Evo Terra (Host): This is Expert Insights with the Carle Foundation Hospital. I'm Evo Terra, and I'm joined today by a cardiologist, Dr. Karen Wiarda, for a discussion about the differences in heart disease between men and women. Thanks for being with me, Dr. Wiarda.

Karen Wiarda, DO: Thank you for having me.

Host: So now until this session with you, I had just assumed that heart attacks were pretty much, heart attacks regardless of sex. But I now know that's not the case. That's why we're talking. So, can you broadly speak to why heart disease is different between men and women?

Karen Wiarda, DO: So men actually develop coronary artery disease earlier in life, with their first MI or heart attack occurring about seven years sooner than women because women are protected by estrogen. So they tend to have clinical cardiovascular disease later, but it does not confer a better outcome because after they have events like a heart attack or heart failure, women actually have equal or worse prognosis than men.

So women generally have a smaller left ventricle, mass and cavity size, a higher resting heart rate, a higher ejection fraction at baseline. They tend to have longer QT intervals, which is the repolarization reserve. So with their conducting system, their electrical conducting system, they don't repolarize as well, takes a little bit longer, and the reason for women is estrogen enhances the endothelial nitric oxide production, which is basically allowing us to vasodilate or allow for a better vascular function. So, it reduces vascular inflammation, and it improves the compliance of the artery. So the artery and the arteries and the vascular are able to actually dilate and constrict easier and healthier.

So when we have a loss of estrogen at menopause, we have accelerated vascular stiffening and increased blood pressure.

Host: Okay, so there are some differences obviously. No, that is a lot to go through. So, alright, so now we know there are in fact differences in heart disease, between women and men. Let's talk about the symptoms of a heart attack. Are those any different? I mean, when I have a heart attack, is that going to be different than my wife having a heart attack?

Karen Wiarda, DO: So both men and women, the main symptom is chest pain. So I never want people to not understand that chest pain is the classic symptom for a heart attack. However, women are more likely to report dyspnea or shortness of breath with exertion, fatigue, nausea, and epigastric or stomach discomfort. So these symptoms were historically labeled as atypical, but really they're now recognized as typical for women and they reflect a diagnostic bias, not biology. So it does make a difference how men and women present.

Host: Wow. That's interesting. I had no idea that there was this much of a difference. Right. I, thought they were all just outliers. But that's good to know that we're actually now getting our diagnoses much better. You know heart disease. I've heard it called it a lot of things. I know it's an umbrella term for lots of different heart conditions. Heart disease obviously has different symptoms than a heart attack has symptoms. But do these symptoms of overall heart disease differ from between men and women?

Karen Wiarda, DO: So actually heart disease can be sort of as a general term. We look at disease of the coronary artery system, so that's coronary artery disease. We look at the pumping function of the heart and the relaxing function of the heart. So that's congestive heart failure or heart failure. Then we look at valvular disease, so whether or not the valves are opening and closing and the blood flow is as it should be, versus whether or not there's too much too leaky of a valve or too tight of a valve.

And then I think the next umbrella would be atrial fibrillation or some sort of abnormal arrhythmia, which can be extra heartbeats from the top of the heart, atrial ectopy, or the bottom of the heart, ventricular ectopy, or a fast heart, which can be supraventricular tachycardia, or atrial fibrillation, which is the most common and the most concerning because it increases your risk of a stroke.

Host: Wow. And are those more prevalent between men or women? Like, my mom has AFib. Is that more likely to happen to women than it is to men?

Karen Wiarda, DO: So AFib is actually more likely to happen to women over men. AFib, there's a couple of reasons for that. One, that biggest risk factor for atrial fibrillation is age. Women tend to live longer than men. And women are more likely to have the risk factors for AFib, which is high blood pressure, obesity, aging, and this microvascular dysfunction, which also increases the risk for heart failure preserved ejection fraction, which is more consistent with a stiffening of the heart, where the pump is functioning fine, but it's not relaxing fine. And so you can get some sex specific therapeutic responses with some of the therapies and women with a specific medication, Entresto can actually have a greater benefit than men. So there is some benefit, with the treatments that women can actually have.

Host: You know, my own cardiologist reminds me all the time that the best way to prevent the heart conditions I know that I'm genetically predisposed to is by lowering my risk factors. So I'm doing all the things I should be doing. I'm working out, I'm following the DASH diet. My wife's doing those things with me as well. But are there certain risk factors more prevalent in women than men or vice versa?

Karen Wiarda, DO: So women tend to have higher blood pressure. Again, they tend to have more obesity, and then they tend to have this microvascular dysfunction. But the risk factors are truly the same risk factors in men and women. Diabetes confers a greater relative risk of coronary artery disease in women than men.

Smoking is a stronger risk factor for coronary artery disease in younger women. High blood pressure is more strongly associated with heart failure with preserved ejection fraction, like I spoke about, in women. The other issue with women, which is unique or predominant, is an adverse pregnancy outcome, like preclampsia, gestational diabetes, preterm delivery, premature menopause, which I don't think people give enough credit to.

So if you're prematurely in menopause because your ovaries are removed or because you have premature menopause; that actually increases your risk. Polycystic ovarian syndrome increases your risk. And the other big one is autoimmune diseases. So things like lupus or rheumatoid arthritis or any kind of autoimmune disease is increasingly recognized as a coronary artery disease risk enhancer.

But it remains underused in risk stratification. So part of the issue is when we look at-risk stratification, there's a lot more to looking at-risk than just the traditional risk factors, family history, lipoprotein a, which is a higher risk of coronary artery disease and aortic stenosis.

So there's other risk factors besides the classic high blood pressure, high cholesterol, lack of exercise, smoking, diabetes. The other big risk is family history. And it is certainly an increased risk, but it does make a difference what you do with your family history, So, it typically, when you look at it, it can be 90% of what you do about it and 10%. There are some people who are going to have elevated cholesterol, no matter what they do, because they don't have the enzyme and they're just going to have elevated cholesterol, so we have to treat that aggressively. High blood pressure, everyone, wants to try to not be on meds, but they aren't always able to make the changes that are necessary.

Host: Yeah, that's one of the things I've learned is that meds just work. Willpower and being strict adherence to your diet and exercise are great, but look, we're not perfect, but if you keep taking your meds, meds work.

Karen Wiarda, DO: And it's really important. A lot of people say, Hey, my meds are working, so I'm going to stop them. You know, it's like they say, well, things are going great, so I'm going to stop my meds. But they're going great because your meds are working. I believe in making lifestyle changes and depending on the situation, some people need to be started at meds while they make the lifestyle changes. Other people, if you catch them early enough, then we should be making lifestyle changes before we start meds. But it very much makes a difference on where you're at in the spectrum.

Host: And these are things we do in conjunction with our physician.

Karen Wiarda, DO: Discuss risk, discuss meds. Yes, absolutely.

Host: A couple more questions before I let you go. What about the issue of when to seek medical assistance for heart related issues?

Karen Wiarda, DO: I think the most important thing is you know your body and when you're noticing changes, you need to seek attention. So some people, it could just be, I'm tired, I'm tired, I'm tired. But this is new and extreme. You should have it checked out. Chest pain, obviously you need to get that checked out.

But if your blood pressure is uncontrolled and you're diabetic and you have all these risk factors and you're still smoking and you're high cholesterol, if you're having any of these symptoms, you should absolutely be getting them checked out with your physician.

Don't ignore symptoms. It is far better to have the workup be normal than to miss the workup and to have things go awry and have a heart attack or a stroke, or heart failure or AFib. So if you feel different, you need to seek treatment.

Host: Solid advice. Last question, I'm going to get personal for a second. Why are you so interested in raising the awareness of how heart disease and heart conditions difference between men and women?

Karen Wiarda, DO: So I think obviously as a female, I think that it's very important that we recognize that women do present differently. Women have risk factors younger than they realize, and that for a long time that women were just sort of ignored and now we've certainly with the Red Dress and with the American Heart Association, and excellent education and studies and research, we have really shown that women very much have the same risk as men.

And the other issue is simply women are protected seven to nine years longer with estrogen, but many, many women these days, don't have that estrogen protectant far younger than they should. And so it's so important, not only certainly as a woman, but that makes up a large part of my practice.

And I have a particular interest in lifestyle medicine and obesity medicine. And there's so much we can do to reduce the risk, but it's just so important to get treated and to get evaluated and to be listened to. And if you don't feel like you're being listened to, make sure that you keep talking.

Host: Very good. Dr. Wiarda, thank you very much for the conversation today.

Karen Wiarda, DO: Thank you for having me.

Host: For more information and to get connected with one of our providers, please visit carle.org. That's C-A-R-L-E.org. For a listing of Carle providers, and to view Carle-sponsored educational activities, head on over to our website@carleconnect.com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital.

I have been your host, Evo Terra. Thanks for listening.