Amanda Wilde (Host): Right now, in the United States, more than three million women have heart failure, and the incidence of the disease is on the rise. For insight into this trend, our guest is Dr. Aditi Nayak, Advanced Heart Failure and Transplant cardiologist on the medical staff at Baylor Scott White Heart and Vascular Hospital Dallas and Baylor University Medical Center.

 This is HeartSpeak from Baylor Scott & White Heart and Vascular Hospital. I'm Amanda Wilde. Thank you for joining me, Dr. Nayak.

Dr. Aditi Nayak: Thank you for having me, Amanda.

Host: First, to get us started at the most basic level, can you explain what heart failure actually is?

Dr. Aditi Nayak: Yes, absolutely. Now, to understand what heart failure or a reduction in heart function is, it's first important to understand what the normal heart does. Now, the normal heart is essentially just a pump. What it does is it fills with blood and then pumps out this blood, typically, for women, about 60% of the blood that's in it with each heartbeat.

Now, it pumps this blood out to the rest of the body so that the rest of the body can obtain the oxygen and nutrients needed to function normally. Therefore, heart failure can be one of two things, either a problem with the filling of the heart or diastolic heart failure or heart failure with preserved ejection fraction or a pumping problem of the heart, also known as systolic heart failure or heart failure with reduced ejection fraction.

Now, one big difference to note right off the bat between women and men is that diastolic heart failure occurs at two times the rate in women than in men. The reasons for this are largely unknown, but are being studied.

Host: Well, that does segue right into my next question, which is how heart failure does affect women differently than men. So, we're twice as high on dystolic heart failure. Do we know why that is? And are there specific symptoms women should watch for specifically?

Dr. Aditi Nayak: Yeah. So, I'm so glad that you asked this question. You know, over the past few decades, there's really been an increasing focus on women's health in the context of heart disease. There is a growing awareness that we as women have unique biological factors, such as our chromosomal makeup and our hormones, as well as unique socio-cultural factors, such as like the roles we adopt in society and our lifestyles that impact every aspect of heart disease, right from how it presents to our outcomes.

Now, what does this mean in the context of heart failure in women? There are a few very important differences in heart failure between women and men. Now, first, as I briefly alluded to, diastolic heart failure, or the problem with the filling of the heart, also known as heart failure with preserved ejection fraction, happens at twice the rate in women compared to men.

Now, unfortunately, the answer to your question of why this happens is really not known, but is a subject of research right now. Then, when you look at really the reasons why we develop heart failure, women are less likely to develop heart failure from blockages in the large blood vessels that supply blood to their heart compared to men. Therefore, they're more likely to develop what's called non-ischemic cardiomyopathy. There's also certain causes of heart failure that are way more common in women than in men. One example is Takotsubo, a stress-related cardiomyopathy, which occurs nine times more commonly in women than in men. Peripartum cardiomyopathy or heart failure that occurs in the later part of pregnancy or in the early postpartum period and breast cancer therapy-induced heart failure are other examples of specific causes of heart failure that are unique to women.

Now, the symptoms of heart failure that you asked about are really related to either the backing up of the blood or the or the body not getting enough blood supply and nutrients. So when you think about it, when blood backs up in the lungs, it can cause shortness of breath, typically during exertion, when you lay flat in your bed or in the middle of the night. And in some people, it can manifest as coughing or wheezing. When blood backs up in the rest of your body, it can cause swelling in your legs or your abdomen, it can cause weight gain. And symptoms related to the body not getting enough blood supply or nutrients include things like getting tired very quickly, dizziness, loss of appetite, nausea, and vomiting.

Host: Which are symptoms that are easy to assign to other things.

Dr. Aditi Nayak: Exactly, exactly. You're absolutely right. And there's also very important differences in the way heart failure presents in women compared to men. Women tend to be older than men when they're diagnosed with heart failure. They tend to have more of these advanced sort of symptoms, have more breathing-related symptoms such as difficulty breathing when laying flat or waking up in the middle of the night gasping for air. They also tend to report a worse quality of life. They're able to do less due to their heart failure, and they also report more depression associated with heart failure. So, I hope you're immediately able to see that a lot of these symptoms can sometimes be quite vague and be attributed to something other than heart failure, which leads to heart failure being underdiagnosed or being diagnosed too late in women.

Host: And when we say too late, does that mean heart failure becomes complete or that people have a heart attack at that point?

Dr. Aditi Nayak: No, what I mean is that women tend to present in more advanced stages of heart failure at times when it would have been easier to manage, say, if they had presented a few years earlier and made contact with advanced centers like ours a few years earlier.

Host: You were talking about how heart failure presents differently in women and women are prone to certain risk factors also that are woman-centered. What can we do to mitigate our risk of heart failure?

Dr. Aditi Nayak: Yeah. So first, I would say let's talk a little bit about the risk factors or what predisposes women to heart failure, because some of these are actually quite unique to women. Now, high blood pressure, diabetes, smoking, and obesity are the largest contributors to heart failure in women. But it's important to understand that all these risk factors are more potent in women than in men. So if you are a woman that has any of those conditions, it's absolutely essential that you do your best to control those diseases so that they don't progress to or contribute to heart failure in the future.

Then, as we briefly alluded to, there's also another very woman specific risk factor for heart failure, which is pregnancy. Now, there are three major pregnancy-associated conditions that I would like everyone to be aware of that actually increase your risk of heart failure in the future. The first is gestational diabetes. Now, this on average affects about 5-10% of pregnancies in the U.S. with the risk increasing with increasing maternal age. Regardless of whether you progress to diabetes after the pregnancy or not, gestational diabetes is associated with a 40% increased risk of developing heart failure in the next seven years after your pregnancy.

Now, the second is a condition that I'm sure a lot of women have heard of, hypertensive disorders of pregnancy such as preeclampsia and eclampsia. This affects about 15% of pregnancies in the U.S., again with risk increasing with age, and this doubles your odds of developing heart failure with preserved ejection fraction after pregnancy with a median time to onset after pregnancy being 2.5 years.

And finally, peripartum cardiomyopathy, which we very briefly spoke about, which develops between the last month of pregnancy and the first five months after you have your baby. This is actual heart failure that develops during pregnancy and complicates about one in thousand pregnancies.

Now, most of the prevention or mitigation strategies for heart failure that you asked about revolve really around preventing the disease that causes heart failure. So if you have hypertension or diabetes, you should make sure that you see your doctor regularly and control these conditions well. Quitting smoking, moderating alcohol intake, maintaining a healthy weight via healthy diet and exercise, aiming for at least 150 minutes of moderate physical activity a week are all very helpful.

The American Heart Association also recommends the DASH diet to reduce your risk of heart disease as a whole. Resources for how to incorporate this into your lifestyle are very easily available online. But in a nutshell, what this diet emphasizes is the inclusion of vegetables, fruits, whole grains, low-fat milk products, lean milk, poultry, fish, nuts, and seeds. It asks you to stay away from saturated fats and added sugar, and also limit your sodium intake to 2.3 grams a day. And essentially, That is one teaspoon of added salt a day in your food.

And importantly, if you have any of the pregnancy-associated conditions that we spoke about that predispose you to heart failure, you should be closely monitored during and post pregnancy, ideally by both your gynecologist and cardiologist. In fact, this kind of multidisciplinary approach is something that we at Baylor are really proud of and proud to offer to women as a part of our Women's Heart Center that we launched in February of this year, that hopefully we get to talk about a little later in this podcast.

Host: Well, good. I think we should talk about that right now. How is the Women's Heart Center at Baylor Scott & White Heart and Vascular Hospital-Dallas, helping women understand and deal with heart failure and heart disease?

Dr. Aditi Nayak: Yeah. So, the Women's Heart Center at Baylor is really a comprehensive cardiac center that's truly for women and by women. Our founding principle was a lot of the stuff that we've already spoken about and understanding that women are not just small men. You know, we're unique in terms of our biology and our sociocultural construct, and this really influences every aspect of heart disease in us.

Unfortunately, however, awareness of this is limited even in the medical community and this leads to women having their symptoms ignored and unheard, their heart disease being underdiagnosed and this overall leads to worse outcomes in women, something that we see in research that's published year after year.

So really, the aim of our center is to bring together physicians and their teams from across disciplines, Heart Failure, Cardio-Oncology, Cardio-Obstetrics, Cardiothoracic Surgery, just to name a few. And all of us are really united in our passion and our mission to provide world-class care centered to women and help women live longer and be healthier.

Part of our mission is also to educate women in the community on how to recognize heart disease so that we empower them to become their own best advocate via educational sessions, seminars, and podcasts like what we're doing right now. Now, a couple of unique features of our women-focused center that we hope encourages women to choose the Baylor Women's Heart Center over a more typical cardiac center is access to truly cross collaborative care that is woman-focused. So just to provide an example, if you're a woman coming to me with advanced heart failure to discuss your options for advanced therapies including a heart pump, you can rest assure that we'll discuss everything that's important to you, from your reproductive options and having you see a specialist for this if needed, to a detailed discussion with your cardiothoracic surgeon on considerations for fitting this pump into a smaller heart that we know is typically associated with women, just to ensure the best outcome for you as a whole.

Another unique feature of our center is access to cutting-edge clinical trials offered by our center. So, all in all, you know, as I mentioned, we at the Baylor Women's Heart Center are a center that was really developed for women and by women in the truest sense, and we really hope that you will let us be there for you.

Host: It's really a holistic approach that you're describing. And at the center, how is heart failure diagnosed specifically in women? And are there treatments that are centered toward the specifics toward women that you've described? Are there treatments available to help manage heart failure?

Dr. Aditi Nayak: Yeah. So, the most important step towards diagnosis of heart failure is really the suspicion of heart failure in women. So first off, you know, if you feel as a woman that something is off or something is just not right, you should bring it up with your doctor. And, you know, coming back to our center, you can rest assure that because our focus is really on delving deep into symptoms of heart failure in women and understanding that heart failure can present differently in women compared to men. We are certainly quite sensitive, and we know to pick up those signals that potentially other physicians could miss. Now, especially if you've had any risk factors for heart failure, we make sure that we discuss it with you at length. But it is important, like I said previously, for you to be your best advocate.

Now, once your doctor suspects heart failure, there's a basic battery of tests followed by more specialized tests that might be required in your specific case to diagnose heart failure, as well as the cause of heart failure in you. Now, the basic battery of tests includes an echocardiogram or an ultrasound of your heart to look at your heart function, an electrocardiogram that records your heart's electrical activity, as well as blood tests such as brain natriuretic peptide or the BNP test. Now, specialized tests that may be required in your case include cardiac catheterization procedures, stress tests, a cardiac MRI, or even genetic testing. And your doctor will generally cater these tests to your specific presentation.

Now, once you're diagnosed with heart failure, we do have a multi-pronged approach informed by many, many years of research and evidence that guide us on how to treat heart failure. So first, let's talk about medications. If you have heart failure, there is a group of four medications that you should ideally be on that are referred to as pillars of heart failure management. Why are they the pillars? It's because they've been shown to make patients feel better, keep them out of the hospital, and keep them living longer. Now, these medications are, number one, the renin-angiotensin system inhibitors, for example, lisinopril, Losartan, or Entresto; two, the beta blockers such as metoprolol; three, the aldosterone antagonists such as spironolactone and the SGLT2 inhibitors, or the sodium glucose co-transporter 2 inhibitors such as Farxiga or Jardiance.

There are some specific nuances of when and in which type of heart failure to use these medications. But without overcomplicating it, if you are somebody with heart failure and you are not on all four of these medications, you should ask your doctor why not. And research has shown that For some reason, women with heart failure are less likely to be prescribed this group of four medications. And again, this is something that our center is really focused on and is very, very intentional about avoiding to make sure that our women are do have outcomes that are at least as equal to their men counterparts as possible. Now, in specific cases, you may be referred for implantable devices, such as a defibrillator or cardiac resynchronization therapy, or for newer devices such as the Barostim device.

Equally important are lifestyle changes that you can implement to manage your heart function. I hope this video has helped you understand heart failure better, such as weighing yourself daily, having a plan in place with your physician's office to manage weight gain from fluid, limiting your sodium intake to 2 grams a day, taking your medications regularly, and keeping all of your other medical conditions such as diabetes and high blood pressure well controlled.

Now, it's important to remember that if your heart failure progresses, in spite of all these measures, we do have therapies for that as well, which are offered in specialized centers such as ours. These therapies are a heart pump or the left ventricular assist device, as well as heart transplantation, which replaces the patient's heart with the donor's heart.

Host: Okay, that's a lot.

Dr. Aditi Nayak: Yeah, I know. Yeah.

Host: That is a lot. But luckily, this is a podcast so we can go back and listen to some of the key parts of this that pertain to each of us. I think one of the main takeaways for me is that you have to prevent or control the diseases that cause heart failure, and you also have to look at those stress lifestyle factors. Like you said, keep your medications consistent. And then, as you mentioned, early detection gives you the best chance of a positive outcome. So, you want to go to the proper specialist. And then, at your center, individualized treatment happens with a deeply multidisciplinary approach so that you don't miss anything and you use everything available. And you even mentioned there are studies at the center. So, it seems like it'd be on the cutting edge of treatment.

Dr. Aditi Nayak: Exactly. Yes. If this is what our audience gets from this, I'd be very, very happy.

Host: Well, Dr. Nayak, thank you so much for your expert insight into heart failure in women, and thank you for your great work.

Dr. Aditi Nayak: Thank you. Thanks a lot, Amanda. This was a lot of fun.

Host: That was Dr. Aditi Nayak, Advanced Heart Failure and Transplant Cardiologist on the medical staff of Baylor Scott & White Heart and Vascular Hospital-Dallas and Baylor University Medical Center. For more information about women's heart health, contact the Women's Heart Center at Baylor Scott & White Heart and Vascular Hospital-Dallas. The number is 214-820-7162. And if you found this podcast episode helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is HeartSpeak from Baylor Scott & White Heart Vascular Hospital. Thanks for listening.

Baylor Scott & White Heart Vascular Hospital, Dallas, Fort Worth, and Waxahachie. Joint ownership with physicians.