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Heart disease isn't just a man's disease. In fact, it's the No. 1 killer of women in the U.S. each year. Leslie Cho, MD, Director of the Women’s Cardiology Center, explains why women don't necessarily realize they're at risk. She sheds light on how women's hearts differ from men's. And you'll learn why women are more at risk for certain heart-related problems and how to spot the more subtle symptoms of a heart attack that women more commonly experience.

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Why Many Women Neglect Their Heart Health (But Shouldn't!) with Leslie Cho, MD

Podcast Transcript

Nada Youssef:  Hi, thank you for joining us. I'm your host, Nada Youssef and today we're talking about women and heart disease. So, make sure you guys send us all your questions in the comment section below. Today our featured expert is Dr. Leslie Cho, director of Women's Cardiovascular Center and section head of preventative cardiology and rehab here at the Cleveland Clinic. We're very happy to have you. Thank you so much for coming in.

Leslie Cho: Thank you so much.

Nada Youssef:   For our viewers that actually would like to get notified every time we go live, tap on the follow button below if you're not following us already and opt in to get notified every time Cleveland Clinic goes live. As always, please keep in mind this is for informational purposes only and not intended to replace your own physician's advice. Thank you so much again for coming in today and I just want to give you a few minutes to introduce yourself to our viewers.

Leslie Cho: Great. My name is Leslie Cho. I am the section head for preventative cardiology and rehabilitation here at Cleveland Clinic. I'm also the director of Women's Cardiovascular Center. I'm an interventional cardiologist by training, but my research interest has been prevention. So, I do a lot of work on women and heart disease and cholesterol and all sorts of things around how to prevent you from getting heart attacks.

Nada Youssef:  Yeah. Great, thank you so much. So, who knew that when it comes to heart disease gender actually matters. Cardiovascular disease is the number one killer of women although it's sometimes thought of as a man's disease. It's around the same number of women and men die each year in the United States, yet only one in five American women believe that heart disease is actually a great risk. It doesn't affect all women alike, right? It all varies. The warning signs are different for women and for men. This is why we're dedicating this Facebook Live to talk specifically about women and their heart. But first things first, I want to talk to you about risk factors and things you can do to decrease your risk factor in general, men or women.

Leslie Cho:  Yep. So, there are classic risk factors. One of them is diabetes. Family history and when we say family history, we don't mean anybody in your family. We mean your mom or your dad or your brothers or sisters having heart disease before the age of 55 if they were a man or before the age of 65 if they're a woman. Another great risk factor is smoking. So, obviously, we don't want you to smoke. High blood pressure is another risk factor and then high cholesterol.

I think one of the most important things we can do is tell everyone that heart disease is preventable. 90% of the time you can prevent your heart disease. It doesn't matter your genetic make up, you can really do something about preventing heart disease. By knowing your numbers, like your blood pressure, your cholesterol, your glucose numbers, and keeping your weight down and exercising, you can really change the course of your health.

Nada Youssef: Great. So, just because someone's parents had a heart attack or heart disease that could totally be preventable as long as you do these things like you said. No smoking, eating healthy. When it comes to eating healthy, I've heard a lot about the Mediterranean Diet being really good for your heart. Do you agree with that?

Leslie Cho:  Yes. Mediterranean Diet is probably the best diet we have out there. There's been lot of talk about going vegan, gluten free, cholesterol free, all this stuff, but the best diet, the diet that has the most amount of study. So, randomized control study, which is what we consider the gold standard in medicine is the Mediterranean Diet. When I tell patients, "You should do the Mediterranean Diet." They're like, "What is that exactly?"

Well, it's not ... So, Mediterranean Diet, the true Mediterranean Diet is eating a lot of vegetables and fruit, complex carbohydrate. So, really nothing white. Then extra virgin, cold pressed olive oil, which is very important. Then for your protein source: beans and fish and really using meat as an accent to your meal once a weak and not having that as the major component of protein in your diet.

Nada Youssef:  Sure, sure. Great. Excellent. What are the biggest differences between a man and a woman when it comes to their heart. What makes us different?

Leslie Cho:  So, very interesting. Women have smaller heart than men. Women's culinary arteries are smaller than men. Women may have different blood stickiness, when they're older or younger. It really depends on their menopausal status, but probably the number one difference is women tend to have more atypical symptoms, when they present with a heart attack.

So, women do have common symptoms such as you feel like somebody sitting on your chest. You feel this very significant heaviness when you are moving around or exerting yourself. That's a common symptom for men and women. But women also have very atypical symptoms. So, more women will say, "I'm so tired. The things I used to be able to do, now I can't do because I'm so fatigued." Or they get short of breath more than men. So, women have more atypical symptoms. So, that's one big difference.

The other real big difference is that although we've been trying to get the word out on showing up to the emergency room early, women, even to 2018, still present later in their heart attack than men, which is a shame because if you ... Every minute counts when you're having a heart attack and you have to present early for us to save your heart muscle. So, every minute delayed is heart muscles being lost. Unfortunately, even now women present later because they're not aware of some of the atypical symptoms.

Nada Youssef:  Sure, sure. Okay. That was actually gonna be my next question about the symptoms. So, thank you for that. So, when we speak about women, I know people say that women are more emotional and they can ... Someone died recently of a broken heart. Is that correct?

Leslie Cho:  No, that's true. There is something called the broken heart syndrome. It's what we call stress induced, cardiomyopathy. It is caused by emotional stress. So, severe emotional stress can release certain type of probably stress hormones that causes the artery to either spasm or to cut off flow and people do have a heart attack. We take them to the cardiac cath lab and their arteries are clean, but they've had a substantial damage. That's mostly found in women. It is very, very interesting why that occurs in women.

There are other things that are unique to women too besides the broken heart syndrome. One of them is called heart failure with preserved ejection fraction. So, as women get older their heart muscle becomes more stiff compared to men and their heart, instead of pumping blood forward, the blood goes back because the heart muscle doesn't relax all the way. So, that kind of heart failure is a uniquely female phenomenon. So there are very, very interesting different symptoms and different disease ideology. Then finally, coronary artery dissection where the arteries are completely clean, but the arteries dissect. So, they tear. That's found more in women than in men.

Nada Youssef: That is because of just the risk factors we talked about?

Leslie Cho:  Well, they think it might be due to something called fibromuscular dysplasia, which is a disease state that affects the lining of the blood vessel and it's more of a women's phenomenon than a men's phenomenon. But coronary dissection is found in men too, but during extreme exercise, whereas in women it's found during postpartum, which is after delivery or during predelivery. That kind of hormonal stresses and then fibromuscular dysplasia.

Nada Youssef: Sure. Now what is a woman to do? Besides the normal risk factors that we know not to smoke and to eat healthy, exercise, all this good stuff, but is there something different?

Leslie Cho:  Yes.

Nada Youssef:  Okay. Let's talk about that.

Leslie Cho:  I'm so glad you asked that question because there are unique risk factors to women and one of them is that if you've had high blood pressure during your pregnancy or if you had diabetes during your pregnancy, you're at an increased risk for having heart disease. So, it's important ... A lot of times, women they go to see their gynecologist and until they hit menopause, they don't really increases your risk. The other thing that's of concern is autoimmune disease. It's when your body doesn't recognize itself and attacks it. 80% of patients who have autoimmune disease are women. If you have autoimmune disease, you're at three to five fold increase risk for having heart attack and stroke. So, if you have these things it's really, really important to be seen. It's a matter of living your life well and not having the heart attack and stroke that can really impact the quality of your life.

Nada Youssef: Sure, sure. So, what you're saying is go to your PCP. Don't just wait for heart symptoms because other things and knowing your numbers affects your heart.

Leslie Cho:   Absolutely.

Nada Youssef: Okay, that's great. Thank you for that. Now in a recent Cleveland Clinic Health Centrals article you talked a little bit about how women often do much worse than men after heart attack. We can send a link out to our viewers if they want to look at that. But can you talk a little bit about that, about the recovery part?

Leslie Cho:  So, I think one of the important lessons of that is that women present older with their heart attacks. So, if you present older with a disease, you tend to have a lot of other disease that you have too. You have a lot of what we call [inaudible 00:10:00]. So, you're more likely to be hypertensive, more likely to be diabetic. So, that's one of the reasons why women have poor outcome.

The other issue is that women present later in their heart attack than men. There might be some uniquely specific women things like they tend to get less advanced care. They tend to not have state of the art care. They tend to have more side effects with the medicines that we are currently using. They tend to bleed more. All these things sort of all play into the poor outcome.

 The best thing that I can say is when you're having symptoms, don't be your own doctor. Don't be a doctor Google and search it. Go see your doctor. Go see your doctor, get diagnosed. The most important thing is know your numbers, so you can prevent disease. Then finally once you get diagnosed, women with heart disease tend to have more depression. They tend to become more depressed, which leads to them maybe not taking their medicines as much, maybe not following up.

Nada Youssef:   [crosstalk 00:11:03]

Leslie Cho:  Exactly, which leads to worse outcome. So, I think once you have disease, it's really important to be involved in a community where you feel safe and where you feel empowered to learn about your disease and to treat your disease. It's important to seek out a doctor that can relate to you on this level too.

Nada Youssef:  Perfect. Great information. Thank you so much. I'm gonna go ahead and get some live questions coming in. I have Courtney. What does it mean for a woman when her LDL is high, but her HDL is also high? What should be done to manage this?

Leslie Cho:  Right. So, that's a very good question. So, women do have very ... So, LDL is the bad cholesterol.

Nada Youssef:  Okay.

Leslie Cho:  And HDL is the good cholesterol. So, we think of HDL as a vacuum cleaner. It goes around the body and sucks cholesterol from the body. So, if you have high HDL, we've traditionally thought that was a great thing. Based on the new guidelines, your risk is really dependent on something called the atherosclerotic cardiovascular disease risk score. So, even if your HDL is very high, if your risk score is high. That means your risk score of getting heart attack in the next 10 years is high, then it doesn't really matter what your HDL is, you should probably be treated. But it really depends on the ratio. It depends on what kind of disease you have too. So, if you already have heart disease, having good cholesterol, having high HDL is good but we really want to target that bad cholesterol number. If you don't have heart disease, then there is much more room to sort of modify.

Nada Youssef: So, that's when you say high cholesterol, we're talking about the bad, the LDL.

Leslie Cho:  Yeah. So, LDL is the lousy cholesterol and we want that number to be low.

Nada Youssef:  Okay.

Leslie Cho:  When you have heart disease. So, if you don't have heart disease, there's more room to sort of modify treatment, but if you do have heart disease, we really want that number to be less than 70.

Nada Youssef: Okay. Great. 70.

Leslie Cho: It's very low.

Nada Youssef: That is low. Okay. Thank you, Courtney, for your question. And I have Joan. What is the most effective way to educate more women of the problems with heart disease? Everyone seems to be aware of all the cancer risks, but heart disease is never discussed, yet heart disease is the number one killer of women.

Leslie Cho:  Well, Joan that's a great question and thank you for asking that. It is true. I mean, it's hard to ... I think American Heart Association has done a great job with Go Red for Women Campaign, which has really raised the awareness. I think the other thing is we have to talk to our daughters and our sisters and our mothers and we have to spread that word among ourselves. I think it's really important. I think getting the gynecologist involved in treating prevention ... I mean, to become prevention minded, I think is the most, I think is another important thing and we're trying to do that. But I really think it depends on word of mouth. I think women do a very good job of communication. So, if you know tell someone you love about their risk and whether they're getting prevention or not.

Nada Youssef: Sure, sure. Just like you said, it's an overall umbrella of good health that will protect you from heart disease. Don't wait until you get the symptoms. Okay, and Faye left a nice message. Hello from North Dakota. I've been a patient with Cleveland Clinic since 2005. Can't say enough about how good they are. Thank you.

Leslie Cho:  Oh, that's so nice.

Nada Youssef:  Great, great. I know we talked on menopause. So, I have a question here from Michelle. After menopause, what can women do to manage a higher risk for heart disease? Do you recommend hormone replacement such as estrogen supplementation?

Leslie Cho:  So, that's a great question and it's been studied in a couple of different trials and unfortunately, no hormone replacement therapy has proven to lower the risk of heart disease. So, currently the guideline recommendation is that you be on hormone replacement therapy mainly for symptoms, but not for lowering your risk.

Nada Youssef:  Okay, can I have you ... Can I just stop you for a second?

Leslie Cho:  Yeah.

Nada Youssef: Kind of take that back. What happens after menopause to your heart? Why are we replacing hormones? What's going on exactly?

Leslie Cho:  So, after the hormone ... After you go through the menopause, there's a lot of symptoms that come on like irritability, sleeplessness, people get hot flashes, but inside your body what's happening is your blood pressure tends to go up because your artery is less elastic. Your cholesterol level goes up because estrogen was helping to lower the cholesterol. Then there's other variables like platelets. Platelets are what makes your blood sticky.

So, in women, when they hit menopause, their blood pressure goes up and their cholesterol goes up. Now we used to think if we gave you hormone replacement therapy that that would lower your blood pressure and lower your cholesterol. It does lower your cholesterol, but unfortunately it doesn't lower your risk of heart attack and stroke. There is actually some data that in certain women, especially the ones with heart disease, it main increase your risk of having more heart attack and stroke. So we actively discourage our ladies who have heart disease from getting on hormone replacement therapy.

If you don't have heart disease and you're going through menopause and you're totally bothered by the symptoms then we say, "Okay, you can take it. You can take hormone replacement therapy for the symptoms, for the symptoms, but not to lower your risk." Hormone replacement therapy would always increase your good cholesterol, but it turns out that it is the dysfunctional good cholesterol it's raising, not the functional kind.

Nada Youssef:  LDL, HDL, we're talking about?

Leslie Cho:  HDL.

Nada Youssef:  HDL, okay. Excellent. Thank you. And I have Angela. I have a pacemaker and some occasional NSVT. Should I get autoimmune testing?

Leslie Cho: I'm not sure if those things are related. So, if you have a pacemaker and I'm assuming NSVT means nonsustained ventricular tachycardia this is probably something that is a little bit out ... A little bit unusual. Probably you should talk to your doctor. But autoimmune testing, I'm not sure what autoimmune testing has to do with that.

Nada Youssef:  Yeah, okay. Well, she can send us more informational follow up. I have Jane as a woman wondering if there are tests I should be receiving at different times in my life for my heart. I am currently 30 years old.

Leslie Cho: So, the only thing we would recommend at this stage is an annual blood pressure check. You can get that with your local gynecologist. You should be getting a cholesterol check every five years if you don't have risk factors. Then you should be getting things like glucose checks, fasting glucose checks if you are increased risk of having diabetes. Those kind of standard testing is what we recommend.

 If you have risk factors, so if you have family history of high cholesterol, if you have family history of early heart disease, then the American Heart Association and the American College of Cardiology recommend an annual cholesterol testing.

Nada Youssef: Oh, annual.

Leslie Cho:  Mm-hmm (affirmative).

Nada Youssef:  Okay, okay. So, otherwise if she's healthy and 30, blood pressure check, cholesterol, and some glucose.

Leslie Cho:  Mm-hmm (affirmative). Then obviously getting weighed and making sure that you're in the healthy range.

Nada Youssef: Sure. BMI. Just to make sure your BMI is ... What is it 25 and under?

Leslie Cho:  Yeah, 25 and under would be good. I mean, I really am a believer in the level of fitness. I think the level of fitness is so much more important than weight. I think for women, weight is such a delicate, sensitive issue because most of us equate weight with image, body image and all these things. What I think is really important, that's really crucial that we're learning in our data is that it's not how much you weigh, it's how fit you are. So, plenty of people who are thin are in terrible shape and actually they don't tend to live as long as people who are a little bit overweight, but in great shape. So, I think the key to health is fitness.

Nada Youssef:  Fitness. That's great. I know we talked about the question that we had, Jane's, but if you're not 30, if you're 40, 50s, 60s, and you are healthy without the heart risk factors or family history, do you still get these kind of same?

Leslie Cho:  You get the same thing? Yep. You get the same thing. You should probably start getting checked every year once you pass the age of 50. High blood pressure check, glucose check, and cholesterol check. I think that's very important. Some people advocate getting a baseline electrocardiogram, which is a tracing, electrical tracing. I think that's important. If you have symptoms, obviously, we can go towards whatever your symptoms detail. Some people are getting things like calcium coronary, calcium score. Some people are getting ultrasound of their heart. I think those are not necessary, unless there is something that drives us toward that test like an increased risk for some reason.

Nada Youssef:  Then with these tests, just like you said, this would go back to the PCP. You don't need to see a heart doctor to get these checks. You can do it from your doctor.

Leslie Cho:  Yeah.

Nada Youssef: Okay. Then May is asking, is there any difference in primary preventative measures and medications for cardiovascular disease between male and female?

Leslie Cho:  Well, the only thing ... That's a very, very good question. The only thing is aspirin. Aspirin is very, very surprising. Aspirin is one of the oldest drugs we have and yet we are still learning about aspirin. Isn't that amazing? So, aspirin was tested in women, whether aspirin helps lowering the risk of heart disease if you've never had heart disease before, which is primary prevention, which is what we are talking about. If you have heart disease, aspirin you have to be on unless there is some you're allergic to it and whatnot. If you've never had heart disease, should you be on aspirin? Turns out women greater than the age of 65, if they're bleeding risk is low, they should be on aspirin if they have risk factors because it lowers the risk of stroke.

Nada Youssef: Wow.

Leslie Cho:  Yeah. But if you're before the age of 65, it really depends on how many risk factors you have. So, in men that's different, but in women it's very clear, greater than the age of 65, the aspirin definitely helps with lowering your risk of stroke.

Nada Youssef:  Wow, very, very good information. Thank you for that question, May. We have Audrey. Does an infection in the arteries cause the plaque to gather?

Leslie Cho:  So, it's a little bit more complicated than that. It's inflammation. In the past we thought that cholesterol just lays down on the artery, but it turns out that when the arteries are inflamed, it's because of high cholesterol, because of high blood pressure, because of diabetes. All these things cause inflammation, which exasperates the cholesterol laying down on the blood vessel. So, chronic inflammatory state increases your risk too. So, things that are cause chronic inflammation are the autoimmune disease that we talked about like lupus, rheumatoid arthritis, psoriasis, all these autoimmune disease where the body doesn't recognize itself and attacks itself, increases your risk for atherosclerosis, which is hardening of the arteries.

Nada Youssef:  You mentioned, again, that was a disease that was mostly found in women.

Leslie Cho:  Yeah. 80% of-

Nada Youssef:  80%.

Leslie Cho:  Yeah, of autoimmune disease are ... I mean, 80% ... Autoimmune disease is this entity and 80% of people who have autoimmune disease are women. So, it's a predominantly female phenomenon.

Nada Youssef: I'm gonna jump on to Cora. If a woman's heart attack symptoms are subtle like neck pain, fatigue or indigestion, how can you tell if you're really having one?

Leslie Cho: That's a great question. This is not yours to decide unfortunately. I think it is something that your physicians have to decide. So, most people who are having these symptoms, they notice it is worse with exertion. That it gets worse with exertion. It's a very annoying symptom that won't go away. So, if you are in doubt, it's really important to go seek a professional help and not to be your own doctor. If you are in doubt, I think it is important to talk to your primary care doctor or call the ... Or go to the emergency room, but it's really important to let someone who knows figure it out.

Nada Youssef: Sure, sure. And if you Google it, you'll never like the answer.

Leslie Cho:  Yeah.

Nada Youssef: We have a few minutes, so I'm just gonna take one more here before I let you go. I have Cheryl. Is there any way to reverse a heart that has become rigid? I am diabetic and obese.

Leslie Cho:  So, I'm assuming rigid means arteries that have been blocked up, I hope. So, if you have ... So, there's wonderful data coming from Dr. Nissen who's our chairman here. He's spent his life working on something called intravascular ultrasound, which is like a television camera that goes inside the artery and we can see how much cholesterol plaque you have. It turns out that if you get your cholesterol level down super, duper low. So, your LDL, your lousy cholesterol less than 60, you can cause plaque regression, that the plaque can actually get less. So, yes, you can do that. So, that's one good thing. If you mean by rigid a stiff heart so that you're having more heart failure, a good thing is weight loss and controlling your blood pressure can really help the diastolic or the stiffened heart failure symptoms.

Nada Youssef: Great, great. Thank you. Well, we're all out of time, but before I let you go, is there anything you want to tell our viewers that maybe we have not touched on just in conclusion?

Leslie Cho:  I think the greatest thing about heart disease is that it's preventable and even if you are overweight or even if you have diabetes or even if you have heart disease today, you can prevent yourself from getting a second heart attack or a second stroke. I think by controlling blood pressure, controlling cholesterol, diabetes, exercising and eating right and not smoking, you can really make a big impact on your life. These pills that we are, that you take are not substitutes. They're merely supplements to a good, healthy lifestyle. So, it's an encouraging news that heart disease is preventable.

Nada Youssef:  Yes, thank you so much, Dr. Cho.

Leslie Cho: Thank you.

Nada Youssef: I wrote so many notes. You have some great information here today. Thank you.

Leslie Cho:  Thank you so much.

Nada Youssef:  Make sure to join us, actually we will be back at tomorrow at noon talking to Dr. Sorrell. Pediatric cardiologist to talk about congenital heart disease. Again for our viewers, make sure to get notified every time we go live. If you see a follow button, make sure you follow us and for more health tips and information follow us on Facebook, Twitter, Instagram, and Snapchat at Cleveland Clinic. Just one word. Thank you so much. We'll see you again soon.

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