Maggie McKay (Host): When it comes to heart health, there are differences between men and women. Joining us is Dr. Manjula Ananthram, MBBS, Assistant Professor of Medicine at University of Maryland School of Medicine and a Cardiologist at University of Maryland Medical Center, to discuss empowering women through heart health. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Maggie McKay. Thank you so much for being here today, Dr. Ananthram.

Manjula Ananthram, MBBS: Thank you for having me, Maggie. It's an honor and a privilege to be here.

Host: Oh, well for us too. Let's just get right into it. Can you explain the unique aspects of heart health in women compared to men and how symptoms might differ?

Manjula Ananthram, MBBS: Maggie, when it comes to heart disease, men and women do not have an even playing field. They are not created the same or treated the same. Sex and gender construct variables influence many aspects of heart health, including women's risk for heart disease, or how they present with heart disease, or the way they are managed and their response to treatment.

In addition to the traditional risk factors for heart disease, women have unique risk factors such as pregnancy associated conditions, and polycystic ovarian syndrome. Although many women will have the classic crushing central chest pain, which is thought of as the telltale sign of a heart attack, they often report three or more additional symptoms.

This was found in the Virgo trial and some of these symptoms include shortness of breath, pain or discomfort between the shoulder blades, shoulder pain, neck or jaw pain, unusual fatigue, nausea, vomiting, epigastric pain, sleep disturbances, anxiety, dizziness, and sweating.

Now these accompanying symptoms can sometimes distract the medical team from a cardiac diagnosis, resulting in delays in diagnosis and treatment of a heart attack. Unfortunately, sudden cardiac death or heart attack can be the first symptom of heart disease in women, especially younger women.

Now, the coronary arteries themselves look different in women. They're smaller. For instance, when a woman presents with a heart attack and they do a heart catheterization, there may be no obvious signs of blockages in the major coronary arteries; although blood flow to the heart muscle may be decreased. This is what we in the medical community refer to as MINOCA, or myocardial infarction of non obstructive coronary arteries. Women also can have microvascular disease. Their plaque buildup can look different. And this is what we refer to as INOCA, ischemia of non obstructive coronary arteries. So those are some of the big differences I see in how women present compared to men. And I also want to point out that because of this, women tend to be treated less aggressively with guideline directed therapies.

For example, they get less aspirin compared to men and they undergo fewer procedures than men. And they have more procedural complications overall. The synopsis of all this, is women tend to fare worse than men. Within the first year of a heart attack; their risk of being re-hospitalized is higher and their likelihood of dying is higher than that of men.

Host: Oh my goodness. What are some common misconceptions about women's heart health that you see and how can we raise awareness?

Manjula Ananthram, MBBS: So one of the common misconceptions that I see is patients who think that cancer is the leading cause of death in women. Now, heart disease and not cancer is the number one cause of death in women. Heart disease can affect women of any age and is responsible for about one in five female deaths. Now initiatives such as the AHA Go Red for Women campaign or the Heart Truth campaign from the NHLBI, can help increase awareness and reduce pre hospital delays in heart attacks and strokes and raise overall awareness of stroke manifestations of heart disease in women.

Additionally, it's interesting to note that the primary care physicians rank heart disease after weight issues and breast health as priorities in caring for women. So dedicated efforts to promote awareness and retrain providers is important.

Host: Are there any specific cardiovascular conditions that predominantly affect women and what treatment options are available?

Manjula Ananthram, MBBS: So, there are certain conditions such as stress cardiomyopathy, MINOCA and INOCA that we touched upon earlier, spontaneous coronary artery dissection, pulmonary hypertension, and diastolic heart failure that are more common in women than men. So for example, diastolic heart failure is more common in older women and can be managed by optimal control of blood pressure, diabetes, sleep apnea and maintaining an optimal body weight.

 There's also a condition called stress cardiomyopathy, or broken heart syndrome, that's more common in women, precipitated by stressful situations, causing weakening of heart muscle and heart failure. And the treatment includes drugs that are proven in management of heart failure. Now spontaneous coronary artery dissection is more common in women. What happens here is there's a spontaneous tear in the coronary arteries leading to decreased blood supply to the heart or a heart attack. And management of blood pressure is important in these patients and they may be treated with medications or invasive therapies.

Host: So you touched on this a little bit, but are there specific risk factors for heart disease that affect women more than men? And how can they be managed or even prevented?

Manjula Ananthram, MBBS: So diabetes and smoking are some of the traditional risk factors that are more potent in women compared to men. Now, we know that there are more male smokers in the U.S. than women. However, a woman who smokes has greater negative vascular effects for the same number of cigarettes smoked when compared to a man.

Biologically, smoking is more harmful to a woman's heart and blood vessels. We also know that emotional, psychosocial stress and depression play a role in heart disease, more so in women than in men. Depression is especially a strong risk factor for early onset cardiovascular disease in women.

Host: How do hormonal changes like during pregnancy or menopause impact a woman's cardiovascular health?

Manjula Ananthram, MBBS: That's a great question. So now, overall in the U.S., the heart health of pre gestational women and pregnant women has declined. Now, this increases the risk of adverse pregnancy outcomes and increases the lifetime cardiovascular risk, not only of these women, but also of their children. Now, women with hypertensive disorders of pregnancy, such as preeclampsia, eclampsia, those that have diabetes, gestational diabetes, have a higher risk of developing cardiovascular disease.

Events such as miscarriages, pregnancy losses intrauterine growth retardation also adversely affect the cardiovascular health of women. They also develop peripartum cardiomyopathy, which is heart failure surrounding the time of delivery. We all know that estrogen has a protective effect on developing cardiovascular disease in women with menopause and estrogen withdrawal.

There are changes in the body fat deposition, they develop higher cholesterol and lipid levels. Endothelial dysfunction, which is dysfunction of the lining of the arteries, inflammation, glucose intolerance, and all of this predisposes to heart disease. Hypertension is also more prevalent in women after menopause.

Host: Dr. Anantharam, can you discuss the role of stress in women's heart health and any strategies to manage stress for better heart outcomes?

Manjula Ananthram, MBBS: Yeah, that's another great question, Maggie. And we all know that adverse social determinants of health, mainly education, income, socioeconomic status, including sexual violence and psychosocial stressors, have a complex role in heart disease in women. And women in turn have greater exposure to such factors and are more vulnerable to this.

Prolonged stress can increase stress hormones and chemicals that promote inflammation in the body. Now exercise is a great way to counteract this. It's a great stress buster and gives the body a surge of mood enhancing chemicals called endorphins. Other techniques such as deep breathing, mindfulness based meditation, music, yoga, and activities such as reading, gardening, participating in support groups help relieve stress and stay positive.

Host: And what are the key lifestyle changes that women can incorporate to promote heart health? You just named a few, but how effective are these changes? And also what about diet?

Manjula Ananthram, MBBS: So, I'd like to discuss what the American Heart Association has put out, and they call it the Life's Simple 7. One, is not smoking. Two, be physically active, and that's very important. It's important to note that women are less likely to be physically fit in all stages of life, so this is something they can change. Add more steps to the day, track the number of steps they walk every day. If they're sitting and working at a desk, get up and walk around for five minutes every hour. Other important things are to have a normal blood pressure, a normal blood glucose level, normal cholesterol level, maintain a normal body weight, have a body mass index less than 25, and eating a healthy diet. Less fatty foods, more plant based foods, minimize red meat. So there's some data that plant based foods help decrease the incidence of cardiovascular disease. So all of these are really important to keep in mind.

Host: I think we can all do that. You just have to remind yourself and put your mind to it, right? Make a list.

Manjula Ananthram, MBBS: Yeah, and make small changes that you can keep up with. Drastic changes are always hard.

Host: True. Realistic goals, I guess. How can healthcare providers and communities work together to improve awareness and early detection and treatment of heart disease in women?

Manjula Ananthram, MBBS: I guess we need to focus on community education and prevention initiatives. I think collaboration between various health care providers in the different disciplines, such as obstetricians, as well as internists and cardiologists to collaborate and treat women in various stages of their life. We could also do this with a screening at health fairs, outreach school based programs, outreach to underrepresented groups, and our campaign should be culturally sensitive and appropriate with translations for the appropriate audiences.

I think that would be one of the key things we can do. An improvement in awareness should include healthcare providers, we should look at our medical school curriculums. Education must include both intrinsic and extrinsic factors that modify risk factors for heart disease in women.

Host: Any last tips or thoughts for our listeners?

Manjula Ananthram, MBBS: So I'd like to remind the listeners to empower themselves, advocate for their heart health, and be your own heart hero. This is one of my favorite ACC CardioSmart slogans. And so, be your own heart hero, make time for self care. And for providers out in the community there; when you treat women, look beyond the Bikini Zone.

A few years ago, Dr. Wenger, one of the pioneers in women's health, had said that women's health focused only on Bikini Medicine, which is the reproductive organs. We need to look beyond that to take care of women.

Host: This has been so informative. Thank you so much for sharing your expertise on this important topic. We really appreciate it.

Manjula Ananthram, MBBS: Thank you so very much. I appreciate it.

Host: Again, that's Dr. Manjula Ananthram. Find more shows like this one at umms.org/podcast. That's umms. org/podcast and on YouTube. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again and please share this on your social media.