Getting To The Heart Of Things
Most of us probably take our hearts somewhat for granted, until something goes wrong. But for women, after menopause heart disease becomes the leading cause of death, putting women on par with men. And so, in recognition of February as National Heart month, let us take a moment to put our hearts front and center.
I would like to say a special word of thanks to Dr. Amy Gin for her contributions to this issue. Dr. Gin, FACC is an interventional cardiologist. She earned her medical degree at New York Medical College. She completed a fellowship in cardiovascular medicine at Kaiser Permanente San Francisco and a fellowship in interventional cardiology at Massachusetts General Hospital. She is currently in practice with the Cardiovascular Associates of Marin and San Francisco.
Defining Heart Disease
Dr. Gin defines heart disease as cholesterol plaque in the heart blood vessels which develops over time. The plaque slowly accumulates until it creates enough narrowing in the heart blood vessels that it restricts blood flow.
When blood vessels gradually become restricted over time, people will often experience angina (chest pain), which is an early symptom of heart disease. Shortness of breath is also typical and both symptoms may be most noticeable during exercise or times of stress when the heart muscle requires more blood flow to get more oxygen.
The stereotypical acute heart attack on the other hand is caused when the plaque in the heart blood vessels becomes unstable and suddenly ruptures. This creates a point of inflammation as the blood passing by the ruptured plaque forms a blood clot in response. This can then lead to complete obstruction or high grade narrowing in the blood vessel.
Risks for Heart Disease
Generally speaking, Dr. Gin says high cholesterol, family history, smoking, diabetes, kidney disease, unhealthy diet, and not exercising are significant risk factors for developing heart disease. She cautions that if someone is extremely sedentary, has a genetic predisposition, or family history of early heart disease (for men before 55 and women before 65), they can develop plaque as early as their 20s and 30s. And it is not out of the question if you have a strong family history that you could have a heart attack in your 20s or 30s.
And for women specifically, going through early menopause (before age 40) also increases your risk for heart disease, as does having PCOS, breast cancer, or an autoimmune disease.
I asked about lifestyle verses genetics as risk factors and Dr. Gin says while it is important to know your family history (what a family member was diagnosed with and at what age), the actual role genetics plays varies from person to person.
Menopause and Your Heart
Before menopause a woman’s risk for developing heart disease is less than a man’s risk but after menopause your risk is the same as that for a man. This is due to the protective effects of estrogen which declines as a woman goes through perimenopause and menopause. Lastly, women tend to develop heart disease later than men due to the protective element of the sex hormones. The “average age for a heart attack is 64 for men but 72 for women.”
HRT and Your Heart
As readers of Holos know, the current thinking on Hormone Replacement Therapy is that “most healthy, recently menopausal women can use hormone therapy for relief of their symptoms of hot flashes and vaginal dryness if they and their providers determine that the benefits outweigh the risks based on their personal history.”
This chart outlines the other benefits of HRT including “improved sexual function, improved bone health, improved sleep and mood, and lower rates of cardiovascular disease.” As always, please discuss your specific situation with your doctor.
Preventing Heart Disease
Prevention is a key strategy in combatting heart disease and Dr. Gin uses the following strategies to reduce the risk of plaque developing or the buildup of plaque from progressing. Prevention is important as heart disease is a progressive disease and often does not manifest until later in life, even though plaque may have started accumulating earlier in life.
First and foremost, she encourages people to be proactive about maintaining their health with regular doctor visits, monitoring their blood pressure, and checking cholesterol levels. She also advises people to maintain a healthy weight and to carve out time for yourself and your health.
She also recommends regular exercise to her patients. Specifically, 5-6 days per week, 30 minutes or more, and to the point where you are sweating and short of breath. This means finding a sustained form of aerobic exercise which you enjoy, and which works for your body. She suggests activities like hiking, walking, jogging, swimming, and biking. She also recommends including strength training and flexibility work.
In terms of diet, she recommends a Mediterranean diet. She has them focus on eating less red meat, more seafood, more vegetables, healthy fats like olive oil, controlling portion sizes, and eating at home more than out.
Screening for Heart Disease
Dr. Gin uses 2 main methods for screening for heart disease. The first is imaging to look for evidence of heart disease. The second is stress testing to look for signs of significant narrowing which restricts blood flow. Stress testing is not normally used unless someone has other symptoms of heart disease.
In terms of imaging, people often get a coronary artery calcium (CAC) scan of the chest which looks for calcium in the heart blood vessels. If the scan detects calcium then you know plaque is present. In general, the more calcium, the more plaque and the older you are the more likely you are to have calcium and plaque.
This 2021 study looked “at the ideal age at which a first CAC scan has the highest utility according to atherosclerotic cardiovascular disease (ASCVD) risk,” and concluded that it is appropriate to consider screening for those without risk factors at 42.3y for men and 57.6y for women and for those with diabetes at 36.8y of age for men and 50.3y for women. Having said that, screening can be done at any age. Dr. Gin will often screen earlier in cases where someone has high cholesterol and they might need more aggressive forms of intervention, like a statin.
In the case of someone having symptoms, a treadmill stress test with or without a heart ultrasound (where pictures of the heart are taken before and after exercise) or a coronary CT angiogram (where they inject CT contrast and time the scan to the heart beating to look at heart vessels filling to look for narrowing and plaque) may be used.
Cholesterol
My guess is everyone is familiar with the link between cholesterol and heart disease, so I asked Dr. Gin to dive a little deeper into this topic.
Traditional lipid panels look at levels of LDL, HDL, triglycerides and total cholesterol. But as Dr. Gin says, “our understanding of cholesterol is evolving.” Physicians now recognize there are additional types of particles which are important and for which she now tests. Two of these are Apolipoprotein B (apoB) and lipoprotein A (Lp(a)) In the case of both, the higher the level, the higher the risk of heart disease.
In the case of a high apoB level, her focus is on lowering the patient’s cholesterol through lifestyle and medication. A high Lp(a) level is tricker to address as it is most often a genetically mediated number and currently there are no medications able to directly lower it (although some are in development). For these patients, she works to control LDL and total cholesterol.
I asked about lifestyle interventions for controlling cholesterol and Dr. Gin says focusing on exercise, diet and weight will always help. For example, if you have a lot of fat in your diet, your triglycerides will go up. But if you have a family history of high cholesterol, and you are naturally inclined to high cholesterol, you might need a statin.
Statins are very well established in lowering cholesterol levels, stabilizing and reducing plaque, and reducing the risk of stroke and heart attack. There are 3 side effects of statins worth mentioning. The most common side effect is muscles aches. If this happens she will stop, reassess the situation, and try a different statin. In addition, statins can increase glucose levels, and very rarely they can cause brain fog/memory issues.
Generally speaking cholesterol levels tend to rise over time as you age.
Heart Attack Symptoms
The signs of a heart attack in women can differ slightly from men, although chest pain or discomfort is the most common symptom for both men and women. Dr. Gin says women also tend to experience shortness of breath, arm or jaw pain, dizziness/lightheadedness, nausea or other stomach pain. It is important to note that because of how these symptoms present, sometimes they are not immediately diagnosed as heart related. As Dr. Gin says, “always check in with your doctor about anything which seems out of the ordinary.”
Treating Heart Disease
Dr. Gin uses diet, medication and lifestyle interventions to treat heart disease. If someone already has heart disease she might focus on diet, add aspirin to thin the blood, and a statin to stabilize plaque. If the situation has progressed and plaque has caused narrowing in the blood vessels she might treat them with a stent. A stent is a mesh metal tube used to scaffold open the heart blood vessels at the site of narrowing. If someone has multiple restricted blood vessels or if the plaque is in critical areas by-pass surgery might be recommended.
Not everyone who has plaque has symptoms and needs to be treated with mechanical interventions. But in the case of a heart attack, generally something mechanical will be done to restore blood flow as it is a narrowing in the blood vessels which is causing damage to the heart muscle.
Parting Thought
My mom’s side of the family has a strong history of heart disease, so monitoring my cholesterol levels, exercising, and eating healthy have additional meaning for me. I owe it to my kids and husband, not to mention myself, to take care of myself so I can be a mom and partner for as long as I can.
To be continued…
