Women's Heart Health: Unique Symptoms and Risk Factors

Next, I'm happy to introduce Sandra Tsai, an internal medicine physician who specializes in cardiovascular disease prevention. Often when we think about heart disease, especially cardiac arrest, we think about men, but women are not immune to heart problems. Stress, diet, and exercise, and even sitting too long, all play a role in the health of our hearts. Dr. Tsai is here to talk about opportunities within our control in preventing heart disease and understanding our risks. Dr. Tsai, welcome so much. Thank you, Dr. Bloom-Cones, and I'm very happy to be here to tell women that the majority of heart disease is preventable. So women can reduce their risk of heart disease by 80% through a healthy lifestyle. The Nurses' Health Study, which is one of the largest prospective study of women in the United States, found that women at the start of the study who had no signs or symptoms of cardiovascular disease, and they were followed for an average of 14 years, the women who adhere to a low-risk lifestyle had 80% fewer coronary events. So this just tells you how powerful a healthy lifestyle can be. Unfortunately, heart disease is still the leading cause of death among women, as it is for men, but a lot of women are not aware of their risk for heart disease. And it's not just a concern for older women. Heart disease does affect women who are younger than 65 years old. We've learned a lot over the past couple of decades as more and more women have been enrolled in cardiovascular disease clinical trials, we've learned a lot of important things about heart disease in women. One of the things we know is that when women appear or when they have a heart attack, they can actually have less common symptoms. So even though chest pain is the most common symptom, some women may present instead with jaw pain, upper back pain, abdominal pain, indigestion, severe fatigue, or even passing out. The other thing we know is that women can have unique risk factors. These risk factors are called nontraditional risk factors, also known as emerging risk factors, but they're just as important as traditional risk factors. They're so important that they have definitely made it into our cardiovascular disease prevention guidelines. Clinicians are supposed to ask their women patients about these, because if they do have these risk factors, they're at increased risk for early heart disease. So some of these risk factors include pregnancy, adverse pregnancy outcomes, also known as APOs. And some of these APOs include gestational hypertension, the more severe form is called preeclampsia, gestational diabetes, delivering a baby less than 37 weeks gestation, or even pregnancy loss. We're not exactly sure what drives the early risk for heart disease, but it's probably a combination of the APO is an independent risk factor, as well as women who have APOs already have underlying cardiovascular risk factors. Another risk factor is breast cancer treatment, specifically breast radiation and chemotherapy with anthracycline medication. So breast cancer radiotherapy, especially if it's on the left side of the left breast, where the heart is, will damage the heart arteries and the heart. And then anthracycline chemotherapy can cause a woman to be at risk for heart failure even decades after the treatment is completed. Another risk factor is autoimmune disorders. So the reason this is really important is because autoimmune disorders disproportionately affect women. And we know that inflammation is a key factor for atherogenesis and plaque development in the arteries. And autoimmune disorders are very inflammatory. Another risk factor is premature menopause. So this is when menopause happens to a woman when she's less than 40 years old. So the average age of menopause is 51. And estrogen is protective. So if a woman loses her estrogen a decade early, she's at risk for early heart disease, especially if she does not have that estrogen replaced. And then menopause is a transition for every woman. And it is already associated with an increase in cardiovascular risk factors. So a lot of women during this time of a decline in estrogen, they'll find weight gain, especially in the midsection. And we know that weight gain in the midsection is associated with insulin resistance. And this brings abnormal cholesterol. This can also bring hypertension. And if a woman is already at risk for these factors prior to menopause, she often will see overt diabetes and overt hypertension happening in menopause. What can women do? What can you do to reduce your risk? I always recommend that women get a cardiovascular risk assessment, especially if they have cardiovascular risk factors and if they have a family history of early heart disease and a first degree relative. We do this at the Women's Heart Health Clinic and the Preventive Cardiology Clinic here at Stanford. During the visit, we take a comprehensive look at all your risk factors and we come up with a plan to mitigate your risks. We use a multidisciplinary team that might include our dieticians, our behavioral therapist, and maybe even a genetic counselor. And sometimes we'll also ask you to do some additional testing to further assess your risk. The other thing I would really love women to do is definitely try and take control of the risk factors that you do have control over. For example, don't smoke. If you have high blood pressure, control your blood pressure, control your cholesterol and your glucose. We also have control over how physically active we are. So be physically active and limit your sedentary activity or your sedentary time. So the physical activity guidelines are a minimum of 150 minutes of moderate intensity activity. So this is something that will get you breathing a little faster, your heart rate up, or 75 minutes of vigorous activity, such as cycling or jogging, or a combination of both per week. In addition, there's a minimum of two times per week that we should be doing resistance training for all our major muscle groups. And for those who want added benefit, definitely do more. The other thing that's really important, the evidence is very, very clear, sedentary time and prolonged sitting time are detrimental. So it can offset all of the gains you get from physical activity if the rest of the day you're sitting and you're sitting for a prolonged period of time. And for other women who want even additional metabolic benefits, we do know high intensity interval training has metabolic benefits over just the steady cardio. The other thing is eat a healthy diet. But the most important thing about a healthy diet is it needs to be sustainable. If it's too restrictive, you're just not gonna be able to stick with it. Your diet should be low in processed foods, processed grains and sugar. It should be high in whole grains and fiber from fruits and vegetables. And it definitely should contain good fats from nuts and fish and definitely limit red meat. And I know a lot of women worry about their weight, but the most important thing to really think about is your waist, because it's the weight that's inside the waist that is the most damaging. It really increases your risk for having diabetes and heart disease. Thank you. All right, great. Thank you so very much. We have a few questions from our audience. When it comes to exercise, you gave us a lot of details. What is the ideal combination of strength training and cardio for let's say somebody over 40? Yeah, so a lot of women over 40 will notice that their exercise tolerance has declined. And a lot of women will notice that they're just not as strong. So just like the physical activity guidelines have said, women really, especially over 40, really need to be paying attention to lean muscle mass and maintaining it, because every year we're losing a little bit more. And the more lean muscle mass you lose, the worse your metabolism gets. So that's one of the biggest things is two days per week, definitely at least a minimum resistance training. And then the 150 minutes of moderate or 75 minutes of vigorous. I mean, and limiting the sitting time. And I definitely think a lot of women who feel like they would like to do a little extra, the high intensity interval training. The sitting time seems almost unreasonable in this idea, with like Zoom everywhere, right? I mean, it's like almost impossible, but how does stage two hypertension without treatment affect the heart in a few years? Hypertension is such an important topic to talk about. It's so prevalent. And I think a lot of people don't realize how important it is to control it. So just so everybody knows, stage two hypertension is defined as a blood pressure of 140 over 90 or greater. And this is the new cutoff. In 2017, the hypertension guidelines changed. They moved, the hypertension used to be defined as 140 over 90, and they lowered to 130 over 80 because there was good clinical trial data showing us that those who have a lower hypertension have fewer cardiovascular events. So now stage one is 130 over 80, but normal blood pressure is less than 120 over 80, just so everyone knows. If we don't treat hypertension, especially if it's very elevated, it does damage the heart because just like any other muscle in our body that has to work really hard, it starts to get thick. So what can happen is untreated hypertension can lead to left ventricular hypertrophy and ultimately heart failure and atrial fibrillation. And the other thing it does is it's very damaging to the arteries and it promotes atherosclerosis and plaque development, which can then put people at risk for heart attacks and strokes. Okay, whoa, all right. Are heart palpitations a cause for concern? And people describe it as like my heart's jumping inside my chest. Yeah, so heart palpitations are so common. It's probably one of the most common reasons people see their practitioner. The good news is most palpitations are benign, especially if palpitations are, they've been happening for a lot of, many, many years, and they're not associated with any concerning features, like no chest pain, no fainting, no shortness of breath. Those palpitations are really, they're most likely gonna be benign, but all palpitations should be evaluated because there's many different causes for them. So we normally evaluate them with a 12-lead EKG or an electrocardiogram and also an ambulatory cardiac rhythm monitor. And as long as these things look normal, we can just reassure the person that the heart palpitations are not something to be concerned with. If everything is normal, sometimes the jumping or pounding that you feel in your chest is actually due to high blood pressure. Oh, wow, okay. What about a heart murmur? If I've been diagnosed with a heart murmur, is that a risk factor for heart attack? Heart murmurs are really worrisome, I think, to people, but they are not always from a negative cause. And heart murmurs do not predispose people to having heart attacks because the etiologies are different. Heart murmurs are the sound that we hear of blood flowing through a valve from one chamber to the next, and sometimes the blood flow is very innocent-sounding, and we call those innocent murmurs. Other times, the flow sounds much more turbulent because the valve is very small and stenotic, or it won't close well. So all heart murmurs should definitely be evaluated. And then heart attacks are due to atherosclerosis or plaque development in the heart arteries, so they're of different etiologies, but both should definitely be evaluated. Thank you so very much. Thank you.