Scott Webb (Host): Many women believe that the greatest risk to their health is breast cancer, but the truth is that heart disease, in the form of heart attack, heart failure, and stroke, is the leading cause of death in both women and men. The American Heart Association has helped raise women's awareness of the risk, but there's still work to be done in this area.

Cardiologist Dr. Stephen Cook, with Franciscan Physician Network Indiana Heart Physicians, is going to walk us through the important points today about women and heart disease.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Dr. Cook, thanks so much for your time today. We're going to talk about heart disease and women and heart disease and everything involved. So, let's start there. What are the risk factors for heart disease that women face?

Dr. Stephen Cook: Yeah, this is a really important question. There are so many specific risk factors for both men and women, but there are risk factors specifically for women. I'll kind of start at the top. One would be hypertension or high blood pressure. And when I think about high blood pressure in women, unfortunately, it is still underdiagnosed and undertreated. And this remains a major risk factor for the development of what I'm going to refer to as either myocardial infarction or heart attack, or what's also referred to as ischemic heart disease in women. And so, hypertension significantly increases our risk for the development of a lot of late-onset complications in patients with heart disease, whether that's a heart attack, heart failure, the development of heart rhythm problems called atrial fibrillation, and even stroke.

And so when I think about our younger patients, our premenopausal women, they're also at a higher risk of end-organ damage to our kidneys compared to all men of similar ages. As women begin to transition into their menopausal years, that blood pressure continues to elevate. So again, such an important thing to recognize. And the reason why blood pressure may continue to elevate is that it is the declining of estrogen levels, which also leads to upregulation of another hormone in our body known as the renin-angiotensin system, which tightly regulates and controls blood pressure. And when these hormones get upregulated, this further constricts our blood vessels and also makes us more salt-sensitive, makes women more salt-sensitive, so thus increasing our likelihood of becoming more hypertensive or developing high blood pressure.

So if you start to look at women who are over the age of 65, the prevalence overall is much greater in women than in men, but then unfortunately less than half of our women patients are receiving adequate therapy. So, this to me is one of the most striking risk factors for women who might be at risk for heart disease and heart attacks.

Host: Right. Yeah. So, knowing risk factors, obviously, and that could be family history or just the natural aging process. And I think maybe we should talk about things that are within the control, right? The modifiable type things. So, let's talk about some of the health steps that women maybe should take regularly to ensure better health, be that managing blood pressure, cholesterol, weight, exercise, you know, the greatest hits, if you will.

Dr. Stephen Cook: Yeah, absolutely. So when I think about what can women do, I think it's just even standing up for your own health, right? Making sure that you kind of demand attention. And to me, that means getting screened every year, knowing not only your height, but more importantly, your weight. Knowing what is your blood pressure, asking your primary care physician, "Is my blood pressure normal?" Getting screened for your fasting cholesterol. Knowing your hemoglobin A1c, which is a reflection of your blood sugars. Are you at risk for diabetes? Another risk factor for the development of heart attacks. Ask questions about your health. Talk about with your primary care doctor, what are your chances for developing heart disease and stroke?

I think another thing, a lot of patients, men or women, don't ignore symptoms. If you're concerned that you may have heart disease symptoms, talk to those about your doctor. If you're overweight, talk to your doctor again. What is your goal weight? Ask about starting an exercise program. Ask about nutrition referrals. These are things about how can I begin a heart-healthy lifestyle.

Host: Sure. Yeah. Let's stay with exercise and talk about the benefits of regular exercise to help protect women against heart disease.

Dr. Stephen Cook: Yeah. I love talking to my own patients about exercise as well. You know, when I think about, again, we talked about high blood pressure and hypertension, you know, routine exercise is going to really help you with so many things. It's going to help you reduce blood pressure. It's going to help you control your weight. And I think there's one other thing that I think we all forget about, it's relieving stress. We are all in this busy, busy work week. We tend not to take care of our bodies and exercise is such a great thing to kind of tackle these three problems.

Host: Sure. Yeah, I want to talk about stressors, right? So, I'm a male in my 50s and I'm married to a female in her 50s. And I have observed, doctor, that over the years, we're just different, right? We handle things differently, we process things differently, and we definitely deal with stress differently. Men and women seem to do that. That's anecdotal at best on my part, but you're an expert. So, let's talk about some of the everyday stressors that impact women's health more than men.

Dr. Stephen Cook: Yeah, I think that stress, you're right, can affect everyone in lots of different ways. There is data to suggest that stress can probably increase our risk for heart attacks and heart disease. But when I think about women, there is data to show that depression can be associated with increased risk of ischemic heart disease, as well as increasing mortality from ischemic heart disease as well. So, there are studies, particularly in younger women, so this is women who are younger than about age 55, that have shown that depressive symptoms were associated with increased risk of death compared to men in a similar age cohort, so younger than age 55 years. And how can this be so?

Well, you know, depression is associated with a decreased control of modifying those modifiable risk factors. So if we're depressed, we're less likely to comply with our medication regimen prescribed by our doctors. We're less likely to exercise, and maybe putting ourselves at increased risk for obesity, high blood pressure, and diabetes. And we know that those are those risk factors that are going to set us up for heart disease later in life. So again, you know, thinking about our patients that may be depressed by our primary care physicians, "How at risk am I for developing heart disease later in life?" Something that you really should focus on from our primary care perspective.

Host: Yeah, I see what you mean. And you talked about menopause earlier and the connections between menopause and, you know, heart-related issues, heart disease, perhaps. So, I want to ask you, does a woman's risk of heart disease increase as she reaches menopause? I just want to clarify. And if so, why?

Dr. Stephen Cook: Yeah, this is really tricky. We know that the incidence of ischemic heart disease does start to increase after menopause. We believe that, again, this decline in our estrogen levels are somewhat implicated, but there may be some unfavorable ratio of just sex hormones overall between testosterone and estrogen that may contribute to this.

I think of it more as menopause itself may not be this true independent risk factor, but think about what's happening as we are aging. As women are transitioning through menopause, they're also developing other risk factors. You know, diabetes, hypertension, and obesity, metabolic syndrome are all happening during this menopausal period. So, I think it's important that we start to really look closely at post-menopausal women for not only just this menopausal period in their lives, but also other risk factors may be truly playing a role in their development of ischemic heart disease.

Host: Yeah, I see what you mean. It is a little tricky, and it could be more sort of direct links or indirect links, but there's definitely a connection, as you're saying. And unlike me, you know, you're quoting science, and it's not just anecdotal, right? So, what are the conditions under which a primary doctor should refer a woman to see a cardiologist?

Dr. Stephen Cook: Yeah, I think as one of the general cardiologists here, a lot of the referrals that I will get are for, you know, poorly controlled hypertension or really evaluating a patient's risk. I'll see patients who might be overweight or obese, but with also what I call comorbidities. They also have hypertension, and they also have diabetes. And really, me evaluating what is that patient's cardiovascular risk? Should they be undergoing stress testing? What is their likelihood? And really trying to help us understand their cardiovascular risk for the development of myocardial infarction and really trying to put that patient together. And I think those are a lot of the referrals that we see both for women and men.

Host: Yeah. I mean, our primary docs are great. You know, I love my primary doctor, but when he gets into the heart and Cardiology and some of these risk factors and managing them, you understand why we have specialists. And, you know, we hope that these podcasts educate folks and get them to speak with their doctors and ask for those referrals and be really you know, strong advocates for themselves and their health.

I have seen, doctor, many times on TV shows and movies, heart attacks represented differently, right? There's sort of the classic sort of male way of heart attack, that "I'm having the big one." We're roughly the same age. So, I watched Sanford and Son when I was a kid and Fred Sanford was always clutching his chest, and "I'm having the big one," right? And I do know, and trying to be a little bit funny, but men and women, the signs of a heart attack present differently in there. It does seem like there's the classic thing with men and not so classic with women. So, maybe you could kind of break that down for us.

Dr. Stephen Cook: Yeah, I agree. I often tell many women that I'm seeing in clinic that a lot of our patients don't read the textbooks, right? And I think women are a classic example of that phrase, right? And so, I'll share with my patients that I still go over a lot of classic symptoms with my patients irregardless of sex. And I think it's important for everybody to know symptoms. And this is what I share with a lot of my women patients in clinic, understanding that there could be an uncomfortable pressure or a squeezing or a fullness type of a pain in the chest. It could also be pain or discomfort in one or both arms, back, neck, or stomach. And that could be their presenting symptom, or it could just be shortness of breath, either with or without chest discomfort, or even just a cold sweat or nauseous sensation. So, I think really understanding there could be a lot of what you're describing, atypical symptoms. And I think that's really important for women to understand and to bring this up to their primary care doctor or to self-refer to a cardiologist and to say, "Am I experiencing heart disease or a heart attack with these symptoms?"

Host: Yeah. And I've spoken with other experts from Franciscan Health and we've had these conversations that women, because of the atypical symptoms, as you say, sometimes they dismiss those symptoms because it is, it doesn't feel like the big one per se. And we really want them to hear this today, to hear from an expert and know not to dismiss these things as just normal part of life or a normal part of aging because they're not normal, right?

Dr. Stephen Cook: Absolutely. Yeah, that's why I say it's helpful to kind of hear, "Oh, this uncomfortable pressure-like sensation in my chest," but it's really helpful to drill down on atypical symptoms and to really think about this and don't come in-- you know, I'm always happy to see anybody-- but to really recognize atypical symptoms and don't sit on these and wait a week or a month or two months, because there's a lot of things that we can provide patients when they come in urgently to consider these urgent symptoms.

Host: Right. Yeah. Time is brain when it comes to stroke. Time is heart when it comes to the heart.

Dr. Stephen Cook: Absolutely.

Host: Yeah, essential that both men and women, but especially women, because of the atypical symptoms, that they hear this and recognize this and speak with their providers, get the referrals to folks like yourself. It's been really good stuff today. I just want to finish up and just kind of address that, you know, women take on many roles, right? They often care for the children and parents and they work. And I'm just wondering, how can we encourage them to take care of themselves and take care of their hearts?

Dr. Stephen Cook: Yeah. That's such a great thing to end on. And sometimes I'm guilty of this as well, taking care of oneself often falls to the bottom of our to-do list. But I think knowing and managing your risk of both heart disease and stroke can save your life, and I think that's such an important thing to remember. And it's also important to remember that deaths from cardiovascular disease are completely preventable. So, I love participating in this today, because sharing this information with our patients is not only simple, but it's incredibly important.

Host: Yeah, that's a perfect way to end. And as I told you before we got rolling here today, these podcasts that we do for Franciscan Health, they're about education, right? About sort of people who want free medical information, free medical advice. And if they hear nothing else today, knowing your risk factors, knowing the signs and symptoms, recognizing that they may be atypical in women, and that there is assistance available, right? That you don't have to die of a heart attack, but you do need to speak with your providers, right? It's all good stuff. So, thank you so much.

Dr. Stephen Cook: Awesome. My pleasure.

Host: And if you want to learn more about preventing heart disease and take a free heart risk assessment, go to franciscanhealth.org and search heart care. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.