Traci Manis, BSN, RN (Host): For decades, medicine treated women's hearts as if they were simply smaller versions of men's hearts. Today, we know women's cardiovascular health isn't simply a variation of men's, it's unique. And understanding those differences saves lives. My name is Traci Manis. And today, on the Care Empowered podcast, I'm joined by two NKC Health cardiologists who are challenging outdated assumptions and ensuring women have the knowledge and support they need to advocate for their hearts throughout every stage of life. Dr. Malay.

Rajya Malay, MD: Thank you.

Host: And Dr. Wilt.

Heath Wilt, DO: Hi.

Host: Welcome to the podcast.

Heath Wilt, DO: Thank you.

Host: Heart disease is still the leading cause of death for women, but many women don't realize it. Why do you think the awareness is still so low?

Heath Wilt, DO: Yeah, it's a really good question. A lot of women don't realize, like you said, that heart disease is the remaining, or the highest cause of death for women in the United States. One in three women, unfortunately, will perish because of cardiovascular disease, right? A lot of this comes down to, I think, a lot of historical misconceptions. Some of this are related to hormonal differences between men and women. We know that women generally have a little bit more of a protective buffer because of their hormones. But later on in life, we lose a lot of that protective qualities.

A lot of women also present with different disease types, different symptoms. And so, sometimes the recognition or the diagnosis is made later, sometimes unfortunately at the consequence to her own health.

Host: Okay. Okay, that's good to know. We often hear that heart disease affects everyone. So, what actually makes women's hearts different from men's?

Rajya Malay, MD: Great question. Adding on to what Dr. Wilt already said, it's not just one thing. It's a wide area of things that are different. If you take the risk factors, for example, a man has diabetes versus a woman has diabetes means same to the patient, but the risk actually is much higher in women to have heart attack or stroke in the setting of diabetes, high blood pressure, compared to men.

Take a man who's a smoker, who smokes a pack a day, a woman may have to just smoke two or three cigarettes a day to get to that kind of risk. So, it is not the same. And the pathophysiology, like looking at why a woman has a heart attack, it's not always related to blocked arteries. They can be coronary spasm. They can be dissection. There can be more abnormal stresses in women, but less blocked arteries. So, it kind of creates a conundrum of what are we treating here? What is the actual cause of symptoms? Because when you look at younger men and younger women, more younger women die from heart attacks even though they don't have as many heart attacks. So, we are still learning a lot about this.

Host: That's fascinating, and very complicated.

Rajya Malay, MD: Extremely complicated.

Host: Wow. Okay. Why have women historically been under-diagnosed or diagnosed later when it comes to heart disease?

Heath Wilt, DO: Yeah. So, we know from years of research, mostly in men, that women are less likely to present with the classic symptoms, particularly with a heart attack. The old classic elephant on the chest that most men experience is less common in women. They're more likely to have jaw pain, shoulder pain. Sometimes it's something as simple as feeling just off or indigestion or heartburn. The same thing carries forward with other cardiovascular disease. So, hypertension, the silent killer, many times symptoms don't arise until complications have arisen. Or strokes, where women are less likely to have objective findings like facial droop, slurred speech, and may just feel off or imbalanced or dizzy.

Rajya Malay, MD: It's not just heart attacks. People get hung up on the whole, "Oh, if it's not a heart attack, it's not important. I'm fine." And seriously, a stroke is, like, so underrated for risks.

Host: Okay, I have a question about that. So, women have typical symptoms. So, it could feel like indigestion. It could feel like just fatigue. When women get tired, they have a lot of responsibilities. How often do you think women ignore those things because they don't want to seem dramatic?

Heath Wilt, DO: I think that happens a lot. In my experience, I'm sure Dr. Malay has plenty of stories of her own. We see this all the time. Women come in, you know, dismissing the symptoms as something else, either because they feel like they don't have the time or the needs to be able to be checked out themselves. So, I always stress to my patients, if something doesn't feel right, if it feels off, that's the time to get evaluated, get checked out.

Host: Better safe than sorry.

Heath Wilt, DO: Absolutely.

Host: Yeah. Okay. Your goal is to close the knowledge gap around women's heart health. What made you passionate about that?

Rajya Malay, MD: Wouldn't that be nice to close the gap?

Host: Yes. Yeah. Please close the gap. Please.

Rajya Malay, MD: So, the gap itself has created the passion, beause think about how long we've known this. We've known this at least—the American Heart Association went with the Go Red For Women more than 20 years ago. And the whole agenda was one in three women die from heart attacks. And the first slide still in our talk is one in three women die from heart attacks. So despite all this knowledge that we've gathered, we really have not made strides in the outcomes yet. So, there's so much work to do that creates a passion. Like, when there's work to do, here we are.

Host: Yeah. And I'm so thankful that there are people like you who do have that passion and who charge ahead.

Rajya Malay, MD: Thank you.

Host: Yeah, you bet. You mentioned that women don't have the typical symptoms of a heart attack, but a heart attack isn't the only thing that we need to be worried about, right? There are other cardiac issues that could lead to serious complications. Can you expand on that a little?

Heath Wilt, DO: Absolutely. So, we've emphasized a couple statistics that are sobering. Fifty percent of all women in the United States will have some type of cardiovascular disease. One in three women will die from a cardiovascular event, and they're not all heart attacks. The things that we really worry about are things like heart failure, abnormal heart rhythms, particularly one called atrial fibrillation or AFib.

And not all heart attacks are built the same. A lot of people think that heart attacks are going to be a dramatic event, the clutching of the chest, you know, maybe some event where people clearly look very ill. But we also know that women are more likely to have a different type of a heart attack called an NSTEMI, and these are signs that the heart is struggling to keep up with the demands. That could be something like a very bad infection. It could be after a major injury, a car wreck. But if there's something that just doesn't feel right, these are times to be checked out. Kind of like we mentioned, not all people are going to present with the same type of symptoms.

Same thing as holds true for stroke, like we mentioned. So, that is another big one that we always want to be very diligent in managing. And that kind of emphasizes, you know, our colleagues, our coworkers, when we see our mothers, our wives, our daughters that look off, they don't look right. And if they are reluctant to be checked out, it's something that we really want to press to make sure that they're not having something like a stroke or problems from really high blood pressure that could lead to an event.

Host: Okay. Now, can some of those injuries be advancing over time, or is it typically something that comes up kind of out of nowhere.

Heath Wilt, DO: Yeah, absolutely. It goes both ways. Something like high blood pressure, it can continue to mount until we have problems like a heart starting to fail because of pumping against high blood pressure, or blood vessel changes that might predispose them to a stroke or a sudden event.

Or it could be something that occurs very insidiously. Dr. Malay mentioned younger females, particularly those of childbearing age, have an entirely different type of pathology or disease process that may be different than those that continue to mount through life. So, women that might have problems during childbearing years of high blood pressure or diabetes that can continue to follow suit and increase their risk long term.

Host: So, it stands to reason that a woman should probably get a baseline with a cardiologist young to see if any changes are happening along the way.

Heath Wilt, DO: Yeah. And again, that's kind of the reason we want to establish a more firm guided program for women's heart care clinics, so we can identify those risks that might become a problem later on that we can start treating now.

Host: Okay. Fantastic. Okay. Many women don't realize that complications like preeclampsia or gestational hypertension during pregnancy can double their risk for heart disease later. Why is that connection so important?

Rajya Malay, MD: This is such an important topic. Ten to fifteen percent of all pregnant women have some kind of high blood pressure or diabetes-related cardiovascular disease associated with it. The reason it's important, it is not just that phase of the life that's affected by it. If you follow all these women for decades to come, their cardiovascular risk is not just two times, not just four times, sometimes as high as eight to 10 times higher, especially women who have preeclampsia. The thought process is actually considering what may be happening in that period is the change in the vasculature that may have caused the preeclampsia that predisposes them to the rest of their life to have more high blood pressure, more risk of stroke, more risk of kidney disease.

So, if you don't look for it later, you'll forget about it. You have your child, you go home with your baby, you take care of your family, and then you forget to check it again. And now, the ACOG actually recommends that people with preeclampsia or eclampsia be checked within the first few years after giving birth to make sure they don't have high blood pressure. So, it is a recommendation now to make sure you follow up and don't forget about these risks that is carried on for years to come in your life.

Host: Not all women go through pregnancy, but all women will go through menopause.

Rajya Malay, MD: That's true.

Host: So, let's spend some time exploring that stage specifically. What changes during menopause should women be paying attention to?

Rajya Malay, MD: A lot of changes happen. It's not just people typically say, "Oh my God, I have hot flashes," or, "I've gained weight." But underlying changes like increase in high blood pressure, increase in glucose levels, and cholesterol changes happen because up until menopause, which again is not a one-week event, a one-month event, or a one-year event, this happens over a period of years. So, you have bone loss, muscle loss. Your muscle is being replaced with fat, so your insulin resistance changes, your cholesterol metabolism changes. From my personal experience, my cholesterol jumped 30 points. For first time in my life, my cholesterol has been never so high, and the only thing I can think of is the protection from the estrogen has dropped. So, that is pretty common in menopause. And while women do experience some symptoms, none of these things like elevated blood pressure or cholesterol cause any symptoms, so they may not even know unless you check for it. So, you have to be vigilant about these changes. So, that is where we come into picture. If menopause is causing these changes and increasing your cardiovascular risk, we can actually assist you figure that out and treat appropriately.

Host: Right. And you're making connections that women don't make because we don't have the knowledge.

Rajya Malay, MD: Absolutely. So, we rely on you. And we can't blame them for that because for years menopause was very natural and patients did receive hormone replacement therapy, but we had some mishaps some research publications like Women's Health Initiative, which kind of brought some bad rap to the hormone replacement therapy. The issue was not actually hormone replacement therapy in those patients who've had bad outcomes. It was the timing of it. It's the timing. When you start is very important. So, that is something we would like to talk to patients on one-to-one basis and see who is the right candidate for this.

Host: Yeah, and that gives women some peace of mind.

Rajya Malay, MD: Absolutely.

Host: Yeah. Yeah. That it's okay. All right. Okay. Stress affects so many women, balancing work, caregiving, family. How much does stress really impact heart health?

Heath Wilt, DO: Yeah, I get this question a lot. I think a lot of people, men and women. But particularly, women I see in my clinic, they talk about stress and how that may influence their cardiovascular health.

And I think a lot of people somewhere misappropriate stress into cortisol, and all people are familiar with cortisol, a hormone that all of us require. Cortisol is not necessarily a bad word, but I look at cortisol as kind of like the accelerant to the campfire. The risk factors are the ones that stack your risk for cardiovascular disease, and cortisol can influence those by things like modulation of how well we digest sugars or increase inflammation in the body.

But a lot of times, the stress is mounted and comes with socioeconomic factors. And we know this through decades of research sponsored by the American College of Cardiology, even European Society of Cardiology, endorsed by American Heart Association, that a lot of socioeconomic factors that a lot of us live in will increase your risk for cardiovascular disease.

And a lot of these include things like sleep quality, you know, financial constraints, air quality. All these have been shown to increase risk for things like high blood pressure, stroke, heart attack. And unfortunately, a lot of women, much like we've talked about, are the cornerstones for their family. There are a lot of single mothers out there that are trying to balance work-life balance, being a single mother, trying to raise the family, trying to make sure that all demands are met. And with those factors, that increases the risk for things like poor capacity for routine meals, for better sleep, and all these things start to increase risk, or they amplify underlying diagnoses like high blood pressure or diabetes and make them harder to manage.

And so, a lot of times, stress is more directly equivalent to the underlying risk factors that then are make it harder to manage. So, stress is absolutely a factor for cardiovascular disease, but I think it's what the stress represents and how we can manage those underlying factors.

Host: Right. It's not probably going away. We just need to learn how to manage it, like you said.

Heath Wilt, DO: Exactly.

Host: Okay. Is heart disease preventable?

Rajya Malay, MD: Apart from genetics and age, most of these risk factors are preventable. The ones that are genetic we cannot change, of course. But if you want to do something for yourself, there are some things you can definitely change. We call them lifestyle modifications. So, our Life's Essential Eight, like know your numbers, know your blood pressure, know your cholesterol, know your waist-to-hip ratio, your weight, make sure you're eating healthy. I mean, obviously, we all can't always be eating healthy, but at least make most of your health choices and your dietary choices keeping your cardiovascular health in mind, and that's something people can do. Move regularly. Thirty minutes of simple activity like walking. I usually tell my patients walk for 10 minutes after each meal, and that is not asking a lot. You can do it indoor or outdoor, and that adds up to 30 minutes a day. Even if you don't do it 30 minutes straight, if your life doesn't allow you to do it, this is something you can adapt, is moving as soon as you eat so you don't sit down, and that definitely helps your metabolism. So, these are the simple steps. Move, keep an eye on your weight, keep an eye on your blood pressure. This is the one thing that I often see women ignoring is hypertension. High blood pressure is really serious. That is why it's called the silent killer. And no, you will not have symptoms because of high blood pressure until it's really late.

Host: So, what's the recommendation for a high blood pressure reading? So if you go to the doctor, you get a high blood pressure reading, but that's abnormal for you. How many high ones in a row make for something that you should pay attention to?

Rajya Malay, MD: So if it's in a doctor's office, we say it has to be two separate readings, at least taken 15 minutes apart, and preferably in two different office settings, okay? We also ask patients to check it at home, because a lot of patients just walk across the parking lot to come there, and they're rushing, and they've just had a cup of coffee, and God forbid, maybe they just smoked a cigarette, or something like that could definitely make your blood pressure go up. So, we do like to know what your blood pressure is at home, in the office. And at least two abnormal ones, more than 130 over 80, we take it seriously. And we may start off by saying, "Try to cut down on your salt. Maybe get a good weight and take your stress into account, or maybe you're not getting enough sleep." And sleep's a really important deal. Like Dr. Wilt mentioned, a lot of us ignore the importance of sleep or getting sleep apnea checked if that is something that is on your radar. Like, if you're snoring a lot, that may be affecting your blood pressure as well.

Host: Is it normal for blood pressure to rise naturally with age?

Rajya Malay, MD: Absolutely. Yeah. So, that's another thing I was going to bring up when you mentioned menopause is when we're aging, and a lot of patients come to me and they go, "I've never had high blood pressure in my life." So even though essential hypertension or the most common type of high blood pressure is diagnosed between the ages of about 35 to 50 is the most common age, but it's not uncommon to get diagnosed as we age older. So, our arteries get harder. They're easily compressible when they're young, harder to compress when you're older. So, it is not uncommon to have high blood pressure in older age.

Host: All right. We've talked about a lot of things today. What's one thing that you want women to take away from our conversation today?

Rajya Malay, MD: I really, really want every woman to know and not ignore that heart disease is a thing that we cannot ignore. It is a real risk, and this is something we all have to come to the table together and address.

Host: Okay All right. Tell us about the new heart care program for women. What inspired NKC Health to create this clinic?

Heath Wilt, DO: It's the conversation we've had here today. It's like Dr. Malay said, there's a gap and that passion to close that gap. We've seen this in the medical community over the last few decades, but only the last few decades where we're closing the gap on mortality and morbidity risk, which means complications and death risk because of cardiovascular disease, and that's coming through better awareness. It's coming through better research. It's coming through better funding, and we want to be able to pass this on to our community. It's our mothers, our daughters, our wives, and there is a discrepancy between the symptoms, how we manage the care, how we provide different types of therapy, different options earlier, different times in life.

That disease is always evolving. As far as the kind of patients that we're looking for, we certainly want to emphasize, I think, a lot of the topics we talked about here today, which is identifying those risk factors early. Have we had problems during pregnancy? Are there strong family histories? An attitude that we really want to continue to provide good long-term care for ourselves? Are we having symptoms that we can't explain that are just new for us? Those are the types of patients that we certainly want to see at the top of the list. But anyone that's invested in their long-term healthcare, those are the type of women we want to get in and help and guide them through their life to reduce their cardiovascular risk and provide best health for them.

Host: I'm so thankful that you have taken this charge and taken women's heart health seriously and are taking it to our community to make our community healthier and for women to live longer, healthier lives. Thank you for that.

Heath Wilt, DO: Thanks for having us.

Host: And to our listeners, thank you for joining us for another Care Empowered conversation.