Women’s Heart Health: Expert Q&A

Heart disease remains the leading cause of death among women in America, killing one in three women. Now, that's more than all forms of cancer combined. Even more tragic is the fact that 80% of cardiac events can be prevented through education and lifestyle changes such as moving more, eating smart, and managing blood pressure. Our experts will discuss ways to reduce your risk of cardiovascular disease, the different types of noninvasive diagnostics and cardiac imaging that's available, and how women can help manage existing heart disease. And they'll answer your questions live coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off with having each of you introduce yourselves to our audience and telling us a little bit about what you do here at UChicago Medicine. And Dr. Polonsky, I want to start with you.

Yeah, hi. Thanks so much for having me. I'm Tammy Polonsky. I'm a general cardiologist. So I spend my time taking care of patients in the clinic and in the hospital. And I focus mainly on heart disease prevention, treating conditions like high blood pressure, high cholesterol. And then I see a lot of women with preeclampsia, which is a complication of pregnancy, and patients with cancer.

Dr. Singh?

Hi, I'm Amita Singh. I am a cardiac imager and noninvasive cardiologist here at the University of Chicago. Like Tammy, I see patients in the clinic and in the hospital and have a personal interest in prevention. But I also spent a lot of my time performing and interpreting some of the cardiac imaging testing that we'll hopefully talk a little bit more about today.

Great, and we want to remind our viewers that we will take your questions during the program. So just type them in the comments section if you're joining us on Facebook or YouTube. And we'll try to get to as many as possible over the next half hour.

Now when we started the program off, I read off a statistic that was honestly a little startling to me how prevalent heart disease is in women and how significant it is as far as causes of death for women. It is the largest cause of death. Dr. Polonsky, if you can start with us, how common is heart disease in women today? And then we'll kind get into some of the details about maybe how people can prevent this.

Yeah, so unfortunately it is incredibly common-- as you noted, one in three women. And so we've had substantial gains over many, many years with campaigns like encouraging people to never start smoking or to quit smoking. And that initially had some improvements in death from heart disease. But unfortunately, with the rise of things like obesity and diabetes, those improvements have really slowed down.

And so heart disease remains a very significant condition that we really have to maintain our awareness of. A big factor in that is especially with hypertension. So high blood pressure drives the risk of heart attack, heart failure, stroke, and then also kidney failure and dementia. And so hypertension is a really big part of that huge burden of heart disease in women in the US.

So Dr. Polonsky, can we talk a little bit about women of color because we've seen many instances where people of color are affected by various diseases at a higher rate. Is heart disease one of those?

Yeah, unfortunately we have significant disparities in the United States, particularly with African Americans and with Latina women. So Latinas are more likely to develop heart disease about 10 years earlier than white women. Things like hypertension, obesity, high cholesterol are significantly higher in Black women than white women as well.

And so we think that it's probably those things that are really driving those disparities. And of course, what leads into health care disparities is really is such an enormous question to tackle because it's things like access to healthy food, access to providers, access to places to exercise, stress in people's lives. There's so many things that go into those disparities. But unfortunately, they are very real and measurable in the US.

We talk about health disparities a lot here at UChicago Medicine. It's a very significant thing that we study. And we work to try to help some of the factors. And you mentioned there's a long laundry list of factors that really can have significant impacts.

And here in South Side of Chicago, there are food deserts, which it's not an uncommon thing to see a neighborhood that just doesn't have a grocery store. Or if they do have a store, it doesn't offer many healthy options. And also to compound that, a lot of times the healthy options are a little more expensive. So there's just a lot of factors-- and I know I'm just scratching the surface-- that really kind of pile up and make it difficult for people of color with these health disparities. And I'm sure that's part of what you see in your practice on a regular basis.

Yeah, we spend a lot of time in clinic with both men and women talking about how to cook healthy food on a budget. It actually-- it doesn't have to be that much more expensive. But it does take a lot of time and planning, which unfortunately a lot of people don't have if they're working more than one job, or caring for older family members, or all the responsibilities that people have.

And things like advertising really make it-- we really want to kind of sometimes find easier options, not just everybody when we think about health care prevention. And so giving people the tools to actually eat in a healthy way is a lot of it. And so education is something that we focus on a lot in clinic.

Great, Dr. Singh, can we talk about the risk factors of heart disease? Dr. Polonsky mentioned diabetes just a moment ago and high blood pressure, things like that. So can we talk a little bit about some of that?

Yeah Tim, happy to answer that question. So there are actually quite a few risk factors. I think the easiest way to think about them is to put them in two groups. So there's sort of the unmodifiable risk factors. Those are things that we can't necessarily change about ourselves, but we know contribute to an increased risk of heart disease.

So age is a big one, right? We all get older. We can't change that. Actually, male gender is associated with an increased risk of heart disease. And then the last one is really kind of our genetics, and whether that's because there's a family history of heart disease or potentially related to certain ethnic groups in which some of those risk factors for heart disease are more prevalent or predisposed. Those are kind of some major but not easily changed things about ourselves.

Fortunately, there's a whole lot of modifiable risk factors. Tammy already mentioned a few of them, which we spent a lot of time in the clinic and on the wards talking to our patients about, things like diabetes. We know patients with diabetes have a very increased risk of heart disease. And it leads us to often sort of look very closely at their other risk factors to make sure everything is as optimally controlled as possible.

High blood pressure, which is really kind of an epidemic and something that we see and treat frequently here at the University of Chicago. High cholesterol-- cholesterol is a little bit tricky because it's something that we need. It's integral to kind of normal bodily function. But there are certain types if we have too much of and whether that comes through diet or it comes, again, because of genetics, high cholesterol is a really important and powerful and modifiable risk factor.

And then there are some things we can change about ourselves that aren't so easy and kind of tie into our lifestyle. So tobacco use or cigarette smoking, probably one of the most impactful risk factors and preventable ones out there. Still about 20% of the US population over 18 is a current smoker. So it's one that we still have a lot of work to do in. Diet, we spent a little bit of time talking about we generally know what a heart healthy diet is. But it's not always easy to carry out in day-to-day living.

Physical inactivity or physical activity, however you want to think about it-- but inactivity is another major risk factor that we try to work on. It's kind of built into our daily lives. And certainly in the Midwest in the middle of winter, a lot of us are guilty of maybe not being as active as we want to be. And then a few other ones that come to mind, stress, Tammy mentioned-- part of our lives not also easily treated, but something that we can hopefully learn to have healthier coping mechanisms with.

And lastly alcohol use-- alcohol, again, a little bit of a tricky one because in moderation, in including the right type, that can actually potentially be cardioprotective. But really kind of having more than one drink a day is, over time, not associated with benefit, potentially makes some of the risk factors associated with heart disease worse, and increase your risk of heart disease and stroke.

You know, it's amazing. You said 20% still smoke, which that number just blows me away. I would have figured after all these years and all the work that's been done, it would be lower than that. And to your point, that's probably one of the most preventable things that people do that causes heart issues.

So let's talk about cholesterol numbers. You mentioned that. And I think everybody always-- that's kind of the question that pops into everybody's head. What are your numbers supposed to be? And we can also talk about BMI and blood pressure if you will.

Yeah, so this is something where I don't want to necessarily make people feel like there's a right answer. And Tammy, I'm sure you feel the same way. People come into clinic all the time and say, I was always told my cholesterol was good. And now you're saying maybe I should be on treatment. So remember that cholesterol numbers and the individual patient always kind of have to be considered in the constellation of other medical problems you might have. But generally speaking, we all have different types of cholesterol.

As a cardiologist and as kind of a community, we really focus on LDL or low-density lipoprotein. That's kind of the quote unquote, bad cholesterol, the one that's really strongly associated with the development of heart disease and vascular disease and stroke. Generally, we like for LDL to be less than 100. In many people, it's a little bit above.

And depending on where you are in your life and what your diet's like, that might be OK. Once you start to get really above 100, towards the high 100's, above 190, we actually become quite concerned about genetic conditions. So LDL, ideally less than 100, sort of in the low 100's is up for debate depending on the individual patient. And then in the high 100's really needs to be treated.

HDL, or high-density lipoprotein, is sort of the good cholesterol. So that's a little bit counterintuitive in that the higher it is, the better. So ideally, we like for HDL to be 60 and above. We consider that potentially to be protective.

And the last number that I'll talk about is something called triglycerides, which is sort of a surrogate for fatty acids in your blood. That's a number that we see elevated in patients who have diabetes or prediabetes. It's something that we see elevated sometimes in people who are overweight.

And generally, we like for that number to really be less than 150. So everything is always subject to kind of interpretation with the patient. But those are sort of the general ranges that we consider to be optimal or ideal.

BMI is, again, kind of a reflection of our overall weight for our size. The ranges that are used-- less than 25, a BMI of less than 25, is kind of considered a healthy weight. 25 to 30 fits criteria for overweight status. And 30 and above qualifies actually as obese.

So for a lot of our patients, some people are in overweight range. But they're doing everything they can. That's OK. It's a number, and we always kind of consider it in the overall context. But that's kind of a general rule of thumb on how we think about what our approach is to BMI.

That's great. And we also talked a little bit about blood pressure earlier. I don't know if-- how much does that vary too, based on age?

Oh, that's a good question.

Because I've noticed mine has changed over the years.

Yeah well, actually, Tammy, did you want to say something? I saw you for a minute.

No, no, no, you can go. And then I'll add. You go.

OK.

So blood pressure, that's something that will, as you said, it'll change according to age. And it sometimes changes according to the time of day. So it's a little bit of a dynamic vital sign. But it's an important one. High blood pressure does become more prevalent as we get older.

And what we generally think of as a good blood pressure is going to be less than 130 over 80. So there are two numbers. There's a top number and a bottom number. We focus on both, really. Patients who have blood pressures of above 140 over 90 really qualify as having high blood pressure.

But you get the sense there's a little bit of an overlap kind of in that 130 to 140 range. When patients come to my clinic, whether or not they're on medication therapy, to me a great blood pressure is going to be generally in the 120's over 80's or less. So hopefully that kind of answers a little bit of your question. And then Tammy, it sounds like you can potentially weigh in with some of your expertise in this situation as well.

I think what we know from large epidemiologic studies, so where we've studied populations of thousands and thousands and thousands of people, is that a truly normal blood pressure where people would have the lowest risk of things like kidney disease and stroke and heart failure is less than 120 over 80. So when we say that less than 130 over 80 is where we use a cutoff in terms of when we would start medication for certain patients-- so higher risk patients, patients who are older, people who have diabetes or kidney disease, we'll use usually that cutoff of 130 over 80.

But we know that even in the 120 to 130 range and the above 80 and 80 to 90 range for the bottom number, that still represents the higher cardiovascular risk over time. And so if you look at somebody's, say, lifetime risk of cardiovascular disease, which the American Heart Association has done a really good job of publicizing that whole concept of not just our short term risk of disease, but also our lifetime risk of disease, even above the 120 over 80 range, long term increases a person's risk.

So that's something that I particularly spent a lot of time with young people on because just because they don't qualify for medication doesn't mean that they're where need to be to really optimize their cardiovascular health. So that's when we really talk a lot about what salt are they getting in their diet? Are they getting enough sleep? Are they getting enough exercise? All of those things that lead us to have our kind of optimal blood pressure is where lifestyle changes really make a big impact. So there's a lot to do even if a person isn't in the 140 over 90 range, where almost everybody, we would be starting medication.

Sounds good. So I promised our viewers we would take questions for our experts. And we do have a couple. So I want to get to those now. And then we'll resume some of our other questions. Dr. Polonsky, we're going to start with you on this one. What screening should young adults have to make sure that their heart is healthy and maybe stays healthy, I suppose, is what they're looking for.

Sorry, I just didn't hear the first part. What should younger people?

What screening should young adults think of? Are there--

Oh, screening, OK. So I think it's important to certainly have your blood pressure checked at least once a year because we know that unfortunately, again, as things like obesity and a sedentary lifestyle are increasing, we see that both in young people, even unfortunately in school aged children, that it is not uncommon for us to see people with hypertension, even in their teens and 20s, and really, getting on top of those numbers as soon as possible. Again, not always starting medication depending on where we can go with lifestyle changes-- that's one of the most important things that we can do.

And so I would say that every year, a person should have their blood pressure checked. Certainly depending on a person's other medical problems, it's reasonable even to check a cholesterol at least once around 25, and then but if somebody has diabetes or if they have a strong family history, then checking their cholesterol. Those kids who are school age, if they've had a genetic abnormality or something like that, then we'll be starting to screen with their cholesterol, again, even when they're school age.

Again, when people are around 40 is also when we want to take another stock of things like our cholesterol. And then screening for things like diabetes, again, also really depends on somebody's medical problems. And their other-- the background, so if they have a family history of diabetes, if a person's overweight or obese, then I would do screening tests for diabetes. And that's just blood tests. That's things like a hemoglobin A1C. And so that's a little bit dependent on somebody's other medical problems.

And a lot of the things that you're suggesting, you would probably get from just a good physical. How often would you suggest someone go in and see their primary care physician and just have a physical and just a general workup done?

Yes, so it's tough because for like women who are of childbearing age, a lot of the time, the main doctor that they're going to see is actually their obstetrician if they're interested in having children or if they're just getting well women checks with things like their pap smear, gynecologic screening. And so that's a big focus of health for younger women. Certainly that doesn't change necessarily that women are, of course, seeing gynecologists when they get older and not just when they're having children.

I think as long as a person's having their blood pressure checked every year, whether that's in their OB-GYN's office or whether it's in their primary care doctor's office, that's really for me as a cardiologist, the main focus. In terms of how often somebody should see a primary care doctor, again, really depends on how a person's feeling, on their weight, and things like that. So it's hard to give a hard and fast number.

I guess it is kind of a moving target. And I'm a firm believer in establishing a relationship with your primary care physician. I think that's really important. But it varies from person to person. So I certainly understand that. Another question from a viewer, and Dr. Singh, we're going to throw this one to you. When should someone transition from seeing their primary care physician to seeing a cardiologist for their heart health? Do you have to have a serious incident for that to happen?

Yeah, that's a great question. And I think not at all. We are sometimes involved in cases where people just sometimes want to be proactive. A situation that comes to mind that sort of touches upon the question that Tammy just fielded is somebody who has a family history of heart disease.

Maybe they're in their late 20s, early 30s, things look good. Their blood pressure's fine. But there are a lot of families out there where certain family members have had heart disease earlier in life. And some of the children of these patients say, what can I do differently right now?

And so I think it's possible-- the nice thing about cardiology is it sort of runs all the way from prevention to kind of critical illness. And so we do take the moments where sometimes it's a patient just asking, is there anything else that you think I should be doing? You don't need to have symptoms.

At the end, that can be kind of a single consultation. And we discuss options. And we discuss lifestyle, if any tests need to be done. Certainly don't want to wait until something has happened, or you had a heart attack. Ideally, we're working with your primary care physicians and their group. They are excellent at what they do and frequently can sort of see that either blood pressure is not going as smoothly as it should or cholesterol looks a little bit concerning.

And I think it's also possible to really have both. We work very frequently in conjunction with our primary care colleagues, whether it's sort of interpreting and ordering tests or sort of helping with challenging cases. So I don't think it's necessary to think about it as a handoff. Ideally, we work together in the care of our patients. And I also don't think that it needs to be a mutually exclusive decision because primary care doctors also manage high blood pressure and high cholesterol just as we do.

So I think we are happy to see patients who are sort of proactive about primary prevention. We're happy to see people who have disease, in which case, we really want to be aggressive about secondary prevention. And we certainly welcome cases from our colleagues where sometimes you just need a second set of hands, second set of eyes to kind of help manage a difficult risk factor.

Dr. Polonsky, you mentioned earlier diabetes, and just how big of an impact that can have, just in I guess your overall health, but particularly heart related matters. How does one know if they are at risk for diabetes?

Yeah, so that's a great question. The first thing that I think about, A, is family history. So we know that diabetes does tend to run in families. But the other thing that I do want to say when we talk about family history in general, especially of cardiovascular disease, I'm going to detour just for a second just to make sure I don't forget this, is that even in people who have a family history of heart problems, the things that we do in our daily life, controlling our risk factors, vastly overwhelms for the majority of people, their risk of cardiovascular disease than whatever runs in the family.

Now there are certain conditions that Dr. Singh mentioned, things like familial hypercholesterolemia, where that's a genetic abnormality that leads to very high cholesterol, where even people who are doing all the right things, taking care of themselves, exercising, eating a healthy diet, still need to be on medicine. But for most of us in the population, even if something runs in our family, we can overcome that risk and substantially lower our risk of having those same problems as our parents or our older loved ones by what we do, like I said, in our daily life.

So in terms of that now going back to diabetes, so family history is important. Our body weight, our body mass index, is also an important thing that we can think about in terms of thinking about our risk. So if people who are overweight or obese, that does increase the risk of diabetes. We can get an idea of our sugar when we get something called a basic metabolic panel. That's sort of one of the first tests that you'll often get if you see a primary care doctor or a cardiologist.

And that lets us see our fasting glucose or our fasting sugar level. And certainly if that's elevated, then we can get a blood test called a hemoglobin A1C. And that's a more complete marker of how the sugar has been, what the sugar level has been over the last three months. And that's a more definitive test to tell us whether or not we have diabetes.

Another couple of questions from viewers, and Dr. Polonsky, I'm going to keep with you on this one. If on blood pressure medications, is there a chance that the medications could be discontinued down the road?

So what I tell my patients in clinic is that if I can stop their blood pressure medicines, that's one of the happiest days for me. I am not committed to keeping people on medicine for the rest of their lives. What I am committed to is keeping their blood pressure under control. And so we make it very objective.

If the blood pressure is getting lower and lower and lower, then there are times where we will stop medicine. Now I don't stop medicine when the blood pressure is normal because typically what happens is that if we stop the medicine, then the blood pressure goes up again. But if people make lifestyle changes-- so let's say they were eating a really high salt diet and their blood pressure was out of control.

And they start exercising, and they lower their salt intake, and their blood pressure starts to really become well below what our goals would be with medication, that's when we'll slowly start to come down. And if the blood pressure stays the same, fantastic, we can keep trying to go down. But I really let the numbers tell me what to do.

Another question from a viewer. And Dr. Singh, let's give this one to you. Should I get checked if I'm having chest pain often?

Yes, definitely, that is a symptom that any physician I think would be in agreement needs a prompt evaluation, especially if it's new. If it's new and it's severe, I mean in that situation, it's appropriate to actually be evaluated in the emergency room. If it's sporadic and intermittent, I think that's a very reasonable time to consult with a cardiologist.

As we've been discussing this whole time, a lot of risk factors are present and prevalent. And there are certain kinds of chest pain syndromes that might catch our attention or be a little bit more suggestive of an underlying heart condition. So absolutely, you should get that evaluated potentially very soon if it's sort of unpredictable or significant.

Let me-- I've got kind of a follow up question. I noticed that is a female viewer that asked that question. And I think sometimes women have a little bit different symptoms than men do if they're having heart issues. Can you talk to us a little bit about that?

Yeah, absolutely. So I think a lot of us sort of envision heart disease feeling like what we see on TV or what we see in movies, which is clutching your chest and falling over. And the truth is it can be so heterogeneous. So there are a lot of different symptoms that people can present with, men or women.

The typical ones, the ones that are sort of more conventional, are going to be the sensation of chest tightness, chest pressure, usually left-sided. Sometimes it'll go to your jaw. Sometimes it'll go to your shoulder. Feeling short of breath with exertion, symptoms like feeling sweaty or feeling like you are nauseous and actually vomiting, those can all sometimes be related to an actual cardiac problem.

Women do tend to present with more atypical symptoms. And what that means is sometimes it's not an overwhelming story of chest pain. It's sometimes upper abdominal pain or back pain. Sometimes it's isolated jaw pain. Sometimes it's fatigue, lightheadedness, or dizziness. So I think what we have learned and recognized and try to improve awareness about is that women don't have to present the same way as men.

In fact, sometimes they don't. But if there is a sort of a new set of symptoms that feel not right, you can't do the activity you used to do, you feel fatigued, you're short of breath-- all of those things could be signs of a heart condition. So I think it's just important for patients to recognize that it doesn't have to feel like what you were told or what you think is only chest pain. It can actually present a whole lot of different ways. And if you do feel something's going on, it's always reasonable to discuss it with your doctor, your health care professional.

Wouldn't doubt it's better to ask for help and get checked out.

Absolutely.

Dr. Polonsky, we're about out of time, but we've got another question from a viewer I want to get to. So I'm going to throw this one to you. It's a COVID question. So should people who have had COVID see a cardiologist after recovering because I think there's been a lot in the news lately about potential issues with your heart.

Yeah, that's a great question. There's obviously so much that we have to learn about COVID in general, even though it's amazing how much has been learned in the last year. I don't think that every single person who's had COVID needs to see a cardiologist. If patients were able to recover from COVID at home, they didn't need to be hospitalized, then I don't think that they, again, necessarily need to see a cardiologist.

We do actually have a study going on right now. One of Dr. Singh's and my imaging colleagues is doing MRI of the heart to try to understand, could there be subtle changes in the heart in people who've had COVID? But I think that if a person feels like they've recovered really well, they feel back to their baseline, they're able to do all the activities that they were able to do beforehand, then I think it's OK just to kind of keep with your regular primary care doctor or your other providers. I think if people are feeling persistent shortness of breath, or chest discomfort, or any limitations that weren't there before, then I think that would be a reasonable time to potentially be seen by a cardiologist.

Sounds good. I don't know how this is possible, and I didn't get to nearly all of the questions that I wanted to ask the two of you, but we're out of time. It was a good show because those that go quickly like this, that's a good sign. And we have a lot of great questions from our viewers. So thank you for taking time out of your busy days. I know both of you are very busy. And we appreciate you sharing this information with our viewers.

And I do want to thank our viewers though, the ones who participated in today's program. You asked some great questions. It was good information. Please remember to check out our Facebook page for our schedule of programs coming up in the future. To make an appointment, you can go online at UChicagoMedicine.org or give us a call at 888-824-0200. Thanks again for being with us today, and I hope everybody has a great week.

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