A Balanced Heart Is A Healthy Heart
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By Dr. Suzanne Steinbaum | Posted Jun 19, 2024
Think of the “Hollywood heart attack.” A man, clutching his chest, keeling over unexpectedly. Like the Godfather in his garden with his grandson or Mr. Big after the Peloton ride. Now, think of the “Hollywood heart attack” for women. What comes to mind? It’s hard for people to name many women who have had a heart attack on the silver or TV screen. In the plainest terms, this is the root of the problem for women and heart disease, especially heart disease in its most common form, microvascular disease (MVD).
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As I’ve seen in my career as a cardiologist far too many times, the more “classic” picture of women and heart disease is not something Hollywood would be very interested in. Unfortunately, not enough physicians are either. It goes like this: A peri-menopausal woman, around 50 years old, who is fairly healthy, tells her primary care doctor she has chest pain and shortness of breath. It’s unclear when it happens, but usually she is just participating in her regular life—catching a bus, preparing lunches for the kids before taking them to school, walking to work, doing laundry, even having dinners with her husband and the kids—when intermittently, throughout the day, she feels a heaviness in her chest and shortness of breath.
Her doctor does the “standard of care.” They check her blood pressure and heart rate, maybe an electrocardiogram (EKG) is performed, and everything seems fine. The patient is then asked if she’s stressed or depressed. Maybe she is doing too much? She is advised to go home, take a couple of days off work, get a babysitter and relax. She wonders if she is just being anxious. She is questioning herself. Upon second thought, maybe she is stressed. Work has been hard, and it’s never easy juggling being a mother and wife with work. The doctor is probably right.
The chest pains don’t seem to be stopping, even after her three days off, taking it easy, sending the kids to her parents, and being pampered by her husband. She realizes that her period hasn’t come. Maybe she’s pregnant? Is that possible? After two negative pregnancy tests, she feels something has to be wrong with her. She goes to the gynecologist who tells her that she is probably in peri-menopause, the stage before menopause, when the estrogen is fluctuating and decreasing. She is told she might have hot flashes, problems sleeping and emotional swings, but there is nothing that she should do about it. It’s “normal.” Now, feeling depressed and defeated, she waits for all of these things to come.
She goes back to her indoor biking and Pilates classes and feels pretty good. She doesn’t have chest pain or shortness of breath while exercising. She almost feels normal. But the next day, she is just exhausted. So incredibly tired. Maybe she has the flu? She decides not to exercise for the next couple of days. By the third day, she is feeling back to herself and goes for a long bike ride with her husband. He was going so fast, and she was able to keep up! She couldn’t be sick, right? Later that night, after dinner, she crawls into bed because she is so tired.
All she can think is, “What is wrong with me?”
Many women go on the hunt for an answer. They see rheumatologists, gastroenterologists, endocrinologists, and eventually cardiologists. The cardiologist listens. They tell her that most likely it is not her heart because she is able to exercise, and she is too young and healthy to have heart disease. But they humor her and do an echocardiogram (ultrasound of the heart) and a stress test, and both look normal. They tell her she is fine. She asks if there is any other test that might help. They order her a coronary artery calcium score, which comes back zero. She is told that means that she has no plaque in her arteries, and everything is fine.
She knows that she is anything but fine, but she doesn’t know what to do.
Without knowing it, she is suffering from microvascular disease (MVD), and because it is the most common form of heart disease in women, you would think it would be easily diagnosed. Yet if you think that, you’d be wrong.
Twenty-ish years ago, Syndrome X became known as “chest pain with normal coronary arteries,” a problem often seen in women. Physicians made this diagnosis when women complained of chest discomfort. Then through all testing, including an invasive coronary angiogram, they were told that their arteries are normal. The syndrome was known and soon described as an offshoot of “the metabolic syndrome,” a syndrome of at least three of five criteria:
1) borderline elevated blood pressure
2) slightly elevated sugars
3) high triglycerides
4) low HDL
5) increased waist circumference.
In fact, it was not uncommon to see women with chest pain and normal coronary arteries who had this metabolic condition, which we now understand as a pre-diabetic state often associated with being overweight or obese, or commonly seen in women with polycystic ovarian syndrome (PCOS).
In 1984, the statistics started showing that more women were dying of heart disease than men. In fact, one in three women will die of heart disease — more than all cancers combined. We have known this fact for the past 20 years. As more women are living longer and spending as much as 40% of their lives in menopause, 70% of them will have heart disease.
In 1993, The Wise Trial began taking a deeper dive in understanding the mechanism of chest pain with normal coronary arteries. This trial took women into the cardiac catheterization laboratory and injected acetylcholine in their arteries. In a normal artery, this medication would cause the arteries to dilate, but in this case, the arteries spasmed. Arterial spasm is associated with lack of blood flow, and therefore a decrease in oxygen delivery — the same mechanism that happens when there is plaque in the arteries associated with chest pain. A new realization was spawned: heart disease in women did not necessarily present or look the same as men. And, because of that, the testing that we use to diagnose heart disease does not necessarily pick up disease in women!
Now, we are aware of ischemia and non-obstructive coronary artery disease (INOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA). This explains how women can have chest pain or heart attacks without having significant plaque or blockages in the arteries despite zero calcium scores and normal stress tests.
It wasn’t until 1993 with the opening of the Office of Women’s Health by the National Institute of Health (NIH) that research was finally done specifically on heart disease in women. Up until that point, research on heart disease was done mostly on men’s hearts.
Think about that. Until 1993, specific research on women’s hearts really didn’t exist and heart disease in women manifests differently than in men!
We are slowly catching up, but clinical research takes time. Challenges to the system through unique ways of assessing disease based on research have not yet become mainstream.
Sometimes innovation occurs in other places. Technology can propel advancement by pushing the envelope. Technological innovation could be the best way to crash through the challenges we have with early identification, diagnosis and treatment of women’s hearts.
But even in the vast, emerging space of medtech, the vast majority of the billions of dollars spent each year are not spent on issues related to women. And to date, there are very few companies dedicated to diagnosis of microvascular disease (MVD) in women and preventative strategies to avert the onset of serious illness and death.
Adesso is truly the first of its kind. Our software and clinical program exists specifically to change this all-too-common disastrous story of women’s heart disease that we just read about. Hollywood will need to rewrite its scripts when it comes to what heart disease really looks like for women.
Bear with me for just a minute as it gets a little technical. This information is so important for you to understand, and can save your life, so hang in there…
Plaque builds up in the large coronary arteries, the epicardial arteries. Diagnostic testing is based on these arteries, which are the main culprit in heart attacks.
The left main coronary artery lives off the left anterior descending artery down the front of the heart. This is the famous “widow maker,” a moniker that was associated with heart attacks in the top part of the artery. Blockage here leads to sudden death, thereby leaving a woman without a husband. Do you see how pervasive our culture is inundated with the myth that heart disease is a “man’s disease?”
That was the good old days, before there was a realization that more women started dying of heart disease than men.
Another artery branches off the left main and courses around the left side of the heart known as the left circumflex. The right coronary artery comes off the aorta and travels around the right side of the heart. These major arteries have large branches, which further branches off, and so on. Behind all of these large arteries there are smaller ones that we can’t really see called the microvasculature.
These arteries are too small to test on a stress test (although sometimes an EKG during a stress test may be nonspecifically abnormal or have signs that there might be some issues with blood flow delivery, but it is unclear). The subtle, non-specific findings that are often easily dismissed are, in fact, the clues to the most under-diagnosed and most common issue affecting women’s hearts: microvascular disease (MVD).
The lining of the arteries is called the endothelium. Typical risk factors for heart disease, such as high blood pressure, high cholesterol, diabetes, smoking, obesity, poor diet, sedentary lifestyle, and lack of sleep, cause this arterial lining to stiffen. When this happens in those big arteries, the sheer force of blood leads to microtears causing cholesterol, inflammatory cells, and proteins to enter the lining of the arteries.
This is the first stage of plaque formation. This area can increase in size through more deposits of cholesterol and more cellular growth causing the plaque to either block blood flow, or rupture leading to a heart attack.
In those smaller arteries, the microvascular ones, the endothelium becomes stiff and the arteries spasm or don’t dilate. This spasm could happen intermittently, throughout the day, and not necessarily with exercise.
Remember our “typical woman” at the top of this article? You got it…the stiffness that begins in the endothelium could cause chest pain, shortness of breath and/or fatigue. It happens at a far younger age than most people think, which helps explain why 70% of women don’t know their own heart risk. With that stiffness, there is the development of microtears causing the arteries not to be able to dilate or to spasm, which often starts with hormone fluctuations associated with pregnancy and/or menopause. It worsens with stress and can become even more significant in women with risk factors of heart disease, like high blood pressure, high cholesterol or elevated sugars.
Having chest pain and being told “you are fine,” is one of the most common problems, because, up until now, the testing has been focused on disease in the big arteries. Microvascular disease has been hard to detect and diagnose, and the treatment strategies have been unclear.
Properly diagnosing MVD in women relies on testing the lining of the artery–the endothelium. The endothelium’s job is to dilate when more oxygen is needed. If these small arteries are stiff or spasm, we know there’s endothelial dysfunction resulting in MVD.
Tests that can diagnose MVD are CMR (cardiac MRIs with blood flow perfusion) and PET scans, both of which are hard to find, expensive, and invasive.
Another test for MVD is an invasive angiogram using medication to see how the artery functions or to assess the flow of blood. It’s an invasive test, and although done frequently, it requires a procedure in the hospital and does have some risk (and cost!) attached to it.
A cardiopulmonary exercise test (CPET) is a simple, relatively easy way to assess microvasculature. It’s also the one non-invasive test that can give you a true understanding of the arteries’ health and cardiorespiratory fitness. The American Heart Association has called VO2 max (rudimentarily measured by Apple watches and workout apps) the most important vital sign, and yet, it is not one that is routinely tested or part of “standard of care.”
Using the CPET, we can not only tell the precise VO2 max, but we can also assess the health of the arteries through its exercise physiology assessment. Exercise is dependent on aerobic metabolism (oxygen exchange) until the body reaches maximum capacity, when it switches to anaerobic activity (using internal fat stores as fuel). With MVD, the anaerobic threshold often happens earlier in exercise, leading to shortness of breath and significant fatigue. For some women, their heart rate at anaerobic threshold can be so low (in the 90s!) due to MVD that throughout the day they are going into anaerobic activity leaving them feeling exhausted and spent.
Using the CPET as a tool to create personalized exercise prescriptions based on a moderate target heart rate zone, not only does the VO2 max increase, but the arteries begin to dilate, thereby improving MVD. The CPET is the first tool done in an outpatient facility that doesn’t take long, is relatively easy and safe, and can give a woman an answer that can provide her with an actionable diagnosis instead of the “you’re anxious, depressed, or stressed.” MVD can be treated with medication, exercise, supplements, diet, sleep and stress management.
In other words, MVD is reversible. But we must diagnose it first!
It’s so important to understand your arteries and know your risk factors. There are basic risk factors that lead to heart disease; the American Heart Association calls them Life’s Essential 8. These key risk factors include: high blood pressure, elevated cholesterol, diabetes or elevated sugars, obesity, poor diet, lack of exercise, smoking and lack of sleep. For women, there are other risk factors that increase our risk.
Pregnancy is often called “the first stress test.”
When there are adverse outcomes of pregnancy, like preeclampsia or gestational diabetes, miscarriages, premature birth or placenta previa, this is usually an indication of endothelial dysfunction leading to microvascular disease. Complications arise because these arteries are not dilating well enough to support the baby and the mother.
For many women this is the first red warning light of coming disease and most often it is missed. Seventy-five percent of women who have preeclampsia will develop high blood pressure later in life, and those with early onset preeclampsia have a 3.6-fold increased risk of cardiovascular death by age 60. Women with gestational diabetes have an increased risk of cardiovascular complications within 10 years postpartum. For many women who had issues during pregnancy, delivering the baby seems like the “cure.” Instead, it means that the endothelium and the microvascular artery health should be investigated before another pregnancy or before peri-menopause occurs.
The next hormonal whirlwind to affect the arteries begins in peri-menopause. As estrogen starts to decrease, the endothelium becomes stiff causing MVD. Hot flashes are the most prevalent and evident sign of stiffness of the arteries In fact, the more intense and frequent hot flashes are, the greater the association with MVD and, later, coronary artery disease. As we enter menopause, sometimes blood pressure will start going up, as well as a woman’s cholesterol. With a shift in hormones, metabolism shifts, and weight gain can also occur. All of this plays a part in the health of the arteries.
Studies have shown depression and anxiety have a greater impact on the health of women’s arteries, including a two-fold increase in heart disease in women who are depressed. With these issues, there is a hormonal stress response that increases stress hormones, including epinephrine, norepinephrine, and cortisol, leading to inflammation. These hormones wreak havoc on the endothelium and lead to stiffness and coronary plaque.
Other issues, like autoimmune diseases, also increase inflammation in the body and affect the arteries. The first manifestation is arterial stiffness and spasm, then leading to MVD, as well as the potential for disease in the large arteries, causing plaque and potentially ultimately leading to heart attacks and strokes.
One issue sometimes forgotten is family history. A history of a father, mother, or sibling with heart issues increases the person’s risk of heart disease significantly. Know your family history and who has had a heart attack or stroke and at what age. Also, if someone has had sudden cardiac death or an aneurysm, as well as history of high blood pressure, high cholesterol, diabetes and atrial fibrillation. The more you know, the better. So, ask the best historian in the family to fill you in.
Screening tests include a coronary artery calcium score, which can identify calcium in the arteries. Calcium is associated with mature, hardened plaque and is a sign that there is plaque in the arteries. The downside to this test is that it cannot identify soft plaque that is developing, or disease in the microvascular arteries and can give women a false sense of security. A score of zero does not mean that nothing is wrong.
Breast arterial calcification (BAC) can also be used as a screening tool. Women over the age of 40 are encouraged to get annual mammograms. Looking for calcification in the breast arteries can give a clue that there might be stiffness of the heart’s arteries. One study shows an association of BAC and coronary artery disease between 80-90%.
Ultimately, knowledge is power. Knowing your own risk is the first step.
A simple blood test can tell you if you have high cholesterol and elevated sugars. Start there! The CPET will tell you your anaerobic and ischemic threshold, which creates a “personalized exercise prescription” as well as a way to understand your VO2 max, which tells you your cardiovascular fitness.
For those who do not have access to that test, we can determine the best heart rate zone for you to exercise based on your age. Let’s do a little math:
If you have a watch or other monitor, watch your heart rate so you can exercise at that zone consistently. If your heart rate goes up, then slow down your exercise.
In doing so, you’re forcing your arteries to dilate by slowing your heart rate down and allowing it time to fill with blood. Over time, when exercising in that heart rate zone for 30 minutes, five days a week, the consistency and continuity of the arterial pressure will force the arteries to dilate. Find your sweet spot in exercise for you to maintain the heart rate you need to be at to get your most effective exercise. Your “sweet” spot is your safe spot.
Let’s not overlook muscle strength! A light weight routine with multiple repetitions twice a week will help build up the mitochondria, or energy cells, as well as improve muscle strength. This not only prevents osteoporosis, keeps your joints healthy, and helps you maintain balance and flexibility as you age, it improves your overall fitness.
For those who have those risk factors we discussed above, medications that treat cholesterol like statins can be beneficial, not only to reduce cholesterol but to decrease inflammation and can assist in arterial dilation in the MVD setting.
Treating blood pressure is critical, yet high blood pressure is often not treated aggressively, especially in women. Approximately 30% of women who have high blood pressure are not treated to goal. We want blood pressure to be less than 130/85.
Diabetes is a significant risk factor and should be managed. Elevated sugars not in the diabetic range should also be addressed. Whether with dietary intervention, weight loss or medications (Metformin, Ozempic, GLP1 or SGLT-2), getting sugars under control is essential. Obesity is also an issue. With these new medications available, it is important to be assessed to see if you are a good candidate.
Empower yourself to take a brave and honest look at your lifestyle choices. Eighty percent of the time heart disease is preventable. How you choose to live can be the cornerstone to treating your coronary arteries. Take a focused look at how you eat, exercise or move throughout the day, manage stress and sleep. Assess those things you know are not good for you and make a decision to make different choices.
What does empowerment look like on a daily basis?
It takes 15 to 20 years for research to become part of clinical practice, when the science gets passed down to the doctors for them to use it for their patients. We are behind in healthcare in how we treat women’s symptoms and cardiovascular disease. Many doctors don’t know about the nuances of women’s hearts, the MVD symptoms and how it often goes untreated. MVD can increase the risk of heart attack.
You need to become your own best advocate by learning about your risk of heart disease and MVD and what you can do about it. We are with coronary artery disease in women today in the same place as we were with diagnosing breast cancer 20 years ago. As women, we advocated for mammograms at 40 years old and we got them. You need to be informed and you need to be proactive. Speak up and speak out to get the care you need.
If you have symptoms like chest discomfort, shortness of breath, fatigue, flu-like symptoms, sleep disturbances, nausea or vomiting with exertion, jaw pain or upper back pain, seek help. If your doctor says you are fine, and your instinct tells you that you are not, then find another physician to help you get to the truth. And don’t hesitate to go to the emergency room if these symptoms persist. The safest thing to do is to get checked.
We can change the statistics surrounding women and heart disease. We can diagnosis MVD early before it leads to heart attacks, heart failure and chronic disease.
If you want any information about Adesso and how we are changing the statistics around women and heart disease with accurate risk scoring, early diagnosis and treatment strategies, email us at info@hearttech.health.
For a limited time, we will email you a free code* to download MyAdesso™ from the Apple Store (Android store coming soon) where you can take The Adesso Heart Score™, know your specific risk and take action to start your own heart health journey!
*Limited number of free codes will be provided, subject to first-come, first-served
