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The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss cardiovascular disease in women. Joining me in this panel is Dr. Ki Park, she’s an Assistant Professor in Cardiovascular Medicine at the University of Florida College of Medicine, and Dr. Kirsten Freeman, she's an Assistant Professor in Cardiovascular Surgery at the University of Florida College of Medicine. Doctors, I'm so glad to have you with us today. And Dr. Park, I'd like to start with you. If you could just tell us what you're seeing in the trends. Define common cardiovascular diseases that you're seeing most these days.

Dr Ki Park: Thank you for much for this opportunity. I'm excited to be here and talk about cardiovascular disease in women. I think overall there's been a trend in our field, more towards focusing on specific gender-related risk factors for cardiovascular disease in relation to auto-immune disorders and pregnancy conditions, which are associated with long-term cardiac risk.

We also are seeing better appreciation for the differences in a wide variety of cardiovascular conditions by gender. We know that women have different presentations in regards to acute coronary syndromes, valvular disease. Really sort of anything that you name within the spectrum of heart disease has some difference noted in women. So I think we're understanding that women are not just smaller versions of men and that this is particularly important when it comes to cardiovascular disease.

Dr Kirsten Freeman: I just wanted to add that in surgery, we tend to notice that women tend to present sometimes later than men, because sometimes the symptoms can be similar to other types of symptoms and slightly different than men with common, crushing chest pain of a heart attack.

Sometimes women have symptoms that are more like shortness of breath or that feel like reflux disease rather than the sort of typical angina-type symptoms. And so sometimes we see later presentations in women than we even do in men.

Melanie: Dr. Freeman, I'd like to expand on that for just a minute. As you've pointed out that the signs and symptoms can be very different, do you, in your opinion, feel that women as caregivers to everybody else that we do, we tend to put off some of those symptoms and brush them away and think they're stress or anxiety or a panic attack? While men are more difficult to get into a doctor, women, we sometimes don't look at our symptoms enough and realize what we have to do for ourselves.

Dr Kirsten Freeman: I think that's very accurate. I think that oftentimes women are making sure that family members are set up and they are in a role of what I call a house manager of sorts. And sometimes, by the time you get through all the normal lists of day-to-day activities, your own health may be at the bottom.

And so I do think that sometimes women push their symptoms off, men also push their symptoms off, but they often are encouraged by family members or spouses to seek treatment. Wherein sometimes women are not pushed by anyone other than themselves to then seek treatment because they often keep their symptoms to themselves.

Dr Ki Park: Yes. And I would just add on top of that, that I think those issues are compounded by the fact that as Dr. Freeman mentioned, women sometimes can have different types of symptoms than men do with the same type of condition. So for instance, I see a lot of women in my university clinic. We have a dedicated women's heart health clinic at University of Florida who have what's known as microvascular disease. So this is disease within the small microvessels, the arteries within the heart that are not amenable to stenting or bypass. And a lot of providers are also not aware of that condition.

So these women present repeatedly for evaluation for chest pain. They undergo multiple heart caths and often their conditions aren't recognized because providers sometimes don't understand that that condition exists. So I think the sort of issues surrounding the whole topic are so multifactorial.

Melanie: Well, they are. And, Dr. Park, because of what you just said and the presence possibly of microvascular disease, so many of the symptoms that we've started discussing here today are similar to stress and anxiety. For providers that are going to see those women, whether they're primary care or gynecologists, whoever the women are seeing, how do we know the difference? Does it take diagnostic tests in the cath lab and such? How do we know whether it's an anxiety attack or stress? Because so many of these symptoms mimic so many others.

Dr Ki Park: Yeah, it's a very important question. I think when we look at a patient overall, you know, we start with the symptoms. So how sort of classic are they? Are they atypical? But then we're also looking at the patient overall, you know, how old is the patient? What kind of risk factors do they have? I think, for a primary care provider and even for sometimes us as cardiologists, it is very challenging to tease all that out.

However, I think that in most patients, depending on the initial assessment, you know, at least some basic testing is likely warranted. We have a wide spectrum of testing that can be done from very minimally invasive such as a treadmill stress test, of course, to the most invasive, which is cardiac catheterization and trying to tease out what's right for which patient is something that's something within our area. But the initial step is to at least recognize that some evaluation is warranted. And again, that sort of depends on the patient's risk profile and oftentimes patients also appreciate some degree of testing at least to ensure that the overall structure of their heart is normal. And that there's nothing else grave that is being missed.

Melanie: Dr. Freeman, let's get into intervention criteria because we've discussed a bit about symptoms. We've discussed a bit about diagnostic criteria a bit, but I'd like to get into some of the intervention that you would try. Please characterize when a disease process needs some sort of intervention and where you come into that picture.

Dr Kirsten Freeman: So as far as intervention criteria goes, for each different pathology we have basic criteria. So when we're talking about coronary artery disease, it has to be of a significant blockage in order to warrant crossing into the risk benefit of either percutaneous intervention versus surgery itself oftentimes related to symptoms and the percentage of blockage for coronary artery disease.

In women, sometimes the size of the vessels can be an issue, meaning that they often are quite small and sometimes the ability to do a bypass surgery may be more difficult purely because of size. Other issues with aortic pathology also is due to size. Women are on the whole smaller than men and so we typically intervene sooner with an aorta. Men, we often wait until an ascending aorta is over five and a half centimeters. In women sometimes, depending on their size, we may want to intervene even earlier. Because we know that the larger the size of the aneurysm, the higher the risk of rupture.

And then there's valvular pathology, and often issues with your valves including most commonly the aortic valve and the mitral valve, they're all wrapped around the type of symptoms you're having, whether they're lifestyle-limiting, can they be controlled with medications? And on an echocardiogram, do they meet certain criteria that put them into a severe category? Usually, the reasons to do interventions are based on symptoms and severity of disease. And then once you get into a scenario of symptoms and a severe disease process, then we can look at the risk-benefit profile of the intervention.

Melanie: Then Dr. Park, as we're talking about the differences, when treating women with cardiovascular disease, speak a little bit about the multidisciplinary approach that's so important when you're working with women, whether it's valve issues or coronary artery disease, whatever the problem is. As you two work together, tell us how this works and who else might be involved because there's a whole cache of healthcare providers that can help women when they have cardiovascular disease.

Dr Ki Park: I think that's a really important point. In fact, Dr. Freeman and I were discussing a patient together this morning. You know, as she mentioned, when we look at a patient, we're considering a lot of different factors. There's anatomic factors, you know, can we actually do the procedures that we want either from a surgical end or from a minimally invasive percutaneous end? Sometimes we need our imaging colleagues to help us determine whether we need other additional imaging to better look at a valve particularly, now that we have transcatheter options. And so that's always important, I think, multidisciplinary care when you look at complex patients.

I think that this is particularly important also in women, as Dr. Freeman mentioned, and the anatomy is different, the sizing of a valves, those types of factors have to be discussed as to what is the best long-term result for the patient.

I also see women in my clinic, who are either pregnant, with a variety of cardiovascular conditions are considering becoming pregnant with known conditions, particularly valvular disease is something that comes up often. And so we need to discuss those patients as to what is the best planning in regards to future pregnancies, what types of valve is most appropriate for those patients? And so there's a really wide spectrum of folks within the team, both within surgery, interventional cardiology, imaging that really need to be involved in order to get the best outcome for the patient.

Melanie: And Dr. Freeman, I'd like to give the first last word to you. As we wrap up, what's exciting in your field in cardiovascular surgery, that you would like other providers to know that you're doing at UF Health Shands Hospital? Kind of give us a rundown or a summary on what you feel is exciting or what you're looking forward to in the future.

Dr Kirsten Freeman: I think what's exciting that we're doing at University of Florida is we're on the cutting edge of all the technologies. So all the new trials, we're just about to start a new trial for mitral valve interventions and doing them in a more and more minimally invasive way. There's a standard open operation that we use most of the time for complex aortic problems, aortic dissections, aortic aneurysms. But we also do all the way down to minimally invasive, where we're using a stent graft inside the aorta to treat aneurysms. So all the way from maximally invasive to minimally invasive, we have available at our fingertips.

You know, treating coronary artery disease sometimes can be done in a standard open coronary artery bypass grafting. Sometimes it can be done using percutaneous interventions. And then sometimes we have to do a hybrid. It just depends on the anatomy. Additionally, our valvular pathologies, more and more, our aortic valve stenosis are being treated by minimally invasive means namely through the TAVR. But there's always the availability for a standard open-heart operation 24/7 at University of Florida. So if for some reason, there is an inability to do something minimally invasive, we can transition very easily with our huge team of people that we use to accomplish complex operations.

Melanie: Dr. Park, last word to you. What would you like other providers to know about the differences between men and women when it comes to cardiovascular disease, the difference in symptoms? And really, and this is your advice to other providers, the importance of listening to their patient and hearing those complaints and taking them seriously and helping their patient figure out what's going on.

Dr Ki Park: I think you sort of hit the nail on the head with the last comment in terms of listening to your patient. As was mentioned earlier in our discussion, women are very busy. They're very caught up in managing the family and everything else. Perhaps at the home and children and whatnot. And I think it's important to recognize that women really deserve full attention when they're in our clinics seeking evaluation. They've taken a lot of time out of their other demands and whatnot to come and see us.

And often the symptoms can really be very subtle. We're always taught that patients with coronary disease have sort of classic, you know, crushing elephant on the chest type discomfort, whereas in women oftentimes, they just have subtle signs of some shortness of breath, or they only have jaw or shoulder discomfort or just some upper abdominal type nausea, those types of subtle symptoms, however they're very persistent. And if they're at the point where they're coming in to seek evaluation, we really need to take time and listen to them and not just say that we can excuse it as either stress or anxiety or some other psychologic condition.

Melanie: Thank you, doctors, so much. What an important episode we've just recorded here today. Thank you so much for joining us. To refer your patient or to listen to more podcasts from our experts, please visit UFHealth.org/medmatters for more information and to get connected with one of our providers.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.