Empowered Health


Ep. 15: Heart disease of the small vessels, a female killer with Janet Wei and Giulia Sheftel | Empowered Health

Heart disease is the leading cause of death in men and women alike, but the symptoms, causes, and outcomes differ among the sexes. Heart disease is a catch-all for many cardiovascular conditions, so for this episode, we are focusing on small vessel disease. Women tend to get blockages in the small vessels, whereas men have plaque build-up in their large arteries. Cardiologists Dr. Janet Wei of the Barbara Streisand Women’s Heart Center at the Cedars-Sinai Smidt Heart Institute and Dr. Giulia Sheftel of Newton-Wellesley Hospital discuss how these blockages happen, Yentl Syndrome, and the interplay of estrogen and heart health.

Show notes + Transcript


I’m Emily Kumler and this is Empowered Health. This week on Empowered Health, we’re going to look at the leading cause of death in women, which is heart disease. It turns out that heart disease is really sort of a multifaceted problem under that umbrella of a number of different kinds of conditions, some of which affect women much more than men. This week we’re going to be talking specifically about blockages in the small vessels of the heart, which disproportionately affect women. Men are more likely to have blockages in the big parts of their heart, which means the testing that most people get in an emergency room are looking at what the men get, not what the women get. So this is definitely one of those episodes that we hope is gonna charge you up to be your own advocate. We’re gonna kick it off by going to California.

Janet Wei:

My name is Janet Wei. I’m a cardiologist and I’m the Assistant Director of our

women’s heart center, the Barbara Streisand Women’s Heart Center at the

Cedars-Sinai Smidt Heart Institute. I’m also the Assistant Medical Director of the

Cedars-Sinai Biomedical Imaging Resource Institute and have interest in the sex

differences of cardiovascular disease, specifically looking at pregnancy related

heart issues in women as well as a woman with chest pain.


I feel like, let’s just start with some basics. Can you explain to us what the

differences are? I mean, I feel like people think of like coronary heart disease,

congestive heart failure or heart attacks, ischemia all of these different things.

Can you sort of break down what, specifically for women, are the sort of

differences or it seems like there’s some catch alls.

Janet Wei:

Yes. Yes. Thank you. That’s an excellent question. When we refer to heart

disease or cardiovascular disease, that is our catchall term for heart attacks, for

heart failure, for hypertension, also known as high blood pressure, stroke as

well as arrhythmias. So having abnormal electrical issues in the heart, and there

are certain, differences in women in which various components of these

cardiovascular diseases as well as risk factors for cardiovascular disease

manifest themselves. We know that for both men and women, heart disease,

cardiovascular disease is the leading cause of death. Over the past 20 years, due

to improvements in our ways of treating men and women in treating acute

heart attacks, death rates have actually been declining, fortunately. However,

the death rates for young women with acute heart attacks.


So what is young?

Janet Wei:

Yes, less than 60 years old.

Emily: Okay. I love that definition of young.

Janet Wei: Yeah. Yes. There’s been an increase in death rates for young women, related to

acute heart attacks and we need to really understand why that is. Because the

discrepancies of the mortality in the past for men versus women used to be

focused on discrepancies in what physicians are doing. For example, in the past,

women were less likely, if they had an acute heart attack, to be treated. They

would be less likely to be taken to a cath lab to have their blockages opened up

if they were having an acute heart attack due to a blockage in their arteries. It

was taking longer for them to taken to the cath lab and there were fewer

women after they had a heart attack who are getting appropriate guideline based medical therapy compared to men.

Emily: And you guys call that the Yentl Syndrome, is that right?

Janet Wei: Yeah. So the Yentl Syndrome is related to that. Exactly. So the idea is that

women sometimes had symptoms that were due to a heart attack that were

different from men. Chest pain is still the number one symptom that both men

and women experience when they have an attack. But women are more likely

than men to have more atypical presentations of that chest pain. They might

experience it more as a chest pressure or a chest burning. And it’s not always

that classic Hollywood heart attack where typically a man is kind of clutching the

center of their chest and complaining of an elephant, you know, sitting on their

chest. Women may feel like, oh this feels like heartburn or actually my jaw is

hurting or I might be more short of breath rather than having chest pain. I might

even be having nausea. So some of these atypical symptoms were what

contributed to lower diagnosis rate of heart attacks in women and men. So if

women’s symptoms weren’t being recognized as a heart attack because they

were not similar to men than they were getting misdiagnosed and then

therefore not getting the appropriate treatment.

Emily: So the symptoms that women present seem less acute, right? Like nausea

versus like stabbing pain in your chest and so I, you know, I feel like the natural

question then is are the heart attacks that women suffer from also less acute,

right? Cause there’s a range of kind of heart attacks. Is that right?

Janet Wei: Heart attacks are all acute. They all happen acutely. However, I think what you

have put a good point on is that there is often symptoms that lead up to a heart

attack. So we use the term is angina. Usually what we refer to as chest

discomfort due to the arteries in the heart, not getting enough blood flow. And

so women and men’s angina symptoms or angina symptoms are similarly

different. Just as the acute heart attack symptoms may be different these

angina, more chronic angina symptoms, may be different. And what we’ve

learned through the National Institute of Health sponsored Women’s Ischemia

Syndrome Evaluation, that was led by Dr. Noel Bairey Merz here at Cedars-Sinai.

She’s the director of our women’s heart center is that about half of women who

have angina and who go to have their arteries evaluated in the cath lab actually

don’t have obstructive coronary artery disease, meaning that they don’t h

big arteries, that these are the vessels that are not working well. They are not

able to increase blood flow to the heart muscle in response to either exercise or

even emotional stress or they may actually constrict.

Emily: So it’s not a blockage in the smaller vessels, it’s some other problem with them.

Janet Wei: Yes. It’s more of a, it’s more of a dysfunction. They’re not able to dilate or relax

as well.

Emily: So we’re going to head to the east coast and get a better understanding of the sort of anatomy of the heart and where the blockages actually occur in women.

Giulia Sheftel: My name is Dr. Giulia Sheftel and I’m a clinical noninvasive cardiologist at

Newton-Wellesley Hospital and basically I see patients all day. I also spend a fair

amount of my time as Medical Director of the Cardiac Ultrasound Lab at

Newton-Wellesley Hospital where I’m very interested in imaging and cardiac

ultrasound, echocardiograms. The heart is a muscle and it needs a blood supply

like any organ in the body. And so I want you to think of the blood supply to the

heart as an upside down tree. We’re going to start at the top. It’s the trunk and

then there might be three or four large branches that take off from the trunk.

And these branches they subdivide into smaller and smaller branches. In effect,

they arborize, right. To extend the analogy of the tree, arborize. They get

smaller and smaller and smaller until they vary into the heart muscle itself. So

that is what we call the coronary anatomy. Coronary comes from the Latin

coronarius, meaning crown. Some very inventive person thought that the

arteries looked like you know, a crown. So that’s where the term coronary

arteries sort of comes from. So that is the basic anatomy of the arterial tree.

And what we’re going to talk about today is the differences between men and

women. In terms of the anatomy of the arterial tree, both in terms of the big

trunks and the little tiny vessels, or what I call the twigs. So one of the things

that is very interesting as we think about the differences between men and

women. Let’s talk for a minute about the big branches. The top part of the tree,

remember I said, you know, you’ve sort of got what we call a main trunk in

cardiology. We call it the left main. And that trunk branches into about oh three

or four main branches, let’s say. And so there are relatively big arteries. And so

one of the things that research has uncovered is that men and women have a

very different way of laying down what we call plaque. Plaque is a buildup of

cholesterol in the pipes. And plaque is made up of fat and cholesterol and little

bits of calcium. And interestingly enough, plaque, it’s not just like a rusty pipe

because it turns out that there’s a lot of inflammation going on in plaque

because lots of cells of the immune system residue in the plaque and that

becomes important. But it turns out that men and women have a very different

way of laying down plaque, which is similar to the way that they put on weight

as they get older. Let’s take a man, you might notice that as that man gets older,

he’s got skinny arms and skinny legs. But what happens to the belly? It gets

bigger, we call it a beer belly. It’s perturbate right? And so that is sort of a male

pattern of laying down fat.

Emily: The actual anatomy of the heart. It’s the same in men as it is in women. But

what you’re talking about is where the blockages occur, correct?

Sheftel: Right, so the basic concept is the same. So yes, the anatomy of the heart is the

same in men and women, right? It’s some muscle, it’s got hard valves, it has a

blood supply, but what I’m talking about now is very specifically, I’m talking

about the arterial tree or the plumbing, if you will. We’re focusing on this aspect

of heart disease. The arteries and the analogy that I’m drawing is that as men

get older and they deposit fat, they put it right in the belly. And what’s

fascinating is that if you look, at a coronary angiogram, which is an invasive test,

it’s also called a cardiac catheterization. This is an invasive test whereby we put

a little catheter tube in a vessel in the groin. It’s advanced to the heart and then

we shoot some dye under x-ray guidance and we shoot some dye into the

arteries of the heart, take x-ray pictures, and we can look for blockages. Turns

out that in men we often see great big blockages. The arteries are obviously

plugged. But in women, we see a slightly different pattern, which is very

analogous to how women gain weight as they get older. For example, in the

menopause, which is they seem to distribute fat everywhere. And I’ve had many

of my female patients coming in menopausal, perimenopausal and they’re very

distressed because they’re suddenly developing fat in areas like their belly or

their arms where they never had it before. And it becomes very stubborn and

resistant to get rid of. They’re very unhappy about that. But it turns out, that if

you look at the arteries of the heart and women on these coronary angiograms,

you don’t see these big obstacles, these big plaques. It’s the way that it’s being

deposited. It’s the way that, for whatever complexity of reasons, mother nature

says in a man, I’m going to deposit the plaque. So it’s just, you know, bulging

into the pipe. But for women, the way that they lay down plaque is different

because they lay it down kind of just not with one big focal bulge but sort of all

over the place. Not just in the middle of the pipe, but along the walls of the pipe

and sort of outwardly. So it’s not so much that they’re pushing it out, that’s just

more of a kind of an analogy. But that’s the way the plaque is being deposited.


Emily: And that’s true pre and post menopause?

Giulia Sheftel: No, it’s typically we see it most, you know, in 50-year-old women and on that

that’s is that women have non-obstructive coronary artery disease more than

men. So instead of having these huge obstructions, women tend to have more

non-obstructive coronary artery disease. That is to say that is the way that they

lay down plaque with this process of atherosclerosis, which is that process of

laying down plaque. That’s how women do it. And so there is a very, very catchy

word for that. Would you like to know what the word is? It’s MINOCA.

Emily: And that’s the small vessel blockages.

Giulia Sheftel: So MINOCA stands for Myocardial Ischemia Infarction and No Obstructive

Coronary Artery Disease.

Emily: So would that be picked up in a cath

Giulia Sheftel: So if you had a cardiac catheterization, which by the way is the gold standard

test that we use to make the diagnosis of coronary artery disease. What you will

find when you do these tests is that in women, more often than men, you will

see non obstructive disease and that’s what we call MINOCA. Or INOCA

MINOCA, it stands for, I don’t expect you to remember that, but the way that I

think about it, these are mini plaques, mini for MINOCA, itty-bitty plaques. So

the heart is not getting enough blood flow, but it’s not because of these huge

plaques that are projecting into the pipe, but they have a lot of non obstructed,

they have small plaques that they deposit everywhere. Just the way a woman as

she approaches menopause and perimenopause, is distributing adipose fat

everywhere. So that is one of the differences. But another very important

difference, as we’re talking about the coronary arterial tree, is that one thing

that can happen with MINOCA, which is non obstructive disease, is a subset, a

large subset of patients have problems with the tiny little blood vessels at the

end of the tree, what we call the little arterials. And it turns out that in women,

more often than men, it’s those little tiny blood vessels that are embedded in

the heart muscle. Those are dysfunctional. And that’s what we call coronary

microcirculatory dysfunction.

Emily: I found Doctor Sheftel’s explanation of where these blockages are happening to be really helpful. But one of the things that again is very frustrating is learning how little research there is on this. And so in her practice when she is treating women who have these blockages, she’s kind of winging it because there aren’t any guidelines to instruct her sort of ability to diagnose and then treat with something that she knows is going to be effective. So she has to kind of personalize everything. She’s going to explain to us next a little bit about how this is challenging.

Giulia Sheftel: You know, doctors rely heavily on guidelines to treat patients. That’s how we do it. Guidelines inform clinical practice and they help and tell us what to do with any individual. Course there’s always the art of medicine, but you always have to put it into context. The guideline, unfortunately right now, there are no guidelines to treat coronary microvascular

disease. There are some interesting studies that are ongoing. There’s a very well

known wonderful researcher, Noel Bairey Merz, and she’s the head of the WISE

study, which is the Women’s Ischemia Syndrome Evaluation study to prominent

researcher. And I believe there’s a trial now that’s enrolling only women. I think

it’s about 4,000 women looking at I believe it’s aspirin and cholesterol

medication to see whether we can improve outcomes in these women with

small vessel disease because in the old days we used to brush it off. You know,

the woman was anxious, no big deal. You’ve got nothing wrong with the big

blood vessels. So see you later. It’s your reflux or it’s your pinched nerve. But

now we’re coming to understand that the prognosis of these patients with small

vessel disease is not benign. And there are ways, important ways, to treat it. But

again, we don’t have guidelines. So a lot of it is just trial and error.

Emily: Yeah, I mean I think that’s tricky because I think historically the guidelines have

been all based on male bodies, right? So they haven’t served women the way

that they probably should have. And people would say like, well, their research

doubly-blind clinical trial, you know, great. But there weren’t any women in the

study, so that’s not actually that helpful. Right. And I think there’s obviously a lot

of information coming out about women and cholesterol that seems to be, you

know, interesting at the very least, sort of suggesting that total cholesterol is

not a good indicator at all for women in terms of heart disease and that, you

know, especially premenopausal women run higher with their HDL and adding

that in somehow is not quite the right way of figuring some of this stuff out.

There’s also a clinical trial that was done looking at the response women have to

statins and how they’re like four times more likely to develop diabetes if they’ve

been put on a statin, which is a conversation a lot of doctors aren’t having with

their female patients when they decide to put them on statins. So I agree with

you in general that like the more research the better, but I feel like historically, I

don’t think women have been included in on so many of the clinical trials that

I’m not sure we can make that argument in terms of guidelines because

guidelines seem to be, you know, as we go towards precision medicine, I also

would hope that we’re going towards some pretty basic sex difference in terms

of hormonal regulation. And all these other things.

Giulia Sheftel: Right. I agree. I think that there has been a vast, we know there’s been a vast

underrepresentation of women in clinical trials, and so I understand what you’re

saying is, you know, here, I’m telling you that I feel more comfortable following

guidelines and yet we know that much of that research has been done on men

and that’s really the problem. That’s the crux of the problem that we’re doing a

one-size-fits-all here, which is why it’s so incredibly important that we really

step up the research game in women. A big thing that I think people don’t

realize is that I’m going to come back to this, is that a woman is, you know,

much more likely to, to die from heart disease than breast cancer. Breast cancer

these days is, many patients who are very well treated, but you know, one in

two women is going to get heart disease, cardiovascular disease, in their

lifetime and one in three are going to die from cardiovascular disease. And

these are shocking statistics that, you know that I think people forget. And the

important thing to recognize is that the disease seems to be gaining strength.

This whole issue of atherosclerotic coronary artery disease is gaining strength in

younger women, younger women, smoking is on the rise, for example, at

college campuses. And we are now seeing a rise in heart disease in young

women. And that’s a problem. That’s a shocker. And so I think we need a way to

popularize, and to spread the word. I think there have been tremendous

campaigns that have raised awareness of heart disease in women. The red dress

campaign, the American Heart, the NHLBI. But I think we’re still kind of, for

some reason, I think it still doesn’t resonate with women. I remember an

interesting story that my chief of cardiol

Emily: And so along those same lines, I think one of the things that I, you know, I think

you know, you just sort of inherit as a bias, is this idea that women live longer

than men. So when you hear statistics about like, women are dying of heart

disease, that, you know, it’s the leading cause of death and the statistics that

you just put out there, 50% can die suddenly. One of the things that I think

allows people to discount it is this idea of like, oh, well they’re old, right? Like

we all have to die of something someday. I’d love for you to talk a little bit about

the interplay between estrogen and heart health and why that after, you know,

sort of going through menopause becomes a really critical point of heart care, I

guess, or heart, you know, concern for women.

Giulia Sheftel: You know, when people enter the perimenopause they can feel quite poorly

with symptoms, hot flashes, sweats, sleep disturbance. And so, and we used to

think estrogen was good, we used to think it improved the cholesterol profile.

We even used to give it for heart health in the older days. But then we found

out that estrogen is indeed not good for the heart. And that not only was it

associated with an increased risk of breast cancer, but it also increased the risk

for stroke and heart attack.

Emily: Are you talking about the Women’s Health Initiative, like women taking estrogen

who are 65 or older? Right. I think that’s probably important to say.

Giulia Sheftel: Right in that subgroup of patients. But I don’t think at this point in time we do

not prescribed estrogen for heart health. I think that if a woman’s having, you

know, really bad vasomotor symptoms, we can recommend estrogen for the

shortest period of time at the lowest doses and I think we can get away with


Emily: So what is it about estrogen before a woman goes through menopause that is


Giulia Sheftel: That’s a really good question. I’m not sure I know the answer to that question.

What I do know, is that we’re really talking about blood vessels. And again, I’m

not an estrogen specialist, but I think one of the things that, you know, women

suffer from is a disease of blood vessels and women tend to be constrictors.

They tend to constrict their blood vessels. I get a lot of women, for example,

with migraine headaches or Raynaud’s phenomenon, they constrict and you

know, it’s possible that when the, with the loss of estrogen, that there are some

abnormalities there. This is an area of research, but, you know, estrogen may be

protective in the premenopause, but I think the important take home point is

it’s not protected in the postmenopause and the reasons why estrogen are

protective, you know I think that’s a complex area of study.

Emily: Is there any visualization that looks different in a premenopausal versus


Giulia Sheftel: Oh, that’s a good question. I don’t think it’s so much that I think it’s just the

disease process. You can have a young woman who has diabetes, a smoker. She

may have blood vessels that look like a 80-year-old woman. You can have a 60-

year-old woman who’s done a great job of taking care of her health, eating

right, exercising, not smoking, and you know she can have relatively good

looking vessels. So I think it depends more on the individual, not necessarily the,

you know, the age.

Emily: How much is it that we’re diagnosing it more. I mean I think it’s also really

interesting that this idea of these, you know, sort of smaller vessels or SCAD, like

these other kinds of ways of identifying damage to the heart are relatively new.

Right? And so if those are getting diagnosed more in women, are we, does that

account for the increase in instances, even though we were probably always

having those problems, we just didn’t know what to call it?

Giulia Sheftel: I think we were always having the problems, we just never did enough research

or it never came to clinical attention. Again, I think this particular area is still

somewhat in its infancy in terms of awareness. I think it’s still in its infancy in

terms of research and again, it’s research that informs guidelines, but people

have to read the guidelines in order to treat patients. Because remember,

medicine is a little bit the art and it’s also the science and you have to do both of

those things.

Emily: Well, it’s frustrating to hear that we don’t have guidelines in place. We don’t have enough research. I did want to go back to Dr. Wei and ask her why she thought this was different in women than it was in men. And so what is the reason for like, why is the structure of the heart or the functioning of the heart or dysfunction, I guess in this case, so different between

women and men?

Janet Wei: That’s the million dollar question.

Emily: I mean my go to is always like where is the estrogen, right? Like what’s


Janet Wei: Right? We are very interested in this and we have found that it’s not completely

explained by hormones. Men can have this problem too and it’s also not

completely explained by traditional cardiovascular risk factors. So for example,

high blood pressure, diabetes, high cholesterol are important risk factors that

can contribute to both microvascular dysfunction as well as obstructive heart

disease where there’s big blockages, but particularly for the microvascular

dysfunction, it doesn’t explain it all. It explains only about 20% of the cases. So

that’s when we think about other causes, such as inflammation. You know,

women are more likely than men to have inflammatory conditions like

rheumatoid arthritis is more common in women. Lupus is more common in

women and we are now finding that there are certain conditions specifically

related to women. For example, premature menopause. So if a woman

undergoes menopause earlier than 40 years old, they’re at a higher risk for

cardiovascular disease later in life. Women also who had certain adverse

pregnancy outcomes, which are things like having high blood pressure during

their pregnancy, or a condition called preeclampsia, or even having a preterm

labor. So, if they had their baby early earlier than 37 weeks of gestation, then

that’s been associated with at least a two fold increase in future cardiovascular

disease in life.

Emily: So that’s so interesting. I mean, I feel like I had an obstetrician that I have

interviewed a bunch of times had said to me that one of the things that he loves

about pregnancy is that it’s also sort of this inflection point in overall health that

if you have an underlying condition it often comes out during pregnancy

because of this stress.

Janet Wei: Exactly. It’s our first, it’s a woman’s first official stress test.

Emily: Right.

Janet Wei: Our heart rate, our blood flow has to increase by at least 50% to accommodate

extra flow to our baby.

Emily: And so one of the things that I think is important to just sort of make sure that

we all have clearly is that it’s not because of this complication during pregnancy

that later leads to trouble with your heart. It’s that during the pregnancy, this

symptom presented itself because it was an underlying problem that you had,

probably, right? And that is sort of a foreshadowing of something later.

Janet Wei: That’s the hypothesis. You know, that was always kind of the, you know, the

chicken versus egg question. And we’re now starting to think that it’s more that

it’s unveiling and underlying predisposition, to cardiovascular disease, but it’s

still not 100%, you know, there’s still a lot of research that needs to be done to

really figure out is it the chicken or the egg?

Emily: And so in terms of the research, like what we know about heart disease, what

percentage of that research has actually been done on women?

Janet Wei: It’s been very, very poor. So traditional clinical trials have a very poor inclusion

of women, less than 30% in most clinical trials. And some, you know, in the past

didn’t even include women because women were often excluded because they

were, you know, either at risk of becoming pregnant or you know, had been

pregnant. And so there’s been recent pushes, especially by the NIH, by the FDA,

to include women in trials, both for testing drugs, for testing devices, and for

particularly clinical trial research. You actually have to now state why you’re not

including women or be specific in the inclusion of women. And this goes for

animal research as well, that we not only need to study male mice, we naturally

need to understand if our mice are men, you know, our mice are female or

male. And that’s a requirement now for all our research studies funded by the

National Institute of Health.

Emily: But I feel like as somebody who’s like really in the trenches on this, I would love

to hear sort of when you realized that there were sex differences, you know,

and you can speak specifically to the work that you do. But you know, I just sort

of like have this imaginary scene in my head of being in med school and learning

all this stuff and being really excited about, you know, the mechanisms of action

and the studies that have been done and building upon this research. And then

when you at some point realize like, so much of this is really about men’s bodies

rather than women’s bodies. Did you ever have a moment like that?

Janet Wei: I did. And actually in medical school, we weren’t taught sex differences in health

other than just what we traditionally understand as, you know, bikini medicine

where you would just focus on breast health, uterine health, reproductive

health. That was really the only kind of sex

Emily: Oh my God, I love that you called that Bikini health. That’s like so funny.

Janet Wei: Right? That’s, you know, that was traditionally what was thought as women’s

health is more gynecologic health. But it’s much more than that. And we’re

seeing these differences in rheumatology or seeing these differences in

cardiology. And the main difference for me was that because I didn’t have that

background when I was an intern taking care of a woman with chest pain and

realize, oh my goodness, there’s so much more than just looking at the

angiogram. You know, the angiogram used to be kind of the end all be all. If you

had a blockage, there you go. That explains your chest pain. But then

understanding that women can actually have ischemia. Ischemia, what you had

mentioned earlier is a term for poor blood flow to the heart muscle. So we can

actually diagnose ischemia in the absence of obstructive coronary artery

disease, that there are functional abnormalities of these heart vessels that are

more common in women than men. Men can have them too as I mentioned, but

that we need to go beyond just looking at anatomy. We have to look at

physiology. That was really the breakthrough that I had. And a particular

example was the woman that I took care of was actually a patient in our

women’s heart center and she had seen multiple doctors for her chest pain was

always told, you know, because her angiogram was normal, was quote unquote

normal, that her pain was unlikely related to her heart. And so here at CedarsSinai, we specialize in a type of test called coronary reactivity testing that

specifically evaluates the function of the small vessels and the large vessels. And

we’re able to diagnose her with microvascular dysfunction. And to my surprise,

you know, she burst out crying, not because she was sad that she received this

diagnosis, but that finally someone kind of recognized that there was something

going on in her heart. It was more of a crying of relief was what she explained

that it wasn’t just in her head, you know, she was kind of labeled that this chest

discomfort is just in her head or it’s just related to stress. But now, you know,

there was a way that we could identify it and then now treat it.

Emily: I feel like we hear that story all the time on this podcast. It’s like, you want to

believe that it’s not in your head, right? Like that you’re really experiencing this

thing and you get a diagnosis and you’re like, there’s a sense of relief because if

you can identify a problem, then it becomes something that you can manage.

Right? Whereas if you’re constantly told like it’s not this thing that your instincts

are saying it is, that becomes troubling in a sort of psychological way.

Janet Wei: Absolutely.

Emily: So it sounds like you were already at the women’s heart center when that


Janet Wei: Yes. Well I was a trainee as Cedars-Sinai, but had worked with Dr. Bairey Merz

with this particular reactivity testing. So because of her, really, was exposed to

these sex differences in heart disease and became even more interested in

understanding how we can better diagnose this, both invasively as I mentioned

through the reactivity testing, but also noninvasively, you know, we need better

tests that are specific to women. And so I’ve been working over the past 10

years almost in this field.

Emily: One of the like basics that I’m still not clear on is that like sometimes people

have heart attacks and they die, right? And sometimes people have heart

attacks like at home and they don’t even realize it until they have like another

one or there’s some other event. And then in the diagnosis of the second or

multiple, they see that there is this scar tissue. Can you talk a little bit about is

there a progress or a progression, I guess to this or do women suffer from these

since the heart attacks are slightly different, do they also build in some sort of

escalating fashion or?

Janet Wei: Yes, that’s an excellent question. So we do know that unfortunately about half

of acute heart attacks can present as sudden cardiac death. And so it’s kind of

their first time presenting with a symptom. And, and that’s why it’s so important

to, for everyone, even if they have no symptoms, to really understand their risk

factors, you know, do they have high blood pressure? What is their cholesterol

level? Do they have diabetes? It’s very important for them to exercise regularly

and eat healthy, avoid smoking. And so what the studies have shown is that

actually some women who, actually both men and women, who exercise

regularly can build up a greater network of their small little vessels that can

form collaterals. So what that means is that even if a big block, big artery gets

blocked, the little vessels due to conditioning from exercise strengthening can

then help create little networks to allow blood flow to still go to the heart

muscle, even when a big blockage is occurring.

Emily: So sort of like a river that’s like dammed off. And then like little streams form.

Janet Wei: Little streams. Exactly. And that that type of network improves with exercise.

We also know that for example, if a woman has a heart attack, not due to a big

blockage though, so as I referred to, you know, due to either microvascular

dysfunction or spasm, from our WISE data, that there is still a 8% risk of scar

tissue, meaning that they actually have heart attacks when there’s no

obstructive coronary disease and there’s a risk about a 1% new heart attacks or

new scar that can be formed in the next one year. When we looked at those

women who had scar, about a third of them were actually never told that they

had a heart attack. So that led us to believe that these women were having

underdiagnosis of their heart attacks because they may either just be suffering

in silence or it just wasn’t recognized that their symptoms were due to their


Emily: Is there any kind of way to check in on your heart? I guess without undergoing a

more invasive kind of procedure, like I’m thinking of like c reactive protein,

which is like what I say about everything to check your inflammation. But I sort

of wonder like, are there other ways of women being aware of like whether

they have had a heart attack or are at greater risk?

Janet Wei: Let’s try to split that up into two questions. One, for someone who doesn’t have

any symptoms, we encourage these women to really understand their

cardiovascular risk. So this risk calculator that I mentioned, there was an update

in the risk calculator guidelines by the American Heart Association and by the

American College of Cardiology for helping a woman and a man to determine

whether they were at risk for having a heart attack or stroke. And this was

published in 2018 and you can actually go online, you can Google something

called the a ASCVD risk calculator, which is also known as the atherosclerotic

cardiovascular disease risk calculator. You put in your age, you put in whether

you’re a man or a woman, you put in your ethnicity, you put in the actual blood

pressure numbers, your cholesterol numbers, whether you smoked or currently

smoke, whether you have diabetes. So these risk calculators will then give you

an estimate of your risk for having a heart attack or stroke over the next 10

years. And the guidelines now have created extra points that if you have search

and risk enhancers, depending on, for example, family history, the pregnancy

outcomes that I had mentioned, you know, that are specific to women who are

having premature menopause. Being South Asian ancestry, you know, there are

certain additional risk enhancers. Another one is the rheumatologic conditions,

these kinds of inflammatory conditions that will then add to your risks. So I think

it’s important for all patients, men and women to know what their risk is by

going to their doctor to have this calculated. And then for a woman in particular

who’s having symptoms. So whether this is feeling short of breath that’s new

when you exercise or having any sort of kind of, discomfort really above the

waist if it’s chest, even if it seems kind of atypical, you know, in the past people

would always focus on whether these symptoms would occur with exercise and

if they would get better with rest. But we now know that women can have these

symptoms even with emotional stress. May happen kind of at random times

during the day, not always consistent with exercise. And if this is really

persistent, they should have an exercise treadmill test as a first step for

generally low risk women. And there are the next steps depending on what their

treadmill shows. But if these symptoms are persistent and they notice that it is

beyond just being, you know, deconditioned for example, that they should

pursue further understanding. And not to always take no for an answer.


I’m Emily Kumler and that was Empowered Health. Thanks for joining us. Don’t forget to check out our website at empoweredhealthshow.com. For all the show notes, links to everything that was mentioned in the episode as well as a chance to sign up for our newsletter and get some extra fun tidbits. See you next week

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