Dr. Poulina Uddin discusses how differences in anatomy can affect EKG interpretations, gender predilection around SVT and VT, and the influence of female hormones on cardiovascular conditions in women.
Mhm. Hi welcome. Good morning everybody. Thank you for spending your saturday morning with us. We're actually very excited about the lineup we have today in our first arrhythmia and cardiomyopathy symposium for women, something we've been actually trying to get going for a while. So we're happy that we're finally able to bring it to you here. We have a great lineup of speakers today. I hope you have a chance to tune in to everybody. One of the things that we wanted to sort of highlight and share with everybody today is this concept of gender differences and some disparities between women and men in all aspects of health care, but specifically when it comes to cardiovascular disease over the last several years, I would say we've actually gotten quite good at recognizing that disease presentation physiology can vary from males, two females and different ethnic populations. And we're actually getting a lot better about recognizing cardiovascular disease specific to women. Certain conditions such as scat and micro vascular disease are becoming a lot more easy to recognize what we've realized that there is still a bit of a knowledge gap when it comes to arrhythmias, heart failure, cardiomyopathy. These are areas where we are really starting to recognize that there is a little bit less research when it comes to women compared to men. Were realizing that women tend still to be undertreated. Sometimes diseases are treated or recognized differently. And so we were hoping to highlight some of those differences today, realizing that we actually don't still have all the answers. But we'd like to present what we've learned so far today and share that with all of you today. So I am actually quite excited about the lineup we have today. We've got some wonderful colleagues and experts in their areas, hopefully sharing what will be some new information as well as maybe a bit of review as well. 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It's going to be sort of a general overview of a lot of the topics you'll be hearing about today. Um I just have to disclosures which fortunately I don't think are relevant to this talk about an electronic as you can see. So when I made this talk, when we came up with the idea for this conference, it was really to highlight and discuss those issues that we kept seeing ourselves come up in clinic or in the hospital when you're taking care of patients. These are some of the questions that have actually I thought I knew the answer to, you know, when I finished medical school when I went through my residency I thought I knew how to address these issues. And then as I went through my cardiology career I realized that sometimes more questions than answers come up. So these are some of the things that I've actually been wondering as of late when I take care of patients in the clinic and in the hospital that hopefully we'll highlight and talk about a little bit today. The first of which is is mitral valve prolapse actually a dangerous thing. Do these hormones, you know what we call girly hormones, estrogen progesterone. Are they? How are they involved? Do they cause palpitations? Do they cause arrhythmia? Is there really a difference between a fib in men versus women? You'll hear more about this later today. Are women is prone to sudden cardiac death as men. Why is it that sometimes they appear to be undertreated or be referred less for devices such as pacemakers A. I. C. D. S defibrillators? Uh Do women benefit as much from these therapies as men? And what's the effect of actually the physiology, the chest or the breast size in interpreting this data and interpreting an E. K. G. Yeah. So these are the things that I will address today and then you'll actually hear much more on various topics from my colleagues as you can see from the agenda. Yeah. Yeah. So the first thing I wanted to talk about is just the regular E. K. G. You know we probably see hundreds of EKGs over the course of a week over the course of a month depending on what we're doing. And you know what's funny is there I would say probably at least a couple of times a month I get a consult in my office for you know abnormal E. K. G. And then we take one look at it and we say oh no no this is fine this is lead placement or you know you don't need to worry about this. And so so there's something about us where we intuitively know that the way you place the stickers on the chest of course makes a big difference and not everyone unfortunately does that correctly. And that's because anatomy differs so much. So this is you know this is just an old article. I dug up about exactly where you're supposed to place the leads on the chest for an E. K. G. To maximize the voltage is to get the appropriate read that you're expecting to see for a normal E. K. G. And what's interesting I actually took a quick minute to google I said well what if you just, this is what happened if I just googled lead placement of e K G. Um does anybody see a woman's chest on here anywhere on the screen? It seems like only men can get EKGs when you google it. So then I thought I got really clever and I googled lead placement e K G lead placement and women and I still got a couple of men and some unrealistic looking women as far as where you should be placing these E K G leads. So I thought this was kind of interesting because you know, we see it a lot in our office. You know sometimes we see of course women with larger, smaller breast implants, mastectomies. And sometimes it can be a little confusing as to where exactly you should be placed in these EKG leads. So this was an interesting study. They looked at over 6000 women and it turns out that a lot of people want to avoid putting e K. G. Leads on top of the breast because it seems like that would muffle the signal or make it inappropriate as it turns out. It's actually better to just go ahead. You want to go into that fourth intercostal space as you go across laterally for those interior leads. If the breast is in the way it turns out, it's better to just place those stickers on top of the breast rather than move down or move up. Um And actually a two centimeter shift longitudinal going either too high or too low can change your our way voltage by up to 25%. So I thought that was interesting because it's very difficult sometimes when you just look at somebody to figure out where is their fourth intercostal space. But it turns out it's better it's the chest size that actually matters more than the breast size so we shouldn't panic and try to put our E. K. G. Leads somewhere strange when we see a woman who has a different anatomy than we're used to. So I did a quick experiment myself in clinic last week because I wanted to see if this was true. So you can see on the left of the screen, we just kept to the fourth intercostal space and put the E. K. G. Leads and one of them above and one below the breast. And you see there's not much of a change is what was suggested by this paper. And if you look at the next E. K. G where we actually shifted the leads lower than they were supposed to be maybe a little bit too low. And you can definitely see a little bit of change in those voltages across across the body. So this is not a very significant change in somebody like myself, but you can imagine in a much larger or differently shaped body you would get a very different kg. And the point of this is we have to be very careful when we just take an E. K. G. And call it abnormal or normal without taking these this morphology of the body into consideration. Another concept, you know, that comes up perhaps that we need to think about is what about breast implants and how do they affect an E. K. G. So it turns out that they do, you know what we don't know? As people can imagine, there's various types of breast implants, different materials that are used that's changed over time and over the years. So this was a kind of interesting study where they just had to electro physiologists interpret EKGs and women who have undergone breast implants. And it turns out up 42-46 of them were actually interpreted as abnormal um independently by these electro physiologists. And the most common changes that came up or inverted T. Waves particularly as you can see the Precor DEA leads, S. T. Depression and infra lateral leads for our wave progression. L. V. H. And early re polarization. So these are just interesting things that I would encourage people to keep in mind when you're actually assessing females with varying types of anatomy. Um you know before giving them a diagnosis of abnormal EKGs or on the flip side calling an E. K. G. Abnormal or saying it's normal when it really is truly abnormal, realizing it may be more difficult to pick up ischemia or something like this. And somebody who has undergone previous surgery, we don't exactly know how the mastectomy affects breast voltages as well. So getting the basics out of the way. I wanted to move on actually now to the bulk of the talk which is arrhythmia. So first of all, we already realized that Justin obtaining an E. K. G, there's a big difference sometimes between men and women. So if you go a little further and say okay well that's fine. We have to be careful. Do men and women actually present differently with their various types of arrhythmias? I found this to be a really really helpful review which is why I've included it here. It has a great summary of the you know, the main types of arrhythmias that we see and what we can expect in men versus women. So you're going to hear a lot more about this later on today, from DR Adams about atrial fibrillation, but I just wanted to bring up what we know already about atrial fibrillation. Hopefully you can see the pink lines on the graphs here are showing mortality on the lower the bar graphs, you're seeing developed countries on the left, and developing countries on the right, and the bottom line is we see that unfortunately women with a fib have higher mortality, they do worse DR Adams will probably explore for us today, some of the theories about why that maybe and get into more detail, but what we do know already is that women are more likely to be symptomatic, present with palpitations, maybe anxiety. We do know that they're associated with higher thrombosis risk, which I think we all know because we've changed from the chad score to the chads, vast score, which takes being female into account as a higher traumatic risk. We do see that elderly women are less likely to receive anti coagulation as well as undergo cardioversion. And we'll have to explore why this is. And although the prevalence is lower earlier on, the lifetime risk is higher as dr Adams will tell you women develop a fib a little bit later in life compared to their male counterparts. So, so we will have to do more research in this area. One of the thoughts I had is, you know, now that we have so many people with luke recorders and things like that, we might be able to to pick up more and learn more about this topic. So I'll leave that for dr Adams to explore for us. Uh more to come there as far as other arrhythmias go, super ventricular tachycardia. You know, we use this sometimes as a blanket term for fast arrhythmias coming from the top chamber of the heart. One of the things that we have seen over and over again is that avian RT specifically seems to be more predominant in females compared to males with a 2 to 1 predilection actually for females over males. Whereas something like W. P. W. Botha I mean but which is actually more rare seems to present more in males than females. Now I'll tell you we don't exactly know why this is we can certainly speculate but we're already seeing that there are differences in presentation. So we'll hopefully talk about this a little bit more this morning. Another really interesting thing is this concept of long Q. T. So in general you know even if you're not talking about familial or hereditary channel open these or genetic long QT syndrome, it turns out just if you take EKGs of women compared to men after puberty. So after about the teenage years or so, the Q. T. Actually shortens a little bit for males on a baseline E. K. G. For women it stays you know, whatever it was. So as we go through life, women tend to have slightly longer cuties compared to men. Just in general. Um the question is that related to testosterone, is it related to progesterone? We're not entirely sure but there is something that happens after puberty that causes the Q. T. To shorten a little bit for males. And interestingly even as far as the genetic familial long QT syndrome, those tend to be more common in women are in females compared to males. The other thing that we know is that the anti arrhythmic that are frequently used, for example for atrial fibrillation or other arrhythmias tend to be a little bit more pro arrhythmic in women compared to men. And um the QT prolongation we've seen in some studies with certain anti arrhythmic is actually inversely related to progesterone levels. So there's some thought that progesterone levels can actually be a little bit protective. So it turns out that the highest risk of this Q. T. Actually becomes slightly longer if you measure it during copulation and actually during menses which is really interesting. So for this reason you know some people say well it may be safer to favor a. Class one C. Anti arrhythmic and women compared to men. But there's really more more research that needs to be done in this area. Um And then speaking of long Q. T. You know the concern of course is this going to degenerate into VT. Women do seem to have more drug induced torso odds or VT compared to men. So overall, you know, even though the numbers may look higher for sudden death or sudden cardiac arrest and men compared to women when we're specifically talking about a long QT syndrome or a drug induced horse odds, that is more common in women. The question, one of the things we've seen observation ali too, is that women with ischemic heart disease seem to be less susceptible to VT and may be more difficult to induce ventricular arrhythmias during FP studies in women. So on the one hand, we see that they're more likely to have VT related to drugs and related to Q. T. But sometimes more difficult to induce VT for ischemic or structural heart disease. And I'm not sure if DR Gibson, it may mentioned this a little bit later today, but there are some theories about why this may be related potentially to hormones in the way that the cardiac melanocytes behave. We do know that are vot ventricular tachycardia, that that site near the right ventricular outflow tract is more common in women. So over and over again, we're seeing that there are different presentations of specific arrhythmias that seem to have a predilection for one gender over another, interestingly in cardiac arrest and women certainly do get cardiac arrest just like men. Um they seem to be more pe a uh pulseless electrical activity rather than VT if you compare two men. So we have to think about why that may be as well. So again, in that same paper that I showed that had the great review. This is a really nice summary that I really liked at the end, that sort of highlights these differences that we just talked about between, You know, for example, a V. And R. T. Being more common in women. The ventricular arrhythmia site for women compared to men. So again, if anyone is interested in this topic I encourage you to take a look at this. This review was really helpful. So what we're kind of I think beating around the bush about a little bit is that we definitely know that there is a difference between females and males with regard to these arrhythmias. And the question really is why? So you can't really talk about women without talking about hormones unfortunately. And so so we've had to learn a little bit more about that. But one of the things we are seeing observation aly is that there is a little more arrhythmia Jenness city, specifically S. V. T. S. Super ventricular tachycardia as during the low till phase of the menstrual cycle. Now I actually had to go back and look up what was the little phase of the menstrual cycle because a lot of people haven't perhaps studied this regularly or remembered it. So that's the period of time right after ovulation and right before the menstrual period which is otherwise known as PMS. That a lot of people will make commercials for and try to sell you medications for and things like that. But what's really interesting is there maybe a little something to this PMS area because it does turn out that the cute prolongs even more during these menstrual and ovulation cycles. And so that can certainly be and it is also associated with increased palpitations during this time. And then we see this again during pregnancy and menopause. So there's no denying that there's fluctuation of hormonal levels is playing some type of role. So I know Dr Adams told me to take this this slide out, but I kept it in because I just had to remind us that you know, you can see nobody likes to talk about the menstrual cycle, but you can see that there is a wide fluctuation of the estrogen and progesterone levels throughout the course is even of a month. Um And so a lot of patients will say that they they they're palpitations or the arrhythmia will follow a cyclical pattern. And if they have a normal menstrual cycle, they can actually pinpoint the days that they know they're going to feel worse. Now. You can imagine how this could potentially be affected by exogenous hormones like birth control. You can imagine the influence of other factors that we know, you know, caffeine, sleep stress, additional medications that may be affecting this. And so sometimes it's not so obvious to find this cyclical pattern because very few people actually just come in with a perfectly normal menstrual cycle, that's exactly on point every month. So in other words, I think when they used to tell women that they are exaggerating, sometimes you feel like you might die when you're having PMS or having your period. You unfortunately are at slightly increased risk of arrhythmia during this time. So, so not to scare everybody, but it is something to take seriously if you're if you're finding patients who are having specific complaints that are very cyclical, it's worth at least a thought or consideration into their hormones. So, um, we're going to have a couple of cases about this later. But what I do want to say is that there is some interesting data that shows that overall progesterone maybe a little bit protective in terms of symptoms that can shorten the re polarization time and extinguish arrhythmias a bit as well. So I just wanted to bring up one quick case example. This is actually a nurse that we work with who was a really really good example of having super ventricular tachycardia and significant palpitations during her menstrual cycle. And you know she was happy to share this information but again you know she never had to have an ablation but she clearly had S. V. T. And even on her monitor it picked it up. Always her symptoms were two words Palpitations, brief episodes of SPT 2-3 days before her period started and after it ended. So um and that was actually able to be picked up on a cardiac monitor. Um So speaking of things that are more common in women and palpitations I wanted to spend a little bit of time talking about mitral valve prolapse. Now what's interesting about mitral valve prolapse and it may seem like maybe this doesn't have a role here in this talk, but I'll try to convince you that it does. So, you know, I've really gone up and down with mitral valve prolapse when um you know in medical school, you know, most of the time they said mitral valve prolapse is not something you need to worry about. You know, follow it clinically if they're not having, you know, significant regurgitation, it's not a big deal. And to be honest for years I thought that was the case. I really thought it had to do with whether or not the valve is leaking and whether or not somebody needs a valve replacement. Um but one of the things that you see a lot is, you know, you'll see these women who were 60 or 70 years old in your office, who who will tell you, oh I've been diagnosed with mitral valve prolapse in my 30s. Um and I'll say why and they'll say, oh I was having palpitations and anxiety and it really didn't make sense to me why this diagnosis was wrapped up. You know, they sort of sell it as this, you know, anxious woman having palpitations. It must be the mitral valve prolapse. And you actually see it depicted that way really, without a good explanation. So this always bothered me because while it is true, the majority of the time mitral valve prolapse ends up having a benign course every so often. There are some and it happens in men of course too, but it seems to have a predilection for women where they're quite symptomatic. So the question is, is this just something you tell a woman? Hey, you have mitral valve prolapse, that's why have palpitations go home or is do you really need to follow these women closely? And so what I what I am going to propose is that there is really a subset of these patients that you really need to take seriously. Um So in general the occurrence of sudden cardiac death with mitral valve prolapse is quite low. You know, point to 2.4, you know, it is really quite low. But that seems strange because you know historically we like to think well if the valves not leaky, what's the problem? Why do you need to follow these women? So as it turns out, there are some high risk features associated with mitral valve prolapse that actually kind of indicate increased risk, particularly for arrhythmia PVcs and unfortunately ventricular tachycardia and sudden death. So again, although these numbers are small, you know, autopsies done of sudden death and young people, as you can see in this kind of bigger chart on the right, These are all people under the age of 50 12 3 of them actually was noted to have mitral valve prolapse, which is interesting, which is higher than expected. The question is, was that clinically significant? Um so what we're starting to learn, especially now that are echoes are getting so good and we're using a lot of cardiac M. R. I. It turns out there are specific features associated with the valve, including the thickness, the mobility and specifically something called mad um mitral annular disjunction that can indicate higher risk. So so as some in order to diagnose somebody with clinical mitral valve prolapse, there's these parameters, you know, this thickened mixologist valve, um but specifically this mad mitral annular disjunction, which I'll show you a picture of here, essentially what happens is the mitral leaflet is anterior or a truly displaced. So it's a little higher up in the atrium, farther away from the ventricle. And there's a little bit of a gap where you would technically have your normal mitral valve. And because of this there's more rocking and disjunction and motion of the valve that can contribute to prolapse. The leaflet itself gets a little bit more tethered by the court and the papillary muscles. And so it does this systolic curling. It actually moves downward rather than together to meet with the other mitral valve causing this prolapse in motion. So what's interesting, you can actually see this and maybe the picture is better than me describing it. Hopefully you can see here this is this mitral annular distinction where this leaflet really ought to be down here and there's a bit of a gap here. You can see it on the echo as well, that's considered a high risk feature, interestingly, you can also see um on MRI. And history Cathal in history pathology, all of the blue over here. This is actually fibrosis. So papillary muscle fibrosis, this micro annular disjunction. These are associated with pvcs arrhythmia high risk feature. These are actually the patients that you want to monitor closely for arrhythmia and sudden death. So it's not so much the mitral valve prolapse, but actually the anatomy of the valve itself. And again, you can appreciate this metro annular disjunction here on cardiac MRI. So, what was interesting about this? So I thought, okay, well, so there's some people with micro valve prolapse that I need to watch closely. Here's a study just on the mitral annular disjunction concept itself, Where they looked at, you know, about 12 of the patients who had this mitral annular disjunction have severe arrhythmic events, interestingly. Now, this was studied by MRI and eco interestingly, if you look at this closely, it turns out that even without the mitral valve prolapse, just the mitral annular disjunction itself, it turns out that that is actually the more concerning arrhythmia genic entity. So those people, it's not the mitral valve prolapse of the mitral valve prolapse goes hand in hand and a lot of times with this mitral annular disjunction. But you'll see several cases of mitral annular disjunction without mitral valve prolapse. And those ones actually ended up being the more arrhythmia genic party. One of the thoughts is that people who also have mitral valve prolapse are followed more closely by serial echoes and followed by their physicians if they have, you know, to monitor for symptoms and that may be why they do better or have less arrhythmia, but we don't actually know. And this is definitely something that's newer being explored. But what's important here is that the most common presenting symptom for all of these people were palpitations. So the reason they got worked up in the first place with an echo or MRI or whatever it was was palpitations. And so most of the time we say, hey palpitations, you have some peaks. You have some pvcs, you're fine. But we have to, I guess, think really carefully about what subset of people that we want to look for this entity. And there is Um, we'll have a case discussion about this later today about a kind of interesting case that came across my office recently. And I'll just mention it here. You know, she's a 39 year old asymptomatic woman. She was referred for a symptomatic bradycardia palpitations. And it turns out she does have this metro annular disjunction completely asymptomatic, but her mother had sudden cardiac arrest in a similar condition. So what we'll talk about that a little bit later on today and I'm happy to take some thoughts about what we should do with her. Um and then the next couple of phases I'll just move on to since we're talking about hormones is pregnancy. So I'll be honest with you, I used to be terrified of taking care of pregnant women just because I thought you couldn't use any medications and do anything for them. But it turns out there's actually quite a bit you can do. And one of the things we've been seeing a lot now, especially since we have some wonderful obese and paleontologists we've been working with here, we get a lot of referrals for women with palpitations and tachycardia or you know worsening arrhythmias during pregnancy. So just as a quick review in general women tend to have faster heart rates than men during pregnancy. The heart rate becomes even higher, vascular resistance goes down. Cardiac output goes up. You can see this, everybody knows this blood volume really increases and women become pro from biotic. So it's a total disaster and a setup for arrhythmias. Heart attack stroke. Unfortunately anyways just by being pregnant alone interestingly because of these changes because of the increased heart rate. The stretch on the atrium, the increased blood volume. You do see a little bit of changes on your baseline. E. K. G. And echo. As you can see here you can get a little bit of T. Wave inversion. Um A little bit of S. T. Depression which is actually which are normal physiologic changes during pregnancy. But again as we mentioned at the beginning reasons to take symptoms a little bit more seriously during these times because it's a little hard to discern. Are these normal physiologic changes with pregnancy or is there an actual worrisome cardiac symptoms? And one of the things that's really difficult is a lot of cardiac symptoms are very similar to pregnancy symptoms like heart failure symptoms sound like pregnancy symptoms. This neo exertion, orthodontia like swelling, you know, sense of impending doom. All of those are similar in pregnancy and heart failure. So certainly we need take those symptoms seriously if we come across them. Um The other important thing potentially why pregnancy can be a more arrhythmia genic time. Um You get stretching of these cardiac maya sites with this increased blood volume. Again this shortens early after deep polarization. That shortens refractory nous and slows conduction. So it can actually be a set up to allow an SPT and a v nodal reentry tachycardia or an A. V. RT. Because of this setup. And then we're learning that both depending on the ratio of the estrogen and progesterone or the estradiol. That's what's really pro arrhythmic. It's not it's not that somebody has estrogen and so they're going to have arrhythmia. It's the fluctuating levels relative to one another. That tend to be more pro arrhythmic and the other you know. Kind of interesting thing that I actually didn't know before I was preparing for this is the estrogen actually increases the hydrogen ergic receptors in the myocardial. So that increases even more during pregnancy. So you're even more set up and prone to potentially some of these cattle column in induced arrhythmias. So I just wanted to show a quick case. This is actually a patient of mine, 32 year old had an emergency room visit at nine weeks. Gestation for rapid heartbeat, heart rate between 1 70 to 1 99. Unfortunately her pregnancy was complicated by hyperemesis, gravity room. So she was having a lot of nausea vomiting. You know dehydrated to begin with has a history of S. V. T. As well as factor five. So somebody you'd want to really keep a close eye on. Um And so here was her presenting E. K. G. You can see on the left, she presented with S. V. T. Uh fortunately she converted with a dentist seen um and continue to do well afterwards. And so what I just want and that's a very very common thing that we see. I mean SGTs again much more common during pregnancy. Um Already for the reasons we discussed it's probably the most common sustained with me. You'll see in pregnancy. Natural things that we would do vagal maneuvers, turns out you can use the dentist scene, turns out you can actually cardioverter if they're human dynamically unstable and there are certain beta blockers and calcium channel blockers you can use. So we don't have to be fearful that there's nothing we can do for, you know, pregnant women with arrhythmia. This is a really helpful article for anyone who's interested in or who treats pregnant women and has a great summary of the medications that you can use. Really, the only one you want to stay away from right off the bat is amiodarone, which is thought to be um cause foetal toxicity. And there's another European guidelines from 2018. Again, it has a really helpful summary of medications and if anyone is interested in that, feel free to reach out to me, I can provide that reference. So, um so you can use beta blockers and I actually have used them fairly regularly. Sorry, in pregnancy, the only one you want to really avoid is a tunnel. All the other ones are fairly safe to use for a short term in the low dose. Um Again, I just want to give you another quick example of myself. DR Adams help me with this. So when I was pregnant last year I started to have a lot of palpitations and PVC, so she put a monitor on me and I turned out I had a 6% PVC board and I never had these before in my life. This was early in pregnancy um as well as some kind of bizarre arrhythmia which you can see here. Um and of course I was certain I was going to develop a cardiomyopathy and have to go see dr Heywood and all of that. But luckily it went away and this was again just in the first trimester of pregnancy due to those hormonal fluctuations. Um You can see my monitor here, I think you can clearly see those pVcs. Um They were quite frequent um and I was symptomatic with it, but of course I could kind of tell what it was. Um and um for those of you who are wondering, I was actually able to pick it up on an apple watch as well. But we wore this. But what I wanted to show you here is in the early weeks of pregnancy, you see this tremendous surge of estrogen which is the red line here followed by progesterone. And so your estrogen levels are quite high. The progesterone doesn't quite catch up. And that may be one of the reasons why that early time can be more pro arrhythmic as well. So and then just moving on, fortunately ventricular tachycardia is quite rare in pregnancy. In in in just a regular uh no structural heart disease individual. If you take somebody who has underlying congenital heart disease for example, hypertrophic cardiomyopathy, arrhythmia, genic RV dysplasia, R. V. D. The incidents, as you can see actually jumps up quite a bit. And so this is these are people who hopefully and presumably you would know before pregnancy that they have these cardiomyopathy. These so that you can monitor them closely again, as I mentioned, it is okay to shock if you know if they're human dynamically unstable. Another option is to use lidocaine is recommended as well as cocaine amount and quantity and are actually considered to be reasonably safe in pregnancy. Presumably these are going to be medications they're going to be receiving intermittently or once and twice rather than daily for idiopathic VT. So no structural heart disease. Someone just presenting with ventricular type of cardio during pregnancy. These tend to be more cata quality and sensitive and that maybe because of that, what we discussed about the estrogen increasing the receptors in the myocardial and so these tend to respond well. The beta blockers even okay to use soda lol, wrap the milk. One thing I wanted to point out since we were talking about long Q. T. Earlier today in pregnancy. Long QT. People tend to actually do well during the pregnancy. It turns out the most high risk time is actually postpartum. So the risk of actually having a ventricular arrhythmia was in the 40 weeks postpartum. It's actually 23% compared to 3.8% during the pregnancy. So I did actually have a patient with long Q. T. And we had to really hammer in the point that you stay on your beta blockers, particularly in the postpartum period. Beta blockers do for anyone who's interested, beta blockers do transmit a little into breast milk but is not considered to be very significant. So so management with beta blockers and long QT is really important, particularly in the postpartum period. Um you're going to hear a little bit more about um cardiomyopathy is from Dr kIM and Dr Heywood later on today. So I will leave it at that last couple slides that I wanted to talk about since again, if we have to talk about hormones and we have to talk about pregnancy, you've got at least mention menopause. Um I think probably a lot of us will notice in our own clinics in our own practice that we got a lot of patients in the office with palpitations around the arrhythmias around the time of menopause. And so um again menopause kind of like pregnancy is a hormonal roller coaster, which is why I really like this slide because it kind of shows you that they don't really know what's going on with the estrogen in that perimenopause period, It's just sort of wacky. Um And so you can imagine if it's wacky like that um if you do have one of these individuals who is very sensitive to their hormones, it's a total disaster. They feel like they have palpitations, they're getting sgts. Some people actually even get a little bit of ventricular tachycardia, we've got some examples of this later on. Um So you're going to hear a little bit more about hormones also from DR Adams later today. What I wanted to just bring up is, you know, I really looked and we don't have a lot of good data about hormone replacement therapy and hormones when it comes to the arena of arrhythmias. You can find quite a bit regarding hormones and cardiovascular disease and stroke and thrombosis, which we've learned about through time from this women's health initiative. These were studies where they looked at hormone replacement therapy and what it does to your cardiovascular risk. And so I just wanted to mention that here. But we don't actually have great data on specifically how to treat arrhythmias or how to manage arrhythmias in the context of hormone replacement therapy. But we do see that we have we have seen that unopposed estrogen tends to make symptoms worse. So adding a little progesterone and later um seems to help symptomatically. But we don't have good data for that just to show you a randomized controlled trial. So bottom line with hormone replacement therapy. Again, just to reiterate, it's not recommended for a heart attack or stroke prevention in women. People used to do that in the past and that's obviously fallen out of favor. Um, there is a dose dependent relationship with some increased robotic risk. I just listed for, you hear some of the trials that historically have been helpful in discussing these issues, as you can see on the bottom of the screen here again, has been a bit of a roller coaster as far as what people are doing with hormone replacement therapy. Initially it was thought to be cardio protective, but then we found that there was an increased risk of stroke, particularly after menopause. So the way it is right now is what we tell our patients, or at least what I tell my patients is, if they ask about hormone replacement therapy, I say, look, it's not meant to be used to prevent heart attack or stroke in some women is considered to be safe for up to five years at the lowest effective dose for symptoms, not for anything other than symptoms. If you're having terrible hot flashes, terrible palpitations, that would be the reason to consider it. But it's contra indicated in somebody with a prior history of stroke, blood clots, breast or endometrial cancer. So it really requires a serious discussion of why you would be doing hormone replacement therapy in the first place. Again, we don't have a lot of information on transgender either. I dug up what I could find, I would imagine this will, you know, maybe we'll have more data hopefully about this in the future. But um, what's important here is that exogenous hormones are different than the hormones that you have already in your own body. And there's there seemed to be in sort of you know giving exogenous hormones from male to female transgender slightly increased risk of DVT but again very small number of small studies. So I would say that this is inconclusive as of yet. I'm presuming there will be more data on this to come, but it's going to probably take a little bit of time. So fortunately I think I made it under my time limit. Um I didn't get to talk about why some of these topics are brought up. You know why women are referred when it comes to you know we have all these arrhythmias, certainly we have medications we can use and then we come down to a population and devices which will be the second half of today. What we know so far as I mentioned before is women do tend to be referred less than men for ablation. You know C. R. T. I. C. D. By ventricular pacing. We'll have to think about why and unfortunately there is data that shows that women tend to be more prone to complications with certain devices hematoma, pneumothorax and again some of that is related to body structure. Will have to think about why those issues are as well. You're going to be hearing more from dr Rogers and Dr Gibson about this. So I think in summary I just like to say as far as the things that we discussed today when it comes to just your regular EKGs chest size is more important than breast size when it comes to lead placement. So don't let those breasts scare you try to get in there and get a proper E. K. G. Even if you have to move things around a little bit. We've definitely seen some examples and we'll see more later today how hormonal fluctuations during the menstrual cycle pregnancy. And menopause definitely influence arrhythmias. Long QT. And avian rtr. Much much more common in women. There is a subset of mitral valve prolapse. Specifically patients with mitral annular disjunction which are associated with increased risk of sudden death and ventricular arrhythmia. So these patients need to be monitored very closely. Um Women do have increased risk of formal symbolic complications from a fit but tend to be under treated. And we'll explore that a little bit more and we'll hear a little bit more about how there is significant gender disparity and utilization of A. I. C. D. C. R. T. D. Um Some ablation techniques, things like that. Um We have a little bit of time before the next speaker I think for questions if there's any any urgent ones right now, I'm going to take a peek in the show. Yes. Doctor Gibson remembers when I had my symptomatic PVC pauline. What's your feeling about why women are referred less for procedures? You know what we were talking about this and Dr Addison Kim and I were talking about it too. And I guess it depends, you know, one of the thoughts I had is that because women's symptoms are so difficult to pinpoint sometimes, um it may just be that it takes longer to diagnose because a lot of the symptoms we may say, oh yeah, that's menopause, that's not really arrhythmia or you know, so I do think there's probably a delay in diagnosis may be part of it, where we try to think of every other excuse we can of why this woman is symptomatic rather than actually just blaming the eighth in, you know, are blaming. You know, that maybe one thing you noticed, I haven't noticed as much I know with coronary disease women, I think it's pretty well documented that women have often times have an atypical presentation. But everything everything I've seen with a arrhythmias makes it sound like women are more symptomatic, they're more impaired. It seems like the diagnosis should be more obvious, Right? That is a great segue to my talk. Yeah. Good. Okay. The answers.