about taking care of women. If they help you go back to your hospital and get the resources you need, those are great accomplishments for everyone and a win for women in our world. A couple of years ago, we wrote a paper about how to start a women's heart center. The resources are out there and you can also pick up the phone and call us.