Dr. Poulina Uddin addresses the signs and risk factors of cardiovascular disease that are unique to women and offers preventive treatment options.
I want to next kind of move on to introduce dr routine. Have the pleasure to introduce. She she's really an expert, general and invasive cardiologist with a particular interest on women's health. She's you know, really got a specific focus on preventive cardiology and went through the scripts uh cardiology fellowship training program as well as the Integrative Fellowship training program. So she's well trained and alternative and integrative therapies. She's got a particular interest in reducing inflammatory inflammatory conditions and cardiac patients following coronary artery disease events and you know, kind of risk ratifying patients understanding genetic risk factors and so forth with patients developing disease. She's kind of the whole package. She's a very sought after cardiologist and our scripts clinic group and it is our honor to have her. And we look forward to hearing about the broad topic of cardiovascular prevention in women. Thank you Doctor routine, thank you for that introduction. I we'll see if I can live up to all of that. So so fortunately I think this is a really great conference because the flow so far has actually set me up perfectly for this. Um, hopefully you can all hear me okay. I heard I had a little mike trouble. So please let me know if there's any issues. So I know we're pressed for time, so I'm just going to dive right in. So, um, uh, just a few, I would say non relevant disclosures. Sometimes I do a little speaking or advisory boards for some of the pacemaker companies, which doesn't end up being relevant today fortunately. So, um, you know, so cardiovascular disease, you know, it's obviously such a broad topic. And so I decided to really just hone it down into the slides are going to be a lot, but really heart attack in women, what's similar in women compared to men for cardiovascular disease and what's unique in women. And then stroke in women as well. And, you know, of course, as we already know, there's a lot of traditional risk factors that are of course the same across men and women, but specifically in this talk, um, I'll focus on what's different about women and what are those unique, either risk factors or scenarios where we need to pay close attention to prevent cardiovascular disease and by prevent, I mean both primary as well as secondary prevention. Because as we all know, a lot of times, um you know, like as Dr Gonzalez was saying, we try to prevent people from going to the Cath lab. But unfortunately, a lot of times we meet our patients after the fact after something has already happened. And so so this is kind of to help us go back and figure out, well, what were the risk factors that got this woman here in the first place and then what do we do going forward to maybe prevent a second event or something like that? So it always comes up? So we'll we'll get a little bit about hormones at the end too. But if there's anything I don't cover, please feel free to let me know and we can we can chat afterwards. So, you know what's really tricky is if you were I just googled this, I just said like heart attack signs of women. And this is what came up. This one of the first things on google and and that's the problem. So I think we all know that women have very unusual or atypical presentation of cardiovascular disease. If you look at some of these symptoms like sudden dizziness, cold sweat, unusual tiredness. I mean unusually tired frequently. So I don't go to the er So there's also, first of all, it's actually very difficult in the first place to diagnose some of these potentially worrisome symptoms in women. And you know, and so that's it's a really important question. I think we know that women have delayed care and under diagnosis and under treatment for all types of cardiovascular disease, but I would say that's not necessarily somebody's fault. You know, it's not that it's a misogynistic society that's not trying to treat women, but I think it actually is more difficult to figure out. Is this sudden dizziness, is this cold sweat, Is this job pain really something we need to take seriously. Um You don't want everybody just going to the er every time they have a poor night's sleep and feel tired. On the other hand, you don't want to miss coordinated disease or stroke. So I would I would say, you know, is there a reason that the women's symptoms are so different than men's and how different is it really? Maybe the symptoms are all our are all over the place, because the path of physiology is actually a little bit different in women compared to men. And um, it's really difficult actually to talk about women and cardiovascular disease without addressing the role of hormones which we'll get into. So, you know, regular cardiovascular disease, you want to split it up into a couple categories. One is what we're used to macro vascular disease that, through sclerosis and plaque, micro vascular disease, invasive spasm, which happens in both men and women, um, tends to be more common in women, as well as stress induced cardiomyopathy, which we'll talk about, and certain types of heart failure as well. So, so we do know that cardiovascular disease is the number one killer and women. But as I think Dr super mentioned to, there's a lot of studies, women aren't included unfortunately in studies for a lot of reasons. But even now, most of the randomized control trials where we get our data for beta blockers, aspirin Staten, You'll see there's only 20-30% women. Um and so we are treating on the one hand, we're saying you want to treat the women exactly the same as we treat men. On the other hand, we don't have as much robust data to say well or is what we're doing actually safe for women. For example, we know that um you can't use race inhibitors and statins in pregnant women. Um and but pregnant women have cardiovascular disease. So then you're a little bit stuck and you don't have the data to help you. So so this these are some of the conundrums we run into when trying to prevent disease in women. So you know why I think we can all speculate on why this happens. But I think in the past it's interesting when they surveyed women or when they surveyed the population in the 90s, only 30% of people knew that cardiovascular disease is the number one killer in women. And then more recently they did the same survey in 2009, which I guess isn't really recent anymore. But um, there was a significant increase in knowledge and awareness that cardiovascular disease is something that women need to pay attention to. Um Traditionally marketing has been great for getting women to get screened for breast cancer and things like that, which is of course very important. Um but it's actually not what's killing most women around here. So I'll go quickly through macro vascular disease because this is what we're all very familiar with. This deposition of plaque build up. But what I'll say about this in women is that unfortunately in the first year following, and my women tend to be more likely to increase mortality morbidity compared to men, they're actually more likely to experience a non S. T. Elevation of my spontaneous coronary dissection, which we'll talk about in viso spasm again, why the symptoms can be a little atypical and difficult to recognize when the person presents to the emergency room. Unfortunately, as with many of our disease processes, black and asian women seem to have higher risk and mortality. I think what's important is the traditional risk factors that we that we know smoking hypertension, diabetes, metabolic syndrome actually tend to Individual a worse outcome in women compared to men. So if you take a 45 year old woman who has diabetes and a 45 year old man who has diabetes, that risk factor of diabetes is actually an increased risk in that woman compared to that man for a bad outcome down the road. Um, well, we'll see this a little bit later. The reason oftentimes it doesn't get recognized is because we know that estrogen endogenous estrogen Has a protective effect. So we usually don't see a lot of 45 year old women having plaque rupture and stem ease. We see it Maybe 10 years later after they've gone through menopause, but the risk is still is still there in a significant. So what I encourage now and what I tell these are what we call these emerging risk factors. And and as you'll notice this comes up a lot probably today, during during these talks is the concept of inflammation. So, we know these things over here on the left, diabetes, smoking, all of that is bad. But what we're learning more recently, specifically with women, you actually have to take a full believe it or not, O B G Y N. In pregnancy history turns out inflammatory conditions like hypertension, gestational diabetes, autoimmune disorders like lupus and even like preeclampsia during pregnancy, which people will get over after their pregnancy actually confers a significant increased risk down the road for development of atherosclerosis and stroke and all of that. So the other interesting thing, which I was learning as I was looking into this is that even if you say, okay, you know what I'm going to, I'm going to be a really good doctor. I'm going to take these women and I'm going to treat them just like I would treat a man and make sure I put them on aspirin and statin and do all the right stuff. Um They actually do have a higher bleed risk from your traditional anti platelets. Um and so so it's sometimes hard to medically optimize the women. The way that you would want to do with men statins, as I mentioned are we know they're beneficial, but we actually just don't have as robust data for women compared to men. Um and in some trials there was it's not fully well understood, but there may even be a consideration that maybe in some women, the statin could increase their insulin resistance. So, so we just need more data on that. That that's what I wanted to mention there. Um The other really interesting thing, and I've seen this a few times is sometimes the actual plaque and lipid deposition into the vascular space can have a different pattern in women compared to men. So, as you can see here, um hopefully you can see in this third cross section of this artery here. This is coronary disease, there's quite a bit of plaque build up. But if you are just quickly doing an angiogram, you could miss this. If this lines the entire vessel, you'll just say, oh, this woman has small arteries until it gets to this point where really this woman here is somebody who needs aggressive medical management may be experiencing angina because technically they have limited blood flow here and you can actually see that a lot of times they've done studies where you can compare men to women. If you look at the top, if you saw this in a coronary angiogram, it would be very obvious that there's a stenosis or narrowing here. Whereas if you look at the lower one, you may miss it. There's obviously plaque there. but sometimes we say, okay, moderate diffuse disease, you know, and oh, your will say, oh it's not significant. And then we say, okay, you know what, your chest pain is coming from anxiety, it's not coming from angina. And we would have mismanaged this patients. So these are really some important things that I see come up um, and then I want to transition over to what I mentioned is microvascular disease. So currently I would say oftentimes, so how I explain this to patients. As I say, look, there's the big arteries that we can see that you can stent and you can bypass and then there's all the tiny little branches that we can't see, but they are just as likely to develop plaque, atherosclerosis and essentially misbehave, you know, the concept of endothelial dysfunction where there maybe a little plaque there. Maybe not, but they're having an inappropriate reaction to the normal hormones or you know, vase odili terry markers that that flow through the body. And so what's important about micro vascular disease is it's a tough diagnosis. There are some centers and I'll show you in a moment there's protocols. I've actually had a diagnosis. But the tricky part is in the bottom line is these women will present with angina symptoms. They may they may have an abnormal stress test and they often do. They will have E. K. G. Changes they could present as typical acute coronary syndrome with an elevated proponent. But then you go when you take them to the Cath lab and you do an angiogram and apparently normal coronary arteries. And so this is tricky because these are the subset of women that are often sent home with you're fine, you have anxiety or you know, something like that when they truly have angina and it needs to be treated as cardiovascular disease. So if you have a high clinical suspicion, like a very strong kind of angina story and they're not having any obvious obstructive coronary disease on Cath. You know, there's these various patterns you can see. They can it would be obvious if they had lipid build up in a macro vessel as well as a micro vessel here. But sometimes the pattern can be evenly distributed and it can really be missed on an angiogram and in these situations, um you know, fortunately the treatment is actually medical management and exercise and there's actually protocols for for exercise for this to increase their resiliency over time. But if there are, we don't do this here at scripts. But we were thinking about it. There are some places that do it. For example, cedar Sinai does it where you can actually test by giving um for example acetylcholine nitroglycerin, various you know infusions down the coronary arteries in the cath lab. And you can actually demonstrate this end a filial dysfunction. You can see this normal coronary artery here. Somebody may send this patient home saying, hey look you don't have any coronary disease. But if you actually do the coronary reactivity testing, you can see that they spasm inappropriately in response to something that they should Visa dilate to. And so so these these patients are important because they really can get like they do get an Emmy. They can go down the road and develop heart failure if they're not treated properly for this phase of spasm or micro vascular disease. And again the treatment is usually medical nitrates. Beta blockers, ace inhibitors, calcium channel blockers. Some people have had some good success with um Reynolds seen um and then may or may not need statins depending on, well, I guess we could do a cardiac ct two according to, you know, based on what Dr Gonzalez said, but so that would be depending on on their baseline risk and most importantly exercise training in cardiac rehab to treat this. Um There is a spasm is along similar lines, but you can actually see it more visually in the larger vessels. And I think a lot of us are or you know, who have actually taken patients to the cath lab, can sometimes you can see this a little bit with your catheter when you engage. So it's important to keep these in mind. Again, this tends to be more associated if you really get the history um look for it and people who have a history of migrant headaches right now towards some autoimmune diseases where they have a little more Visa motor reactivity anyways. Um and they tend to do well with calcium channel blockers. So I want to spend a little bit of time talking about spontaneous coronary dissection. So this fortunately now is getting properly recognized as something to look for it. It certainly can happen in men and women both, but it's much, much more common in women as you can see about More than 80% women, younger women, about a quarter of it in the peri partum period, which is quite terrifying associated with fiber muscular dysplasia. And this is really often underdiagnosed because these are young, otherwise healthy appearing women, but can can be life threatening. You may hopefully you can see there's a tear in the lining of the vessel here. So What's important about this? Um when talking about prevention is this is one of the ones that does have about a 20% um known risk of repeat recurrence down the road. So particularly if you have like, like I have a patient in my clinic who had already had four Children develop this like postpartum a week or two after she had her last baby and then came to me and said I want to have 1/5 baby. And I was like, are you out of your mind? But it's hard to tell a woman no, you shouldn't have another baby. But I had to really show her this data and say, hey look, we don't know why this happens more and women and we don't know why it happens more in this period party period. But um you got to be aware that this is something that could happen to you again, because it's hard to prevent this from happening again. You know, we have some data that says, okay, maybe avoid very vigorous exercise, but on the other hand, you do want them to exercise. So it's a very difficult thing to manage. And it's a conversation that needs to occur. What's important about spontaneous coronary dissection is depending on the pattern or the the nature of the way that the artery is dissected. You don't necessarily always have to stand if you have good flow distantly, you actually can leave it alone medically manage it and then just follow up with symptoms. You know, ischemia, evil stress test. We don't routinely go back and do another angiogram unless there's bothersome symptoms. But what's and as you can see here, this is a really great review article by Dr Hayes that's fairly recent, that shows the different types of deceptions that occur. But the thought is it's something causing that vessel to misbehave. Maybe some underlying genetic disorder, Maybe a component of hormones as they cause a lot of Visa motor reactivity, dilation, spasm. So there's some increased shear stress on these arteries. That's worse during hormonal fluctuations that increases the propensity towards this. So So that's why we think it happens more during massive hormonal shifts. But we don't know exactly 100%. Um And then another thing of course more common in women which a lot of people have heard of this is stress induced cardiomyopathy. You know broken heart syndrome. Again intense emotional stress presents like a true heart attack. E. K. G. Will be abnormal proponent will be elevated. You take these people to the Cath lab, they end up having this, they call it talking lips, they end up calling it Takatsu bow. As you can see. It is named after octopus trap. Which I guess is what somebody first thought when they saw the shape of the heart on this. Um angiogram as you can see here there's a little bit of ballooning here, here's the heart, it's a little bit dilated and then just the apex balloons has to do with the positioning of cata cata cola mean receptors. Um stress hormone surge. Um the good news about this is usually people do well. It's certainly much more common in women. You treat it with beta blockers conservatively managing heart failure symptoms and repeat the echo and most of the time it goes back to normal. But again this is another one that tends to recur so you really need to counsel these patients on stress. We have great data. I just love to include this on, We happen to be monitoring people during terrible natural catastrophes like earthquakes, and the you know the September 11 attacks. And these were people who were we're wearing monitors or had pacemakers and you can see they have significant increased cardiac events, ventricular arrhythmias. Um you know, all sorts of bad events provoked by stress. Um This is my favorite slide. I always included in every talk if I can. Um and I know we're running low on time. So I'm gonna go quickly. But bottom line is this slide demonstrates its a nuclear profusion stress test. And on the bottom you see the control good blood flow. You see with exercise a profusion defect here you're not getting all this fill out of profusion. And here you see somebody doing some very, very strenuous math and they get a profusion defect. So like the math problem was stressful enough to cause ischemia. So depending on your personality type, you really got to be careful and pay attention to stress as a as a true marker of ischemia. So, again, with prevention of this, you want to you really want to look at these unusual variants and women, yes, they can get regular coronary disease and you have to treat them appropriately. But look for these other subtypes and of course address stress because that causes a lot of these these issues. Um, I'm going to jump ahead a little bit so we can get to part two. I wanted to show you here. If you can see on the end here, these are just some heart failure trials. And I just wanted to show you in general 20% 23% 20% 13%. Or how much women? The percentage of women included in these trials. So we're doing our best but we just don't have the data to treat women the way we would like. And another really important thing to think about when you can't talk about women without talking about pregnancy polycystic ovarian syndrome, which is linked with obesity, insulin resistance. And then you have to think about breast cancer. So what's tricky is a lot of times I'll see people in clinic and also do you have any medical history and they say no. And it turns out they have breast cancer, mastectomy, chemo, all this stuff, but it's over with and they got it's done. And so they don't think of that as a medical problem anymore. But we know that that, you know, the radiation can increase the risk of plaque build up. We know certain chemotherapy agents can cause cardiomyopathy. So these are all things that we actually need to pry and ask because I've been surprised how many times I go to examine a woman and realized she had a mastectomy, and she told me she had no medical history. From their perspective there, like I beat cancer, I don't have to talk about it anymore. Um I'll jump ahead to pregnancy, basically. What I'll say about pregnancy is that it is a metabolic disaster. Um it's a total disaster. So everything bad happens. So think about pregnancy as having heart failure with D. I. C. That's basically what it is. So your cardiac output goes up, it's pro thrombosis. Stick, your systemic vascular resistance goes down, your lipid profile shifts to less favourable. So you're it's basically a setup for an Emmy or a stroke. The incidence is a bit higher, 3-4fold higher of actually having acute coronary syndrome in pregnancy. And as I said, all those terrible metabolic shifts happen and the pregnancy itself is an inflammatory state. So um I know where. I think we're shifting a little on time. So I'll jump ahead and say is most am I in pregnancy is non atherosclerotic. So we think scad spontaneous coronary dissection and you actually treated the same. You you do your E. K. G. You want to avoid a nucor Alexis can that can be a terrible hygienic in the beginning and it's actually if somebody is actually truly having an M. I. Or obstructive coronary disease during pregnancy you actually can cast them. You can do an angiogram bearing in mind just baseline pregnancy causes a few changes in the E. K. G. A little bit of baseline T. Wave inversion, a little bit of left axis shift and dilation of all the chambers on eco just from the increased blood volume in the stretch. So that happens anyways. So pay attention to that. If you're worried you can use aspirin, you can use Plavix, you can use beta blockers. We can actually even use drug eluting stents now. Um It's actually been shown to be okay. We don't have good data on like a fiend and Berlin to just because it hasn't been studied. So that's being avoided and it's actually okay. The amount of floral that's actually received is actually quite low compared to you know like a cT or something like that. Of course. Think about pulmonary embolism. I just put this up for later to look at if there's medications you you want to know what are safe versus not safe to use during pregnancy. Um And here's just a quick reminder that arrhythmias are significantly increased during pregnancy as well. So medications that are safe to use for S. V. T. S. Which are very very common Pvcs during pregnancy. Also, as far as hormones go will keep in mind that for women who have had like breast cancer or hysterectomy early in life technically they've gone through menopause early so they are slightly increased risk of premature cardiovascular disease. And in these women it's reasonable to consider short term hormone replacement therapy up into the age that you think they would have gone through menopause naturally. Now what I'll say that's really important here, this has been very controversial over time is I get this question at least two or three times a week about hormone replacement therapy isn't safe. And you know the thought as well, we know that when women go through menopause the risk of heart attack and stroke goes up. So logically people thought well great I'll take hormone replacement therapy and I'll be a young woman forever and I'll never have heart attack and stroke. Unfortunately, the studies, particularly women's health initiative and hers trial. Um we're looking at just that and it turns out that not only did hormone replacement therapy, it did not have a significant benefit in reducing am I? But there was a slight increased propensity towards stroke as well. So subsequently there have been several trials and I have them listed here before even up until the two thousands, like for example, the elite trial where they thought, well maybe if I time it just right, I can I can protect these women. But the bottom line of all of these trials where we are currently with the data is that you don't recommend hormone replacement therapy for prevention of cardiovascular disease. It may be associated with increased risk of stroke, particularly in people who have had a history of blood clots, history of breast or endometrial cancer however, And low risk people, it's considered safe for five maximum up to 10 years, but you're only using it to treat the symptoms of menopause. You're not doing it for any other reason beyond that. So, you know when it comes to cardiovascular disease prevention, um, what to prevent disease in women, You have to realize that not only are the traditional risk factors conferring a higher risk in women compared to men, but look for these really a typical things. Microvascular disease, stress induced cardiomyopathy. Um, I didn't get into heart failure, but heart failure with preserved ejection fraction tends to be more common in women compared to men like diets, what we call diastolic heart failure. But really ask, I mean people don't like to do this, but you really have to ask about their O. B. G. Y N. History there. You know that girl, the girly parts. What happened? Have you had breast cancer? Have you had a hysterectomy? Most women actually have by the time I see them it seems like hysterectomies were a lot more common. Um For more minor issues in the past I think they're actually less common now. But most of my my female patients were in their seventies or eighties. They're like oh yeah I had a hysterectomy. They don't think anything of it. And when I asked them why they say I don't know. Um So so that becomes important to and then pregnancy itself is a cardiovascular disaster but we can deal with it. So I think you know I actually have some slides on stroke but I don't know if we have time for it. What do you think? Should I keep going or stop here? I got five minutes. Should I blast through them? Okay this is what we're gonna do. We're not going to talk about all of them. I'm just gonna say when it comes to stroke, we're gonna jump ahead realize this. This is how many women die a year from stroke. This is breast cancer. So it's quite a bit. Um What I will also tell you about stroke is as far as the traditional risk factors for stroke that we know hypertension. A fib diabetes, the three that are more associated with worse outcome in women are a fib diabetes and migraines. So keep those in mind. Ask for those histories. Look for those histories, particularly in women, if you're trying to prevent stroke. And um the other thing too is hormones. Once again, the bottom line is there's no difference um with so sorry, with endogenous hormones. So if you just take a woman who has a high estrogen level versus a low estrogen level, that doesn't mean anything with regard to their stroke risk. But once you start adding in exogenous hormones, hormone replacement therapy after menopause birth control pills and young women, all of that increases the risk of stroke slightly compared to not. So keeping that in mind. Um birth control pills specifically, you want to counsel your patients if they're smoking. If they have displayed bohemian obesity or migraine with aura there at significantly increased risk of stroke. We don't exactly know why, but we believe it has to do. There's some association. I'm going to jump ahead. I have some slides on transgender. Bottom line is we don't have enough data about hormone replacement therapy and male to female or female to male. They're very, very small studies that more to come on that um And again pregnancy significantly increased risk of stroke. But what I wanted to jump ahead and tell you um is for women, look for a fib ask about history of migraine headaches, prevalence of migraine is three times more common in women compared to men. And the studies show that women with history of migrant headaches and P. F. O. R. At a significantly increased risk of stroke. So we even though we know that we don't have robust data to say that you should close Cfos or SDS or any of that in women. There's been a number of trials looking at this. What we do know that is if you retrospectively look at people, women who have had stroke, more of them have P. F. O. Then don't. But if you prospectively follow a bunch of people with P. F. O. They don't all have increased risk of stroke. So we're a little bit stuck there. The data is inconclusive but I would say when you're looking to prevent stroke and women look at exogenous hormones history of migraine headaches, um diabetes and A Fin. I think I'd like to stop there um And just talk about overall prevention in women. The bottom line for both heart attack or cardiovascular disease if you want to say and stroke is that the reason it's hard to prevent heart disease in women is because I think the symptoms are a typical, so we're not as good at recognizing the signs and symptoms. Um You know sometimes it's really difficult to tell the difference between a migraine with aura and a stroke and that woman could easily be sent home from the er with a diagnosis of migraine or anxiety or stress. On the other hand it could really be a stroke. So we have to take all the symptoms seriously on our end and then realize that unfortunately even with our best intentions of wanting to treat women like we treat men and make sure they get all the right meds and get sent to cardiac rehab and recommended exercise. We do just still have unlimited data in that. So I think I'm going to stop here and take a couple of questions because I'm getting all these flags that we've gone over time. Thank you so much. Doctor Dean. Great talk. You know, we asked you to cover a ton in a short amount of time. But you really, I think we did a comprehensive review for us and highlighted for me that we really need to keep a careful eye on our female patients, particularly given you know, the atypical presentations that you highlighted. Um don't offer complicated math problems and you know, I think we really need to focus on stressing how would you calculate tips and things like that? You know, evaluation of emerging risk factors. And I think biomarkers are really gonna be helpful here, but we'll clear you with some questions after Dr Meadows talk and the Q and a session. If that's okay, just keep things moving. Thanks guys. Thank you.