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Ep. 98 - LiveWell Talk On...Women's Heart Health (Dr. Laila Payvandi)

episode 98

Ep. 98 - LiveWell Talk On...Women's Heart Health

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Laila Payvandicardiologist, St. Luke's Heart & Vascular Institute and St. Luke's Cardiology

Dr. Arnold:
This is LiveWell Talk On...Women's Heart Health. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. According to the American Heart Association, cardiovascular disease claims the life of a woman about every 80 seconds. It is the leading cause of death in women. But despite increases in awareness over the past decades, the CDC says only about half of women recognize it as their number one killer. Joining me today to talk about women's heart health is Dr. Laila Payvandi, cardiologist with St. Luke's Heart and Vascular Institute and St. Luke's Cardiology. Welcome.

Dr. Payvandi:
Thank you. Thanks for having me.

Dr. Arnold:
First things first, the Payvandi name in cardiology is legendary. How's your dad?

Dr. Payvandi:
He's doing well, thanks for asking. He's looking forward to rejoining the free-medical clinic where he's been very active. So yes, I think he's doing great. Thank you.

Dr. Arnold:
Well, he's missed. You know, I can remember that women's presentation, or atypical findings, for heart disease became I don't want to say—but in the late nineties. You know, I mean, I started in '93 and I could see the transition there where we started talking about it. And part of it was the coronary calcium scores came out and women have soft plaques. And then, so there were people with normal coronary calcium scores are very low having heart attacks, you know? And so that started the discussion as well. But what are some symptoms that women have that differ from men?

Dr. Payvandi:
When we, you know, think about heart disease, we think about kind of the middle-aged Caucasian gentlemen, you know, fist on the chest says feels like an elephant sitting on them. But for women and for some men, that's just not how they present. That's kind of an idealized way of categorizing heart disease presentation. You know, with women in particular, I look for more nuanced symptoms. Like, you know, I just noticed I can't keep up with the same workout that I was doing six months ago. Or, I'm somebody that normally wakes up at 6:00 AM ready to hit the ground running, and I'm noticing this sort of heaviness or fatigue about me through the day. This sort of exertional intolerance as a harbinger of maybe heart disease that has been building over time. I also look for shortness of breath that, you know, obviously can be multifactorial. But acutely, you know, you look for other things like upper abdominal pain, nausea, back pain. That with other factors can raise suspicion. So it isn't always that classic, you know, frontal chest pain syndrome. We really have to kind of think outside the box and look for sometimes more subtle cues, particularly in women.

Dr. Arnold:
Are the risk factors the same for women, or is smoking more contributory or less contributory?

Dr. Payvandi:
The risk factors are more or less the same. However, you know, how the hormone component, particularly post-menopausal hormone status, the role of estrogen in certain unusual forms of heart attack is obviously unique to women. But a lot of times I have seen in my own practice, that the family history component sometimes gets overlooked more in women than in men. It's just not as much in the forefront of the patient's mind and or the primary care provider mind. So I have noticed family history can sometimes get kind of lost in the mix, I have seen.

Dr. Arnold:
Yeah. And my experience was always that, with any patient, was if you made a doctor's appointment, because something's bothering you and you have risk factors, it's heart disease until we're done, you know. I mean, just it's there. Throw a stick and you'll hit someone with heart disease. You know, I remember I read a statistic one time that in the early nineties, 50% of people with heart disease presented with cardiac arrest. In that, you know, that number is significantly down. You probably know a percentage better than I do, but we've made progress, but there's still work to do.

Dr. Payvandi:
Yes.

Dr. Arnold:
Men are men and women are women and are from Mars or from Venus, I can't remember the name of that book. But why do you think women downplay that? You think there's a reason for that? One is, a mom's never off duty. You know, my daughters are daddy's girls, but man, if they got hurt: where's mom? You know, not to be disparaging to people that don't have children, but I think mom's always on duty.

Dr. Payvandi:
I agree. And I think women in particular, you know, as they approach that age where clinical heart disease can become an issue, that sort of coincides often with where women, not just women, but especially women find themselves kind of in that bridge where they're caregivers, perhaps for elderly parents and yet they have children at home. And they're sort of spread as a caregiver more or less in multiple different directions, plus add a career, plus add other personal responsibilities. So I think there's an unconscious tendency to sometimes put yourself last. And not to tend to things that maybe under different circumstances, you would.

Dr. Arnold:
I think it's hardwired, you know. I used to, like at Thanksgiving, Tanya always thought about making sure the girls had their plates filled before hers. Where, you know, I was elbowing my way up there to get the good stuff. And so I think he's just hardwired and that's a good thing. Are there certain types of heart disease that are more common in women than men? Is it all atherosclerotic heart disease, or?

Dr. Payvandi:
Yeah. So, you know, heart disease can be broken down into several big categories. When we hear the word heart disease, we tend to think about heart blockage disease, which is the entity that can lead to heart attack. You know, but we also have to think about heart rhythm disorders, heart failure, valvular heart disease, congenital heart disease, which is the structural disease that we're born with. But there is a form of that does, you know, occur more commonly in women than in men. It's called a stress induced cardiomyopathy, or sometimes in the media it's described as the broken heart syndrome. And that does occur more commonly in women. And what that is, is typically a transient form of heart failure and heart dysfunction that can occur after a high stress, emotional, or physical event. So we've seen it for example, in patients where they were at the funeral for a loved one and then present with signs and symptoms that looks and smells and breathes like a heart attack, when in fact it's actually this transient form of heart failure that can occur as a result of the stress hormones that are released in those situations. It can also happen after extreme physical stress. So if you're in the hospital and you're septic, for example, you can develop this. The entity itself is more common in women than in men, but if you compare men and women, the form that occurs in women is more typically associated with emotional stress compared to men. And so that's something we have to be kind of mindful for in the female population.

Dr. Arnold:
There's a, it was a Milwaukee marathon where they looked at stress induced cardiomyopathy from marathons. And it was really common, just people recover from it. And I've had—there's one of the anesthesiologists on staff said that he doesn't drink caffeine, but he always felt better when he drank caffeine after a marathon. I was wondering there's some sort of ionotropic sort of effect made that made the heart squeeze a little bit more and made them feel better.

Dr. Payvandi:
Maybe.

Dr. Arnold:
You know, earlier you mentioned estrogen, what role does hormone replacement play in cardiovascular health for women?

Dr. Payvandi:
So back in the day, there was the concept that placing post-menopausal women on hormone replacement therapy could potentially prevent heart disease development. Fast forward, what we ultimately find from randomized control studies, is that is not the case. It does not prevent heart disease and hormone replacement therapy can actually increase the risk of stroke.

Dr. Arnold:
Right.

Dr. Payvandi:
I see women in my own practice who maybe went through menopause 10/15 years ago, were suffering from severe hot flashes or other post-menopausal symptoms at that time. They were started on hormone replacement therapy, estrogen and progesterone if they still had a uterus, with the intention of that being kind of a short term thing. And then fast forward 10/15 years, they're still on it. And it's something that I'm very mindful for when I'm reviewing a patient medication list because we really should not have women on hormone replacement therapy long-term unless there's a strong, compelling reason to do so. For the reasons I mentioned: increased risk of stroke, increased risk of blood clotting disorders, and it can worsen your overall metabolic profile in terms of blood pressure and cholesterol. So a lot of times women come to me for, you know, a hypertension consultation and what we end up spending the bulk of the appointment about is why we need to get you off of the estrogen, oral estrogen that you've been on for 15 years. And that's a conversation where I have to work with the primary and the gynecologist, but it's something that I think can easily be missed and there's a lot of misconception about it.

Dr. Arnold:
So, that's an interesting side note. You had all these women that are on this low dose of Synthroid, right. And it used to be decades ago, they had this admission to the hospital admin panel and it had a TSH on it. And so people come in with pneumonia and, you know, sick euthyroid syndrome, their TSH would be a little high, the doctor would put them on like 25 micrograms. And 50 years later, they're still taking it. And you know, they don't have hypothyroidism. It's not enough to influence it. You see that all the time, much less now, but you see that all the time.

Dr. Payvandi:
It takes a lot of re-education because at the time sometimes that it was started, it was that's the standard of care that we're going to do for your severe symptoms. And trying to educate and explain the rationale for why we don't want our female patients on this long-term unless there's a compelling reason, that's sometimes a challenging conversation to have.

Dr. Arnold:
Yeah. Are there gender disparities, as far as men and women in access to healthcare? Probably not locally. I mean, that's probably about the same. But just, how do you approach that in your practice, the possibility of some sort of disparity between the sexes?

Dr. Payvandi:
I haven't seen it since I've been in practice here. I, like you mentioned, I'm not aware of it in my day-to-day practice. And I'm not aware of any lack of vigilance on the part of our primary care providers in referring to cardiology. In fact, I think our primary care providers are very vigilant and appropriate in their referrals for symptom consultation, but also for prevention consoles. So I do see a lot of very, you know, astute primary care providers that say: Hey, I know you're here for your annual well visit, but you have so many risk factors for heart disease. Have you thought about seeing a cardiologist just to get another set of eyes? And I love seeing those because obviously we can make interventions before clinical vascular disease occurs. So I will say though, I think our community does a really good job of public education and helping our community be health literate. So at our annual Go Red for Women event. It might not seem like a lot, but actually those meetings alone generate a tremendous amount of self-referral for women that say: you know what, I think I need to sort of take the lead on my health care here. And, you know, there's so much we can do from a preventative perspective too.

Dr. Arnold:
As we started, you know, I think the mental image of someone having a heart attack is Lou Grant, but actually Mary Tyler Moore can have just as many heart attacks as Lou Grant. You know, but you think of the guy kind of shaped like that, et cetera. Shaped like me if I lose a little more hair perhaps, I don't know. Is there a certain age that you'd recommend women get screened for heart disease if they have family history? I mean, do you approach it like that at all?

Dr. Payvandi:
I don't think there's an age cutoff, but I think we hit the point where you start to have multiple intersecting risk factors. So primary care provider now is recommending a lipid, a cholesterol lowering medication you're on a blood pressure medication. Maybe you smoked in the past, you have your family history. You know, once multiple risk factors start to intersect, I would say two or more, then it's time to start thinking about: Am I on an optimal regimen of preventative medications and lifestyle measures, I think is a way to approach it. You know, the whole lifestyle component is obviously a big piece of the puzzle, huge piece of the puzzle. You know, and so I can put you on blood pressure medication all day long, but until you're limiting your sodium, exercising, and treating your body with respect, then you know, you're kind of fighting against it.

Dr. Arnold:
I used to tell patients that it was kind of like a revolver, an unloader revolver of your family history. And you know, you smoke, you put two bullets in the chamber, you have diabetes, you put three bullets in the chamber. Pretty soon, now you have a very dangerous gun that previously it was empty. To think of it that way, you know, because just the more you get, the more dangerous it becomes.

Dr. Payvandi:
That's a beautiful way to put it because so many of those things are self-inflicted, right? But tobacco is self-inflicted and you know, poor diet measures and not exercising. Yeah, that's all kind of like you're loading your own gun.

Dr. Arnold:
Yeah. Well, heart month is February. Go Red will be there, and we'll look forward to that. This is really great information. Again, this was women's heart health and Dr. Laila Payvandi with St. Luke's Heart and Vascular Institute and St. Luke's Cardiology. For more information, visit UnityPoint.org. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.