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Melanie Cole (Host): In women, heart disease symptoms can be dramatically different than they are in men. The more a woman knows about heart disease, the better her chances of beating it. Thanks for tuning into Back to Health, the podcast that brings you up to the minute information on the latest trends and breakthroughs in health, wellness, and medical care.

Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insight that will help you make the most informed and best healthcare choices for you.

And today, on this Women's Health Wednesday, we're discussing women's heart health with Dr. Nivee Amin. She's the Director of Women's Heart Program and Preventive Cardiology at Weill Cornell Medicine. Dr. Amin, thank you so much for joining us and what an important topic. You know, I don't think we can talk about women's heart health enough.

So, can you tell us a little bit about heart disease in women, not necessarily heart attack, but heart disease, how common it is, and really how awareness of heart health in women has changed over the years?

Nivee Amin, MD, MHS, FACC (Guest): Well first, let me thank you for inviting me to speak about this important topic. And I'm excited to share with you about heart disease in women. Many women may not realize that heart disease is the number one cause of death in women and heart disease accounts for about one in every five female deaths, according to the CDC, based on recent data. Women often are less likely to call 911 when they're experiencing symptoms. And a lot of that has to do with the fact that women sometimes experience symptoms that are unique from what are considered traditional symptoms related to heart disease. And only about half of women recognize that heart disease is their number one killer. In terms of trends, this has improved over time, but awareness seems to still be a significant reason that women don't recognize heart disease as their number one cause of death.

Host: So, the risk factors. Let's talk about those for a little bit. There's modifiable and non-modifiable factors that can contribute to this. Can you speak about some of those?

Dr. Amin: Modifiable risk factors include hypertension, which is high blood pressure, diabetes, hyperlipidemia, which is high cholesterol, smoking, weight, exercise. These are all factors that go into, whether somebody may develop heart disease due to conditions that they may be able to control. But there are some factors that are not modifiable. Whatever you are born with, such as your genetic predisposition for heart disease, something that may be inherited from your family.

And interestingly enough, there is some time factors across the woman's lifespan that may contribute to heart disease. For example, some sex specific risk factors that may increase a woman's risk for heart disease. I would also like to highlight some of the sex specific risk factors for women. A woman who goes through menopause at an age earlier than the average age of menopause, may be at increased risk for heart disease during her lifespan. A lot of that has to do with the fact that estrogens are quite protective in the sense that they regulate blood pressure, help with blood vessel health, cholesterol metabolism, even body fat distribution, and a woman who loses her estrogen at an earlier age may be at higher risk for heart disease across her lifespan. Some of the other sex specific risk factors include pregnancy complications, such as high blood pressure during pregnancy or diabetes during pregnancy. Even having a baby come a little bit too early is a sign that, that woman may potentially be at higher risk of heart disease in the future. Some women experience metabolic challenges associated with polycystic ovarian syndrome and some disorders of the immune system, such as auto-immune diseases or certain systemic inflammatory disorders tend to affect women more than men.

So these are some sex specific risk factors that need to be considered. I'll also highlight that we don't really talk as much about some risk factors such as socioeconomic disparities, abuse and intimate partner violence, even poor health literacy can contribute to an individual's risk for heart disease. And this is something that we need to highlight in women along with men, but some of these conditions appear more frequently in women than in men. So I wanted to highlight that now.

Host: I'm glad you did. And that could be a whole podcast in itself about the disparities in health care for women and for women in underserved communities. And that's a big topic and I thank you so much for highlighting that. So, now let's talk about signs and symptoms, the signs and symptoms of cardiovascular disease versus men and women. But also, can you differentiate between, do we know if we have heart disease versus the signs and symptom of an impending heart attack, because that's what we've seen in the TV, the grabbing the arms and all of that. Can you speak about signs and symptoms of heart disease that we might notice and then heart attack?

Dr. Amin: Absolutely. Let me start by doing a quick anatomy lesson if you will bear with me. In the chest, we have multiple organs sharing, a very tight space. We have bones that make up our ribs and sternum. We have the esophagus, which is the food pipe, connecting your mouth to your stomach. We have our lungs and we also have the heart and all of these can potentially be sources of pain or discomfort in the chest.

So, sometimes it's hard to distinguish what might actually be related to the heart or what may be related to your muscles and bones versus the esophagus, or maybe your lungs. So, it's really important to understand and recognize that, if there's discomfort in the chest, we need to make note of the circumstances that the symptoms are occurring. For example, if somebody is having chest discomfort, right after a stressful conversation, that may be related to anxiety or stress, but sometimes maybe an early sign that there is some strain on the heart that we need to recognize because stress can uncover heart disease. It can also be a cause of heart disease.

One might recognize if they're experiencing symptoms right after eating, because that may be more so related to the esophagus and the stomach. One might recognize whether their symptoms are occurring with exercise, which is another situation where we're putting the heart under a little bit of stress. Exercise is a good kind of stress, but it may uncover heart disease because people who may have symptoms with exercise or activity, may be showing that their heart needs a little bit of attention. So, these are some ways that an individual may distinguish whether some of the sensations in their chest may be related to the heart.

In which case that may be something that needs to be dealt with a little more urgently versus something that can be managed with other sorts of therapies and treatments. Either way, if anybody has a concern about their symptoms, they need to talk to their doctors about it. If somebody's having a heart attack, the traditional symptoms that an individual may feel may include discomfort in the center of their chest or the left side of their chest. Often people describe it as pressure. Or as though they have an elephant sitting on their chest. Sometimes people experience trouble breathing. The discomfort may travel up to their jaw or down the left arm. They may experience sweating or nausea. And these are considered some of the traditional symptoms, but often women have distinct symptoms. For example, a woman may experience pressure in the chest, but it may not be on the left side.

It may be more so in the center towards the right, or maybe, a woman might experience trouble breathing associated with some sweating. So, it's really important for physicians who are listening to women to really get down to the circumstances that the discomfort occurred, whether it was associated with other symptoms, such as shortness of breath, sweating, nausea.

We have women who come in unique symptoms and they could be in the middle of a heart attack. So, it's really important for women to not only recognize that heart disease is a possibility, but also for healthcare providers to recognize that we need to keep asking questions, to get down to the bottom of why a woman may be in front of us and expressing some discomfort.

Host: That's very good advice. What would you do? What tests are available to detect heart disease? are we doing stress tests, is blood work enough? What do you recommend for women that may fall into some of those risk factors that are concerned? Maybe they feel a pain in their leg. They're worried about a little blood clot or they are a little bit overweight or any of these things. How do you detect heart disease? What's the best test?

Dr. Amin: There's no one best test, but I will say that along with a thorough history and physical exam with a physician or a really experienced healthcare provider, a woman might undergo an electrocardiogram which is also called an EKG or an echocardiogram, which is an ultrasound of the heart. We've been employing specialized blood tests to understand the nuances of cholesterol metabolism.

So, we can check all sorts of different fats in the blood. We can check for inflammation in the blood and we're using CT scans to see if we can detect heart disease even earlier than people might start experiencing symptoms. That test is called a coronary calcium score, and it tells us if somebody has been living with plaque long enough to mature and form calcium in the chest. You mentioned that a woman may be concerned about blood clots. We can definitely use blood tests to measure for certain chemicals in the blood, or even do ultrasounds of the legs, to be able to detect clots. Our medical technology is advancing every day and that's why this is such an exciting field to be in.

Host: Well, it certainly is exciting. So, now let's talk about prevention and really, I think this is probably the most important part. We hear a bunch of these things about aspirin a day for women that may fit in something to ask her doctor, but I'd like you to speak about a glass of red wine or an aspirin, or the link between sleep and diabetes and heart disease. All of these things kind of fit into this total picture. Yes?

Dr. Amin: Everything goes together. We can't focus on one without focusing on the other. And so what I always advise my patients, is that we want to have a good balance in whatever we're trying to achieve. So, making sure that whatever dietary changes an individual makes to try to achieve health goals, are sustainable. In general, if a person's eating lots of healthy foods, whole grains, fruits, vegetables, lean proteins, they're on the right path. People who are doing routine consistent exercise are on the right path. We have seen that people who have moderate alcohol consumption, and that means one glass of red wine, for example for women per day, or up to two in men per day, may be beneficial for the heart.

But I would advise that if it's already part of one's lifestyle, it's probably okay to continue. I wouldn't recommend that people start drinking in order to help improve their heart health. It kind of goes along with a whole lifestyle. An aspirin a day has been studied extensively. And more recently we realized that people who do not have active heart disease or an active diagnosis of certain other conditions may not benefit from a daily aspirin because there is a risk for bleeding.

I recommend that people who are already taking an aspirin a day or many days of the week, discuss with their doctors before stopping the therapy. And many people have really good reasons to be on aspirin that may not be directly linked to heart disease. This is why it's so important to talk to one's doctor about it. Sleep is really important for the body to restore itself. And it's an important time during which our cholesterol metabolism occurs. When an individual has less sleep than what is recommended for their bodies, they may increase stress hormones, such as cortisol. And this changes metabolism in the body.

People who have an increased level of cortisol in the body are at increased risk for diabetes and even heart disease. So, there is a clear link between reduced sleep and significant changes to the body's metabolism. When a person is not sleeping, they're also increasing general stress on their body. And we know that there's a clear link between stress and heart disease.

Host: We certainly do. And this is so much information and it's really, it's really great for women to hear and for the people that love them. As we wrap up, obviously we, women, are the caregivers of the world, Dr. Amin, and we can't take care of the ones that we love, unless we take care of ourselves, put on our own mask, as it were, which is a little bit ironical this time of a little bit, ironical is not a word, little bit of irony in this day and age, but we certainly do have to, can you please offer your best advice? If we are told we have high blood pressure, to stay on our medication, to get exercise, look at our diet and our sleep, and certainly our stress. Wrap it up into a nice little package for us to prevent heart disease.

Dr. Amin: As women, we need to take care of ourselves. It's really important also to forgive yourself. And if a woman can do her best to balance her own health needs by adding a little bit every day in a sustainable way, it will be so helpful for the long-term. Take that moment to take deep breaths and calm oneself. Try to incorporate a little bit of exercise in your day to day. Try to reach for healthy foods, definitely focus on stress reduction. And it's so important as you said, for a woman to make sure that she can take care of herself so she can be there to take care of all of the other people around them.

Host: Great advice, Dr. Amin, thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. We're so glad you joined us for Women's Health Wednesday, and we hope that you'll tune in and become part of a community and a fast growing audience of women looking for knowledge, insight, and real answers to hard questions about their bodies and their health.

Please download, subscribe, rate, and review Back to Health on Apple podcasts, Spotify and Google podcast. For more health tips, you can go to weillcornell.org and search podcasts, and parents don't forget to check out our Kids HealthCast. I'm Melanie Cole.

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