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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
Sam Elgawly, MD (00:01):
Welcome to, Should I Call a Doctor?, the podcast where we dive into the questions you have about your health and today's trending health topics to separate fact from fiction. I'm one of your hosts, Dr. Sam Elgawly, an internal medicine physician at Inova.
Tracey Schroeder (00:13):
I'm Tracey Schroeder. I lead communications for Inova. Dr. Sam will give you the clinical perspective while I ask the questions that keep patients up at night. Joining us today is Dr. Paula Pinnell-Salles, who is a co-founder of Inova's Women's Cardiovascular Program. She's board certified in cardiovascular disease and specializes in general cardiology and vascular medicine. Welcome, thank you for being with us.
Paula Pinell-Salles, MD, FACC (00:37):
Oh, thank you. Nice to be here.
Sam Elgawly, MD (00:39):
This is an important topic. As you of course know, heart disease is the leading cause of death worldwide. And while this is an important topic to talk about broadly, whether it's men and women, there are clearly differences, in terms of how cardiovascular health manifests in women, whether it's risk factors or otherwise. So could you just, maybe we start with you broadly telling us how it's different between men and women.
Paula Pinell-Salles, MD, FACC (01:04):
So I think there are many reasons why it's important to focus on the, on women in heart disease, in part because they have under-recognized risk. And so there needs to be greater awareness of different risk factors and addressing women's risk globally in a different way. And that's also confounded by the fact that we present with more atypical symptoms that can make it harder to diagnose heart disease. And so women have to have more awareness of their risk and be better advocates for themselves to get the appropriate workup. But alsothat there are different, uh, presentations of heart disease that are more specific to women or more common in women. So men more commonly will have blockages of their large arteries, which we can treat mechanically with stents to restore the blood flow. Whereas women may be more likely to have the same presentation with chest pain, heart damage, and it is a heart attack.
Paula Pinell-Salles, MD, FACC (02:04):
But at, uh, angiography, when we do the heart catheterization, they may not have any obstructions of their arteries. And until very recently, those women would be kind of falsely reassured that, Hey, you came in with chest pain, you seem to have a heart attack. But the good news is you don't have any blockages. And they would go home untreated. And what we're learning more and more is that these are just variants of heart disease that are different and they carry the same risk. In fact, those women go on to have, uh, you know, a 50%, uh, increase of heart failure and recurring events and a quarter of them present with recurring heart attacks.
Sam Elgawly, MD (02:43):
Okay. Men, like you said, heart attack, myocardial infarction, blockage and artery. So if it isn't that mm-Hmm. in women, have we figured out what it is?
Paula Pinell-Salles, MD, FACC (02:54):
Yeah. So I I we don't fully understand. So a lot of it is that it's what we sort of perceive as microvascular dysfunction. So when we are doing the angiogram and looking at the large arteries, we're looking at the large pipes, but then the tiny branches that go into the muscular, into the muscle to feed the muscle, there's dysfunction at that level. There can be spasm at that level. Interesting that carries the same risk, presents the same way, but obviously you're gonna not, there isn't a Yeah, I see it as well. There isn't clear way to see it. And there's nothing to physically, mechanically treat. Women, for example, are also more likely to have something called spontaneous coronary artery dissection, or SCAD is the acronym, which is a tear in the lining of the coronary artery. And this, uh, this sort of phenomenon of SCAD happens more in women, tends to happen more towards middle age.
Paula Pinell-Salles, MD, FACC (03:46):
So a third of women with heart attacks will present before age 60. When we do the angiogram there, you can see the tear, you can see the abnormal flow. But we've learned that as opposed to the blockages that we treat in men, where we go in there, restore the flow, put a stent in and restore the blood flow. These are situations that are more unstable and actually best treated conservatively without any catheter intervention and just with medications. Can you just tell us a little bit about yourself? I am a, I've been a cardiologist since 2009 and I have always had a strong interest in women's health and in primary prevention we've developed a more formal women's health program and women's cardiovascular health program within Inova. And, and within that women's health program, I'm, uh, do cardio obstetrics, which is basically dealing with heart complications that can arise in pregnancy, uh, which are both you know, can be very serious.
Paula Pinell-Salles, MD, FACC (04:47):
And they're very challenging problems to, to deal with acutely and very sick patients, but also a, a very powerful opportunity for prevention over the long term, which is something I'm very passionate about. And so I'm really, I I enjoy that piece so much. How do we keep you healthy? How do we prevent those long term risks? 'cause we know that many of those pregnancy related outcomes like preeclampsia or, gestational diabetes or premature delivery, these things that a lot of women hearing this podcast might have had Mm-Hmm. and never have processed as a, as a marker of their risk.
Tracey Schroeder (05:27):
One, you mentioned that symptoms in women can sometimes present differently or atypically. Yeah, and you also mentioned that, you know, you don't, you don't attack it the same way. You don't treat it the same way that you do oftentimes in men. And so how do women think about, you know, either raising their hand to their primary care doctor, saying like, oh, I had just destinational diabetes. Do I need to be considered for some more, you know, cardio screenings or, I don't have any of these things but, you know, heart disease runs in my family. Right. Or what are the markers I should be looking for?
Paula Pinell-Salles, MD, FACC (06:01):
So I think it starts with first knowing your risk, right? So having an honest conversation with your primary and, and sort of knowing your family history, going over your obstetric history, all those things to kind of gauge what your risk is and then know your body, right? So yes, not every woman with heartburn who takes a tums and relieves it needs to worry that there's heart disease and seek an urgent evaluation. But if something is more persistent and unusual for you, then listen to your body and seek, uh, seek more urgent attention. And definitely if you have underlying risk factors, if you have had preeclampsia, you have a strong family history, or if you're diabetic, have known high cholesterol, any of those risk factors. If your symptoms are persistent and unusual for you, and we'll talk about those symptoms in a second. But if they are persistent, then do seek some urgent evaluation. And oftentimes it means not just presenting to an ER to be evaluated, but then to advocate for yourself. 'cause you may honestly, they may be dismissed er or primary care. And even cardiologists will tend to underestimate a woman's risk until she's postmenopausal and without a clear diagnosis, they may not get the EKG and the blood work and the evaluation that would be necessary to provide that first layer of reassurance before they get discharged to see somebody as an outpatient to review it further. That's
Tracey Schroeder (07:26):
So interesting. 'cause I think we're hearing about that more and more. Like there's greater attention being paid to women's health, which is great and overdue. And also that there is more screenings for things. What are the screenings for cardio for women as we think about managing and advocating for our own health? We
Paula Pinell-Salles, MD, FACC (07:44):
Do such careful screening of for breast cancer, right. And yearly mammograms that we get after age 50, I think now is the guideline that shifts, and your risk of breast cancer, versus your risk of heart disease over your lifetime. I think it's a tenfold difference, right? You are far more likely to develop heart disease, and yet we're less proactive about screening for the heart disease and heart disease risks because we sort of assume it's going to be a disease of the elderly and something that we'll address once we're postmenopausal and get there. Yes, which really misses the opportunity to look at the beginning, right. And try to modify that risk over a lifetime, because that's what's gonna really impact your risk and make you a healthy 85-year-old, which is what we all aim to be. Going back to sort of the, just the initial sort of risk evaluation with your primary care.
Paula Pinell-Salles, MD, FACC (08:36):
In the last prevention guidelines, which were in 2019, they added some enhancing risk factors, which not still are not sort of universally incorporated in that risk assessment. But I think if you're, if you're aware of these and go to your primary care kind of armed with that information, you're more likely to get that comprehensive, uh, look. So women with autoimmune disorders, chronic inflammation like rheumatoid arthritis, lupus, psoriasis, those things carry a lifetime risk because of that chronic inflammation, which we know accelerates the, uh, atherosclerotic progression or plaque buildup. And then there are, our guidelines tend to look at a 10 year heart vascular risk, which is, it's important because it kind of frames, you know, is there an imminent danger? Is there something actionable that we need to therefore be very proactive about lowering our risk today? But it also, especially in women, can be somewhat shortsighted, right? Because our risk, unfortunately is pretty flat. It's very hard to be in your 40 to 50 and in any of our risk calculators come to a level where you are high risk enough where you, where your risk factors are actionable and where you should do something beyond just the heart healthy diet. And when you hit menopause, typically the cholesterol does get worse. You're good cholesterol, uh, falls, your bad cholesterol rises, the risk sort of takes off. And then that risk has slightly has sort of taken off. And you,
Sam Elgawly, MD (10:20):
You're saying that with cholesterol, but is that sort of the same theme? Same theme with just overall risk? So for example, you mentioned some of the risk factors that women should be thinking about as it relates to screening and kind of getting ahead of it with your primary care doctor, right? Chronic autoimmune disease or inflammatory disease and other lifestyle factors. Is there an age related component to this? Like basically at what age would you say someone should start thinking about these things? Other than that menopause cutoff, but if pregnancy unmasked something or creates something, is there, you know, generally if you're over 40 or over 45, or is there something like that in women that is like the age plays a particular role other than these other variables or not as much?
Paula Pinell-Salles, MD, FACC (11:07):
No. So, so I actually would would totally frame it differently. I would say you should start when you're, you know, nowadays teenagers get their cholesterol profile and we do that not because teenagers need to be on medication, but because if your cholesterol's high when you are 18 and it stays moderately high for your whole lifetime, that area under that curve, if we kind of plot your cholesterol over your lifetime, the larger that area we're talking about a lifelong exposure Yeah. That translates into higher risk. There's a study called a coronary calcium score, which is a CAT scan where they put EKG leads on and they register how much calcium is in the region of the heart arteries or coronaries and that gives you a raw number and some indication of plaque buildup. That is a really powerful test because it is more of a reflection of your lifetime risk.
Paula Pinell-Salles, MD, FACC (12:05):
Wow. Right. Whereas every other marker, if we just take your cholesterol today Mm-Hmm, it just reflects how you're doing with your diet today. But if you've been very poorly controlled for 15 years prior, that has already taken a to into your coronaries, right? Yes. There are many tests that we order as for prevention, right? We don't order every mammogram expecting that this is the one that we're gonna catch the cancer. Right? Right. You order it expecting it's gonna be reassuring. And do you, and we do, and we should do the same. Maybe I I am, I'm more comfortable ordering calcium scores when I fully expect it should be zero, and that the likelihood of a non-zero is going to be extremely low, because it's a low radiation, low cost test. Right. Too. So there's not a lot of risk associated with it. But if it's nonzero, like you're saying, right. It's a game changer. Right. 'cause then you're already in a 45-year-old woman, a non-zero score. You're in the 95th percentile, you have more plaque production than 95% of women your age. Wow. And that speaks to your risk in a huge way and really transforms how we should manage your cholesterol
Tracey Schroeder (13:08):
And how like, so mammograms every woman knows, like over the age of whatever they say you have to get a mammogram every year. And that's, you know, so there's, there's no eligibility other than being a woman of a certain age. Is that the same for these types of heart scans?
Paula Pinell-Salles, MD, FACC (13:24):
So actually almost universally it's not covered by insurance. Okay. It's usually an out-of-pocket expense. That said it's within in health scheme of what healthcare costs are. It's, uh, fairly, do you know it's not cost prohibitive in most circumstances. Okay. We can find places where they do it between 102 hundred $50. Okay. And this is a scan that if you have, you don't repeat within 10 years generally. Okay. So it's not a common task that you're gonna repeat and follow annually.
Tracey Schroeder (13:52):
So, so would you say every woman should think about getting this or,
Paula Pinell-Salles, MD, FACC (13:55):
Well, I think if you have markers of risk, yes. If you have markers of risk or a family history, I, I wouldn't advocate using it in anybody without huge markers of risk before age 45. I think it's reasonable to do as a baseline in somebody who's 45 or older with risk factors. Or if we're coming to the question of hormone replacement, which I do wanna get to and how that might impact that screening process. There are groups of women that I wanna highlight are different from outside of every other risk conversation that we've had here, which is, and, and should know that they are being diabetic or having what we call familial hyperlipidemia, which is sort of a genetically driven high cholesterol with a family history of heart disease that tends to be signaled by a bad cholesterol, LDL above one 90 mm-Hmm. .
Paula Pinell-Salles, MD, FACC (14:50):
And being a smoker, those three things elevate your risk to be equivalent to that of a man. Hmm. You no longer have a premenopausal cloud of reduced heart risk and therefore your risk is you should be treated proactively to more aggressively lower those risk factors. Which is why our guidelines say in women over age 40 who are diabetic or with that degree of cholesterol where we think that you have a familial type hyperlipidemia, it, it doesn't, we don't do any risk calculation. We don't to decide whether you should be on some treatment because the data is so strong to say that we should. So again, you then have the risk of a man your age, you no longer have some protective.
Speaker 4 (15:48):
Yeah.
Tracey Schroeder (15:50):
Thanks for tuning in. We hope you enjoyed this episode. If you liked what you heard, be sure to subscribe.