Cheryl Martin (Host): Heart disease is a leading cause of death for women here in the United States. Unfortunately, we women sometimes fail to recognize our own heart health warning signs. But the good news is with awareness and education, we can lower the risk and the number of unnecessary deaths. Here to tell us more as Heide Chaney, Doctor of Nursing Practice in the Jefferson Healthcare Cardiology Clinic.

This is To Your Health, a podcast from Jefferson Healthcare. I'm Cheryl Martin. Heide, delighted you're on to talk about heart disease in women.

Heide Chaney: Thank you.

Cheryl Martin (Host): Why is it so prevalent among women?

Heide Chaney: Well, it's prevalent because it is the number one killer of women in the United States. Heart disease, first of all, is kind of an umbrella term that includes coronary artery disease and heart attacks. And when you put all of those statistics together, it still is the biggest cause of death in the United States for women. In 2020, which is the last official statistics that were completed, the CDC reported over 314,000 women that died from heart disease, and that's one in every five female deaths. That's a very high number for a disease that can, for the most part, be managed with diet and exercise

Cheryl Martin (Host): So, women then should have a better understanding about heart disease. There's that need.

Heide Chaney: Yes, they absolutely should. Heart disease in women really, it's understudied, it's underdiagnosed, it's undertreated, and I think it's underappreciated. They did a survey last year sometime, and only about 56% of women actually were aware that heart disease was their number one killer. So that to me says that almost 50% did not know, and that's a number that I think we need to focus on changing.

More women typically are worried about breast cancer than about having a heart attack, even though heart disease kills about six times as many women every year. I think this is because fewer women know someone who has had a heart attack. More women actually know someone else who has experienced breast cancer. And this is probably because heart attacks have a later age of onset for cardiovascular disease. In fact, usually the average age for women to have a first heart attack is about age 70. Whereas breast cancer increases with age, so it starts earlier, it's about a median age of 60 or 62 But it remains that worldwide cardiovascular disease is responsible for 35% of deaths in women, and this is more than all cancers combined.

Cheryl Martin (Host): So, do you think that there's just been a better job of promoting breast cancer over women's heart health also?

Heide Chaney: Yes, I do agree that that's true. I think heart health is kind of put on the side burner and we'll talk about that to a degree a little bit later. I'll make some points about that.

Cheryl Martin (Host): So, any other reasons why you think that women don't recognize heart disease?

Heide Chaney: Yes, I think for women, for many, heart disease is still considered a man's disease, and the reality is that it's not, almost as many women die each year from heart disease as men and women commonly share that their providers just don't talk with them about heart disease in their routine physical exams. Unfortunately, on top of that, women are known to minimize their own symptoms. So even when the topic is brought up and the symptoms are disclosed, they still report feeling that they're dismissed or that they're unheard by their provider and then those symptoms are often brushed aside or they can be attributed to stress or panic disorder or hypochondria. So unfortunately, women are treated differently than men in many instances.

Cheryl Martin (Host): I want to talk about that difference, but you mentioned symptoms, so what are the symptoms women should look for?

Heide Chaney: Well, there are a number of symptoms that women should look for, and they can present much differently than in men. Women can experience chest pain or chest pressure, which is the most common symptom reported by men, but they can also simply experience nausea, sweating, vomiting or pain. And that pain can be referred to other places in the body other than the chest. It can go to their neck, their jaw, their throat, their abdomen, or their back. Only about one in eight women actually report chest pressure or tightness or aching, which would be a typical type of chest pain.

Cheryl Martin (Host): Now, let's talk about women not being treated for heart disease. Do you believe that there is some gender bias then in treating women with heart disease?

Heide Chaney: Yes. But this is not always intentional, and it's not a new problem. Gender bias in medicine and particularly in cardiology, there's been underrepresentation of women throughout the care continuum. So, there are more male cardiologists. There's more male researchers. There's more male trial participants. And over time, this has a tendency to skew medical education as well as guidance and research and even quality of care, and it skews it toward men as the baseline. So, providers have to be careful and they have to recognize their own implicit biases, which can then pose problems when they conflict with variations in symptoms, in risk factors, or clinical manifestation.

The reality is that heart disease can develop and present very differently between men and women, as we just spoke about. And it's important for providers to be aware of these differences so the patient can be treated accordingly. For instance, there's biological difference in the anatomy and physiology between men and women. Women have smaller hearts, they have narrower vessels, and this can make heart disease manifest differently in men and women.

Cardiac catheterization, which is one of the tests we use to help determine blocked blood vessels, has been the gold standard for diagnosing heart attack for a long time. But this test tends to look for blockages in large arteries. And since women are more likely than men to experience more plaque buildup in the smaller arteries of the heart, sometimes this test might not be the most appropriate to diagnose heart disease in women. Sometimes a cardiac CT or an MRI might be a more appropriate test. And medical providers are just only now starting to really study and realize that the same test, the same medications and the same procedures that have been used on men for centuries might not be the answer.

Cheryl Martin (Host): So, this is why it's even more critical for women to watch for the symptoms that you mentioned, and then talk to their healthcare providers about them and be proactive.

Heide Chaney: Yes. And actually, they should never wait. Heart problems can develop silently over time, and we can fine tune prevention and we can help reduce a woman's risk of heart disease in an annual checkup. Lifestyle changes can have a significant impact on reducing cardiovascular events, even if it runs in someone's family history. So, women need to know their risks, and they need to know the steps that they need to take to reduce those risks.

Cheryl Martin (Host): Talk about those steps specifically. What should women do? Educate us.

Heide Chaney: Well, we have what we call both modifiable and non-modifiable risk factors that we look at in both men and women. And the modifiable risk factors are risk factors that we have the power to change. Those would be things like high blood pressure, high cholesterol, high blood sugar, smoking, obesity and overweight, stress, dietary measures. But among all of these modifiable risk factors, there are some pretty extreme differences between men and women. For example, a woman's reproductive history can affect her risk of developing heart disease. If a woman has gestational diabetes or preeclampsia during a pregnancy, they're strong predictors of heart disease. So, these women should focus on and adopt healthy lifestyles early, and they should also make sure that their provider is aware of this increased risk.

Estrogen also, it helps protect women from heart disease. It increases the good cholesterol that's called high-density lipoprotein or HDL, it's commonly referred to. And it also decreases the bad cholesterol, which is low density lipoprotein, or often called LDL. And after menopause, women lose this protection And also with age, women's body fat increases and fat distribution changes and those cholesterol numbers can change.

Triglycerides, which are another component of cholesterol, they're also an important contributor to cardiovascular disease in women. And the cholesterol plaque that can build up on the inside of vessels from that elevated cholesterol can cause blockage or inflammation.

And we talked earlier about the anatomy, compared between men and women, men typically develop this plaque in the large arteries that supply blood to the heart. Women are more likely to develop this buildup in the heart's smallest vessels. It's called the microvasculature. Medical providers, they have a lot of experience treating typical cholesterol plaque buildup in the large blood vessels. But there's not as good of understanding in how to treat plaque in the microvasculature or even in inflammation of the heart.

So additionally, we have some other factors like diabetes in women. Women who had a previous previous heart attack, diabetes doubles the risk of a second heart attack. And women who smoke are more likely to have a heart attack than men who smoke.

So, there's a lot of different kind of things to think about as far as risks. And another thing that comes to mind is that women are more likely to suffer from diseases also that mimic a heart attack. So, coronary spasm is when a blood vessel clamps down and it can mimic a attack. And that's more common in women than in men. Women are more likely have a coronary dissection when one of the coronary arteries opens up or splits when the wall of that vessel tears. And there's also a condition called Takotsubo cardiomyopathy. That's an inflammatory response that causes the heart to enlarge or get bigger after an emotional stressor, oftentimes the death of a spouse or something like that. It's called broken heart syndrome. So as you can see, there's a lot of risk factors that differ between women and men.

Cheryl Martin (Host): So, it looks like women need to be proactive in studying this themselves, but also when they have, let's say, a yearly physical, should they then take the initiative and ask their doctor or express their concerns?

Heide Chaney: Absolutely. I think more women should be coming forward and asking about heart disease. they will be the ones that will present those risks, like we talked about, having a history of gestational diabetes or pre-eclampsia, because not every primary care provider, especially if you travel to different places or move to different areas, will know that history. Your family history is important. But we can take a lot of steps to prevent heart disease if we just know the facts.

Cheryl Martin (Host): Speaking of facts, is the risk of cardiovascular disease different in women than in men?

Heide Chaney: Yes, the risk is different because of some of those things that we talked about before. Now, women and men both have the modifiable and the unmodifiable risk factors. But men do have an age difference. Men over the age of 50 as compared to women over the age of 60. Those can be cutoffs that we kind of watch for. And also, men just by the fact that they're men have a little bit higher risk of heart disease than women.

Cheryl Martin (Host): So, what if a woman changes her diet and exercise? Or even if she doesn't, but she still has a heart attack, what signs should she watch for?

Heide Chaney: Well, kind of like we talked about before. Women should take more care to watch for, I would call it uncomfortable pressure, maybe fullness, burning or squeezing in the chest rather than outright chest pain. pain ,Also unusual shortness of breath. We mentioned before nausea, vomiting, dizziness, sweating. Fatigue can be a common sign in women. And if they have these symptoms, they definitely want to immediately report those to their provider. Obviously, they need to call 911 if the symptoms can't be relieved with rest or nitroglycerin.

But the other thing that I wanted to make mention is that there's a number of things that women can really do to help prevent cardiovascular disease. And this ties back into talking with your provider about things you can do because there's a number of steps that are very helpful. Eating a healthy, balanced diet is absolutely crucial to maintaining a healthy heart and a good circulation system as well. So not just the heart, but all the vessels in the body. With that healthy diet, they should include a wide variety of unprocessed and fresh foods, and that's a common problem in our society, right? Everything is processed. This should include plenty of fruit and vegetables, and that's five portions a day for most people. Whole grains, nuts, foods that are low in saturated fats, sugars, and salts. Be very wary of processed foods because these often contain high levels of salt. I talk to my patients a lot about avoiding things that come in boxes, bags, or cans, because what they add at the dinner table is really not what's significant. It's where sodium hidden in our diet.

Also, drinking lots of water, which can help with weight loss. Exercising regularly. It only takes 30 minutes of moderately intensive physical activity about five days a week to improve your cardiovascular health. Any adult aged 18. Up to over age 65 should get at least 150 minutes of that moderate intensity physical activity that we talked about or 75 minutes of a more high intensity physical activity every week. So, trying to just make exercise a regular and enjoyable part of your life using the stairs instead of elevators. Get off the bus a few stops earlier, walk the rest of the way, walk to work if you're able. So, there are a lot of those steps that we can do.

And for women and men, if you stop smoking, your risk of coronary heart disease will be halved within a year. And it will return to normal level over time. That's dependent on each person. But also, just avoiding smoke-filled environments. Exposure to secondhand smoke can significantly increase your risk of a heart attack. And to remember that all forms of tobacco are harmful. And as with tobacco, there's also really no safe level for drinking alcohol. And even though there's studies out there that say a little wine is good, right? We all want to believe that but the detrimental effects of alcohol absolutely far outweigh any potential protective benefits of alcohol. So while drinking less may reduce your risk of cardiovascular disease, the evidence actually shows that the ideal situation for health is to not drink at all. Even moderate drinkers notice health benefits when they stop drinking alcohol.

And probably one other thing I want to add, especially for women, is that stress is very significant. It causes the arteries to tighten and this can increase the risk of heart disease. Exercising, deep breathing, relaxing your muscles and making time for the things you love. Those are some of the things that you can do to help manage your stress levels. And if things are starting to feel out of hand, don't be afraid to talk to someone or to seek help, professional help, to help deal with that.

Cheryl Martin (Host): This has been really, really informative. Thank you so much, Heide Cheney. I so appreciate you providing answers on what we women can do to lower our risk of getting a heart disease.

If you'd like to book an appointment today, call the Jefferson Healthcare Cardiology Clinic at 360-344-1001. That's 360-344-1001.

If you found this podcast helpful, please share it on your social channels. You can check out the full podcast library for other topics of interest to you at jeffersonhealthcare.org. That's jefferson healthcare.org. This is To Your Health, a podcast from Jefferson Healthcare. Thanks for listening,