Scott Webb (Host): This won't come as a shock to many of you, but men and women are built differently, especially our hearts and how our bodies react to heart related issues. And joining me today to discuss the unique aspects of heart health in women is Dr. Stephanie Kochav. She's a Board Certified Cardiac Clectrophysiologist specializing in the diagnosis and treatment of heart rhythm disorders.

 Welcome to Conversations Like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. I'm Scott Webb. Thanks for listening. Dr. Kochav, it's great to have you here. We're going to talk about and explore the unique aspects of heart health in women, but welcome to the podcast.

Stephanie Kochav, MD: Thank you so much for having me here. I'm so excited to talk about women's heart health, which is near and dear to my heart. Literally.

Host: Yes. Literally, pun intended, all that good stuff. Well, it's great to have you here and it's important, I think that we have these conversations and yes, heart attacks are heart attacks, heart health is heart health in men and women. But there's some unique aspects, right, to heart health in women.

So let's start there. Why is it important, do you think, to talk specifically about heart health in women?

Stephanie Kochav, MD: So in the United States, heart disease is the leading cause of death for women and can affect women at any age. The problem is this is so, so common. Over 40% of women in the US are living with some form of heart disease. This includes coronary artery disease, which refers to plaque build up in the arteries that can lead to heart attacks, heart failure when the heart is too weak to pump enough blood to the body.

And arrhythmias, which is my particular focus, and includes the heart beating too slowly, too fast or irregular. All of this translates to over 60 million women being affected, but studies have shown that only half of US women recognize their risk.

Host: Yeah, it's interesting and of course, not being an expert myself, just basically being a lay person, it's always great to have an expert on, but you know, we could be talking about sort of electrical issues, plumbing issues, those kinds of things, when it comes to the heart, and I've heard this before, and you know, maybe in television and movies. I'm old enough to remember, Fred Sanford on Sanford and Son. He was always having the big one, clutching his chest, but heart symptoms, really do look different between men and women. So what should women be on the lookout for?

Stephanie Kochav, MD: So common symptoms in men are squeezing chest pressure or pain like you were talking about. Jaw pain, arm pain, shortness of breath. But women don't always have chest pain. They can have pain in the lower chest, abdominal pain, indigestion it can feel like, or they can just be severely fatigued. They can faint, there can be dizziness. Or really nothing. Sometimes women don't have any symptoms. I think the important take home point is for women to be attuned to their bodies and note any changes, you know, and seek medical care when something doesn't feel right.

Host: Yeah, that, that's such great advice and I've heard that before. And it leads me to my next question about you know, maybe why exactly heart attacks in women are undiagnosed or misdiagnosed? Is it because as you're saying that some of the symptoms are just kind of nebulous or there are no symptoms or women aren't speaking up? Is it all the above? Like what is it, doctor?

Stephanie Kochav, MD: I think it's a combination of unusual symptom presentation as well as historical underrepresentation of women in medical research. And I think there's a gender bias in medicine. So first off, women tend to be more dismissive of their symptoms. We've all heard of man flu. You know, men are worse at being sick than women.

Host: Yes are.

Stephanie Kochav, MD: It's a popular, it's a popular theory that with the same illness, men are more symptomatic while the women carry on with whatever they need to do. You know, work, childcare, life. But there's actually some scientific evidence to back this up. In 2017, there was a study published in a neurological journal, Brain Behavior and Immunity that looked at mice and they looked at male versus female mice and showed that with the same infection, the male mice had more fevers, more signs of inflammation. So there's something there that's legitimate. In our lives, women are busy taking care of everyone else. They often dismiss their symptoms. And I think it's our job to educate women to be cognizant of their symptoms and again, to seek medical care because the delaying really can be life or death when it comes to a heart attack.

At the same time, because their symptoms are different, medical personnel like doctors, nurses are more likely to miss the diagnosis in female patients. And this has been shown time and time again in scientific research studies. Unfortunately, I think our culture tends to perceive women as more anxious or dramatic, and this can lead to underdiagnosis and insufficient cardiac testing.

And then when we get to the testing, there's different gender differences in the testing. So if one were to feel they were having a heart attack, they would come to the emergency room and the first lab test that would get done is called a cardiac troponin level. This is a blood test, and a higher level means more heart damage, and there's a clinical threshold that tells doctors how to act on that on and whether to move forward with treating or not. But that clinical threshold, differs across sexes and, you know, we have to apply gender specific cutoffs for diagnosis. And then the next step beyond that is, is what's called a cardiac catheterization. And again, many studies have shown that women are less likely than men to undergo this procedure.

But this is the way you treat a heart attack. This is how you get a stent or a blockage opened up. You need this procedure done. And, again, women are less likely than men to have this done. And, some of that, at least in part is, is explained by physician gender bias. And so, you know, I think that we, as physicians and nursing also have to be aware of this inherent bias and act upon it.

Host: Right. Yeah, I, speaking anecdotally, uh, personally as the son of a mom and having a wife and a daughter, the women in my life, and I'm sure for many listeners they're really tough, you know, and they tend to suffer in silence and they tend to not put themselves first, their health first, their heart health first. And maybe we should talk about the, like hormonal changes, right? We're talking about the sort of sex differences here. So pregnancy, menopause, birth control. How do those things impact women's heart health?

Stephanie Kochav, MD: Yeah. So, even taking a step back and looking at, for example, a normal healthy pregnancy. In a normal healthy pregnancy, the heart undergoes significant hemodynamic changes to increase blood flow to the developing baby. So often pregnant women experience a racing heart, which I see a lot of patients for.

This is usually appropriate. This isn't pathologic. This is what's supposed to happen. But arrhythmias that are not physiologic can also flare during pregnancy as well, such as SVTs and, and atrial fibrillation. And this is a big part of what I manage. Then beyond a healthy pregnancy, there are dangerous pregnancy conditions such as preeclampsia, gestational diabetes, gestational hypertension, or high blood pressure, which are all powerful predictors of future heart disease as they are strongly associated with the development of true essential hypertension or high blood pressure and diabetes later in life.

The other sort of pieces that, aside from pregnancy, younger women with endometriosis are three times more likely to develop a heart attack, and we don't fully understand why that is. But estrogen is thought to be protective against heart disease, before menopause at least. But after menopause, a woman's cardiovascular risk goes up, so they're more likely to get high blood pressure, high cholesterol. The menopause transition period, those few years where a woman is transitioning seems to be an especially vulnerable time.

And as clinicians, I think we need to pay special attention to that group. A lot of people ask about hormonal replacement therapy, but unfortunately the risks and benefits remain controversial. And I think needs to be individualized on a per patient basis. It should be noted that birth control pills that contain estrogen, can be associated with an increase in blood clotting, pulmonary embolism, heart attacks.

Though for most young, healthy women, this isn't really a cause for concern. It's more for women who have other risk factors, older, obese, smokers, or with genetic clotting disorders. Then they may want to consider like a non-hormone based birth control method.

Host: Okay. Yeah. Are there some heart conditions that are just more common in women than men? We were talking earlier, I sort of dumbed it down a little bit, but you've got some could be plumbing issues, right? Electrical issues, but just in general, when we think about the heart and you know, we know time is brain with stroke.

Time is heart when it comes to heart attacks, so are just some conditions more common?

Stephanie Kochav, MD: Yeah, I mean women are more likely to have other diseases that mimic a heart attack, such as coronary spasm where the artery suddenly closes and opens.

Host: Hmm.

Stephanie Kochav, MD: Dissection where the artery spontaneously tears or what's called broken heart syndrome, which is associated with heart failure and dangerous arrhythmias, usually triggered by an acutely stressful or emotional life event.

And these diagnoses need to be thought about. Clinicians need to be educated so that women don't get overlooked. We need to have a high suspicion for these diseases in the right clinical context.

Host: Yeah, I'm sure maybe that comes up in patient history. You're talking about the broken heart, literally and figuratively, and that's very much an emotional, maybe a psychological thing initially that you know, manifests as something physical, right? So is that where patient history, like really trying to understand what's going on in a woman's life may be beneficial?

Stephanie Kochav, MD: Absolutely. Yeah. I mean, I, I think for anybody taking a good history is the first step in trying to make a diagnosis and treat a patient appropriately, but particularly in, in that case, you know, understanding what led a woman to come and seek medical care, not just what they're feeling, but what else is going on?

Host: What's, what's going on behind the scenes, right? That isn't obvious, you know, can't, won't show up in blood tests and things like that. So I think the most important thing doctor here is how do we help women, to protect their hearts, to protect their heart health, especially at these different life stages?

Stephanie Kochav, MD: Yeah, there are so many things we can all do to protect our heart health, and it starts at a young age. First off, get plenty of regular exercise. I see many patients with atrial fibrillation, physical inactivity or being sedentary or a couch potato has been shown to be an independent risk factor for AFib.

A study that I like even showed that just doing one higher metabolic equivalent during a treadmill test can lower your risk of incident AFib by 7%. So it's really time to get moving and generally we recommend 150 minutes of moderate intensity aerobic exercise per week two strength training sessions per week.

Your heart rate should increase by at least 50% of your maximal heart rate, which you can calculate. Anybody can calculate by subtracting 220 minus their age. And, remember too, that like anything counts as exercise, dancing, gardening. The next thing I would say is avoid obesity. Maintain a healthy weight. This lowers the risk of metabolic syndrome. Eat healthy, exercise, get help if you need it. Valley has a weight loss center that I share a lot of patients with. They provide nutrition support, bariatric surgery consultations, prescription weight loss drugs. Any way you do it, it doesn't matter how you do it.

But getting to a healthy weight is, so important. And of course, limiting alcohol intake. This varies for men and women. It's really less than five drinks a week for men and less than three drinks per week for women is what's advised. Alcohol can be directly toxic to the heart. Avoid or quit smoking.

Watch for signs of sleep apnea. If you're overweight and snore, you should be diagnosed. You should be treated for that because that really, sleep apnea is really associated with, the incidence of cardiovascular disease. And you know, I want to say that, while these recommendations are meant for everyone; women's heart health seems to be more affected by lifestyle risks than men, at least according to a health study from Canada, which included over 175,000 adults, and they watched these people over 11 years. The study looked at eight established cardiovascular risk factors, their BMI, blood pressure, diet, physical activity, sleep, smoking, and other blood tests. And it showed that women who had tended to have more favorable risk profiles than men in general, they maintained healthier profiles over the course of the study. But after adjusting for age, the data revealed that both men and women with poor intermediate cardiovascular health were at greater risk for a heart attack, stroke, and death, but that the impact was more pronounced in women.

So women face nearly five times the risk of heart disease compared with men who were in poor health who only had 2.5 times the risk as their peers who were in good condition. And so I think that's really important to think about that for women it may be more important for us to really maintain a healthy lifestyle.

Scott Webb: Right. Yeah, of course we can't outrun our family history and genetics, right? But we can control our behavior, our lifestyle, our eating, our exercising, all of those things. So, good advice for men and women, but especially in the context of our conversation today for women. Doctor, if there's just one thing, that you would hope or wish listeners, especially women, would take away from this, what would it be?

Stephanie Kochav, MD: Advocate for your own health. I think the best medical care is achieved when there's a partnership between the clinician or the doctor and the patient. Know your cardiovascular risk and share it. Ask about important diagnostic tests and treatment options. Educate yourself and learn the symptoms of cardiovascular disease and remember to seek medical care right away if something feels off.

Host: Yeah, we have to listen to our bodies of course. And, in general, especially women, take care of ourselves. Listen to our bodies, listen to the signs, advocate for ourselves. All good stuff. So thank you so much.

Stephanie Kochav, MD: Of course. My pleasure.

Host: We hope today's conversation with Dr. Stephanie Kochav has helped shed some light on the unique aspects of heart health in women. Remember, symptoms can look different, risk factors can vary, and your voice matters, especially when it comes to your heart. If you have questions or concerns about your heart health, don't wait. Talk to your doctor.

 For more information and resources, visit valleyhealth.com/heart. And as always, be sure to subscribe and share this episode, and take good care.