A Cardiologist’s Guide for Women: How to Prevent Heart Disease
Cardiovascular disease is a global crisis, affecting tens of millions of people every year—but because heart health research and education programs have always focused on men, women worldwide get too little, too late.
Dr. Rony Shimony, a cardiologist at Mount Sinai in New York City, says there’s a lot we can do to keep our hearts healthy. Most of the classic wisdom still rings true for him: Control cholesterol and hypertension, manage stress, don’t smoke. But modern science has revealed more ways to recognize symptoms (some specific to women), control risk factors, protect your heart, and even, in many instances, reverse damage already done.
A Q&A with Rony Shimony, M.D.
Breast cancer accounts for the death of one in eight women—but cardiovascular disease accounts for the death of one out of three. Even though mortality rates between genders are very similar, cardiovascular disease research and prevention efforts are largely targeted toward men. There is a very large impact for women, too, but research and education don’t reflect that.
Women don’t usually get classic chest pain. Many of them present with more subtle shortness of breath, often with exercise. For a while, before we understood this, women’s cardiovascular risk was not appropriately managed. But now I think there is more awareness, and similar testing can be done on women as on men. It’s important, though, to recognize that the symptoms may be much subtler for women.
If you’re noticing an increase in shortness of breath as you’re walking or a decreased exercise capacity with increasing breathlessness, or having pressure in your chest, neck, arms, or back that’s reproducible with exercise, those are signs we need to check things out. Not every chest discomfort is cardiac in nature—we have muscle and bones and an esophagus and GERT, and these other things can create symptoms. But if there are persistent symptoms, particularly if you’re in an age group of concern, it’s important to get medical attention.
What’s stood the test of time, in terms of what we know about cardiovascular disease, is that it’s very important to control hypertension, hyperglycemia, hyperlipidemia, and high cholesterol, and that fat around the waist is a risk factor. All of this amounts to what we call “metabolic syndrome.” Right now, we’re seeing younger kids exercising less, gaining weight, and becoming prediabetic and diabetic—and that increases cardiovascular burden.
It’s important to know and control cardiovascular risk factors because 40 percent of people who have acute heart attacks don’t have prior symptoms.
The impact of cholesterol is absolutely not exaggerated. When we’re born, our LDL cholesterol—low-density lipoprotein, or the “bad cholesterol”—is in the 30s, and it climbs up throughout the life span, which is a phenomenon that happens only in humans and not in other animals. And there’s no question about this direct relationship: As the LDL climbs up, we have more cardiovascular events. If you test your LDL, and it’s, say, at 190 mg/dL, you need to be treated with medication, because if your LDL cholesterol remains that high, you’re almost inevitably going to have a cardiovascular event.
“40 percent of people who have acute heart attacks don’t have prior symptoms.”
That we have medicine for: cholesterol medications, like Lipitor and Crestor, as well as more complicated drugs called PCSK9 inhibitors, for people who can’t tolerate statins due to pain, that you can inject twice a month. PCSK9 inhibitors cause the level of LDL to plummet by preventing LDL synthesis in the liver. The data on having a low LDL level is very good. We really ought to have a level of less than 70, and ideally about 50—especially for patients in secondary prevention, meaning they’ve already had a cardiovascular event, like a heart attack or stroke, and we’re trying to prevent another one.
And while a lot of this is predetermined by genetics, HDL, the “good cholesterol,” can climb up with exercise. That’s good. We don’t currently have any medicines that pick up HDL, which is protective against heart disease.
Hypertension control remains the number one priority for cardiovascular disease risk reduction. More than 50 percent of the population over the age of fifty is hypertensive, and 1 in 14 patients is in the severe range of hypertension. If we use aspirin in primary prevention to try to prevent strokes, it’s much less—like 1 in 1,400.
We thought maintaining blood pressure at 140 over 90 was enough, but now, as a result of several recent studies, including last fall’s SPRINT Study, we know that really controlling hypertension means keeping systolic blood pressure at 120, not 135. Now guidelines will likely change to lower blood pressure even more to reduce strokes and heart attacks.
Right now, we’re paying a lot of attention to systemic inflammation and inflammatory markers in cells. We know inflammation plays a major role in cardiac death because of scientific research on atherosclerosis, diet, and diabetes, in which the cells and vessels are inflamed.
Looking at how the artery closes in a heart attack, there is a vulnerable plaque—where fatty tissue is stored from atherosclerosis—and a fibrous cap along the inside lining of the blood vessel. The inflammation of these vessels leads to plaque rupture, which ultimately leads to the formation of a clot inside the artery. So when you hear about someone jogging a marathon and spontaneously dropping dead, often we’ll see it’s because these vulnerable plaques are dislodging and suddenly closing blood vessels, leading to heart attacks.
“We know inflammation plays a major role in cardiac death because of scientific research on atherosclerosis, diet, and diabetes, in which the cells and vessels are inflamed.”
To evaluate systemic inflammation, there are several markers we look for, including C-reactive protein (CRP) and homocysteine levels. We also try to look beyond cholesterol, HDL, LDL, and triglycerides. There is another, noninflammatory lipid that called lipoprotein(a)—or Lp(a)—that some of us are born with and ultimately stuck with because we cannot modify its presence through diet, exercise, or medication. These are the people who we suggest should be more aggressive about reducing their cholesterol, modifying their diet, exercising, and especially quitting smoking. Cigarette smoking leads to elevated inflammatory markers and unstable free radicals.
When men are around forty and women are around fifty, they have similar rates of cardiovascular events—women’s risk catches up to men’s by the time their periods stop. At these ages, it’s advised that men and women get a regular blood test for blood glucose and lipid profile, including lipoprotein(a), a check for hypertension, a routine EKG, and, at some point, a walking stress test with a monitored EKG.
We also have a very sophisticated test that is becoming more available called a coronary calcium score; it’s a rapid CT (or CAT) scan of the chest to see if there’s any coronary plaque buildup in the heart. It only takes a few seconds, and the radiation dose is less than what’s used for a mammogram. If we see there’s any plaque buildup, then we can be more aggressive about treatment.
In higher-risk people—those with strong family history of heart disease, or hypertensive smokers, or diabetics who want to run marathons, etc.—understanding coronary anatomy and coronary plaque burden allows us to further stratify their risk. There are ongoing studies as we speak, but we have the capacity to image the heart vessels. In another part of the CAT scan, called a coronary CTA, we inject the vein with contrast material (dye) and can actually see the coronary arteries on a computer. And we also recommend carotid Dopplers, which are sonograms of the arteries going to the brain, to see if there’s any plaque burden there. An echocardiogram allows us to see the heart by sound waves; in people who are hypertensive, the heart muscle is thicker. We can check the function of the valves as well.
Some damages are permanent. In a very large heart attack, a scar forms because the heart didn’t get blood flow within a certain period of time—be it the first ninety minutes, the first six hours, the first twenty-four hours. The sooner you open up the artery, the more viable the heart function is and the less heart muscle damage you’ll have permanently.
It turns out heart function is the single best predictor of long-term survival, and it’s all about damage prevention. In people who have had heart attacks that left a permanent scar, you may not be able to improve that atrial wall motion. But if the heart is strong, people live.
On the other hand, take alcohol: Excessive alcohol consumption causes alcoholic cardiomyopathy, the weakening and thinning of the heart muscle. It also causes irregular heartbeat, and irregularities such as atrial fibrillation. But this can be reversed—cutting back on alcohol allows the heart to recover from the toxicity of the alcohol.
“Heart function is the single best predictor of long-term survival, and it’s all about damage prevention. If the heart is strong, people live.”
Uncontrolled hypertension can also cause significant damage, but treat the hypertension and then the heart-wall thickness, stiffness, and even heart failure can reverse, because the wall thickness can return to normal or at least regress to reduce symptoms. Sometimes the heart can get weak from viral cardiomyopathy, and it can recover from that in some cases. For those with leaky valves, we can fix leaky valves and heart weakness reverses.
So outside of damage from major cardiovascular events, it is important to address the primary reason why the heart became weak and work to reverse the root of what’s wrong. Healthy habits, exercise, and hypertension control remain paramount.
I think we ought to look at populations that really live long lives—like some of the Greek island populations in the Mediterranean, who have terrain where they have to walk and who eat olive oil and tomatoes from the garden rather than fast food or processed, sugary foods. In general, exercise and the Mediterranean diet are associated with longevity.
There are also some areas in Japan, such as Okinawa, with long-lived populations. They eat fish and natural foods out of the garden, get a lot of exercise walking up and down sloping villages, and don’t smoke or drink much alcohol. They have family structures that don’t leave the elderly to be totally alone—they go to dinner together, have parties, and have people who care for them. They also have lower rates of depression.
We should look at these populations and learn from them and then adjust to your taste what you see these populations eat. It’s primarily a reduction of bread, pasta, potatoes, and rice, as well as meat and saturated fats. And an increase in consumption of vegetables and certain foods, like blueberries and pomegranates, that have lots of antioxidants, which help reduce inflammation. That is: a food pyramid with plants at the top.
That’s been a complicated issue. Traditional medicine doesn’t always talk about supplementation, and then, on the other side, there are folks who are supplement mavens. The FDA looked at various vitamins and supplements and found many of them do not change heart health outcomes. It’s a multibillion-dollar industry, but there was no data proving that supplements such as zinc or selenium have any long-term benefit for the heart.
However, we have looked at things like CoQ10—coenzyme Q10—used for the heart, and there seems to be some benefit to it, although it’s not a must. We also looked into omega-3 fish oil, and for a while we all prescribed fish oil capsules for heart health, but recent data suggests they don’t really help and you’re better off having a piece of fish.
You should always review supplementation with your health care provider to see what’s reasonable—don’t just take a bunch of tablets because you think it’s a good thing unless there is an evident nutrient deficiency that we can measure. (Vitamin B12 and vitamin D deficiencies are common.)
We’re very interested in a holistic approach with good food, nutrition, yoga, mindfulness, and stress reduction—all those things are very important. And stress clearly plays a major role in heart disease. But the jury’s out on supplements.
Stress is very important. When people are anxious, adrenaline mediation leads to a state of high risk for plaque rupture, which leads to toxicity that can affect the heart.
For example, there is a condition called “broken heart syndrome”—or takotsubo cardiomyopathy—which was first described in Japan in the 1990s. In this condition, the heart becomes very baggy. The apex balloons out and looks like the pot they caught octopuses in, hence the name “takotsubo,” meaning “octopus trap.” Doctors noticed 90 percent of the affected patients were women, and the condition occurred during periods of extreme stress—when someone died in the family, there was a breakup, or there was financial stress. We don’t fully understand the mechanism, but it presents with the exact same symptoms as a heart attack. But when you look with coronary angiography to see if there are coronary blockages, there aren’t any. These hearts mostly recover back to normal within a month. What is that? It’s an emotional release of adrenaline leading to inflammatory markers and instability. It may be an autoimmune process. The heart is a very neurohoromonal organ—it undergoes neuronal effects and hormonal effects, and it gets injured in this process. We know, in this extreme case, that stress plays major role.
Stress can also bring on arrhythmia—irregular heartbeat. And data shows us that stress management leads to decreased cardiovascular events.
Life is stressful. We have to find a fine balance between stress that’s appropriate and stress that’s inappropriate. Like when someone in the family is sick and we have to take care of them, a project at work that needs to be done on a tight deadline—those are stressors, but we need to learn to cope with them in a way that isn’t overwhelming to the point that they’re deleterious to overall health. That’s not to say that stress is always manageable. At times that it becomes overwhelming, there is appropriate mental health care. It is very important to consult professionals and experts who can help people manage stress and develop better health habits rather than maladaptively cope with alcohol, drugs, unhealthy food, or social withdrawal.
We have routine recommendations even for those who are not at high risk, because we know plaque formation begins early—even in childhood. If you incorporate good healthy habits from the beginning, you will have less risk of cardiovascular events later on. A consistent habit of exercising ten minutes a day reduces total risk of cardiovascular events by up to 50 percent, and exercising thirty minutes a day reduces that risk by up to 75 percent.
Everyone should be doing some weight lifting to tone up the muscles. The heart prefers leaner body mass with strong, slim muscles that can carry the weight of the body as you get older—so you don’t have to do high isometric work to build and maintain large, bulky muscles.
Aerobic exercise is the most important for heart health. Working up to about 80 percent of your estimated maximum heart rate—we calculate that number as 220 minus your age—is a reasonable target when you’re young. As we get older, we don’t want to tax the heart so much, and it’s best to try to keep the heart rate up to about 65 to 75 percent of max, if you can, and sustain it for about twenty minutes.
And aerobic exercise has tremendous benefits for the brain—it is great for dementia risk reduction as well. At the end of the day, the cardiovascular system, including all the arteries, are one tree, and the effects are head to toe. What’s happening in heart and the blood vessels is also happening in the brain. We need to think of the heart as the organ that we screen, but we’re really thinking of taking care of the brain.
I don’t want people to be frightened but just to be aware that there are other causes, not just plaques, hypertension, hyperlipidemia, and diabetes, that can lead to strokes. And one of them is an irregular heartbeat, or atrial fibrillation.
Atrial fibrillation is an irregular, disorganized heartbeat that usually occurs in left atrial areas, toward the pulmonary veins. This irregular heartbeat causes the atrium to squeeze abnormally, allowing a clot to form, particularly in the left atrial appendage, a portion of the left atrium. This is a leading cause of strokes. Irregular heartbeat can be benign—sometimes we all feel a little palpitation or a skipped beat—but when the rhythm becomes regularly irregular, a sustained atrial fibrillation increases the risk of stroke. Being female is a risk factor in what we call the CHADS2 vascular score for atrial fibrillation. It’s also typically the case that those who are diabetic get atrial fibrillation as they get older.
There are valve problems—like mitral valve prolapse, leaky valves, and congenital valve deformations (the aortic valve, for example, usually has three leaflets, but some people are born with two)—that can lead to changes and dysfunction within the heart. If these issues lead to a heart murmur or irregular heartbeat, medical attention is necessary.
Cardiovascular disease is the leading cause of death in the world: That’s 17.9 million people worldwide, and it’s expected to rise to 24 million people by the year 2030. We have to look at not only our country but also the impact on global health. We have to look at what can we do to reduce this enormous burden.
Dr. Valentin Fuster, the chairman of the department at Mount Sinai and the editor in chief of the Journal of the American College of Cardiology, published an article in December 2017 that looks at the future role of the United States in global health. We’re seeing improvement in sanitation worldwide, decreases in infectious disease burden—that’s tuberculosis, malaria, and cholera, among others—but we are starting to see a rise in chronic, noncommunicable diseases. Now, globally, we’re looking at a lot of deaths from cardiovascular disease and cancer; if we can curb those two, we can see a big impact on population health.
We have to look at not only our country but also the impact on global health. We have to look at what can we do to reduce this enormous burden.
On an international scale, the countries with low and lower-middle income actually take the brunt of this cardiovascular death burden. And it’s an enormous economic burden to these countries when their workforce is suffering from these morbidities—when people are sick, their productivity decreases and it takes more money to take care of them. I think we’re going to see a big trend in improving global health in noncommunicable diseases as we have addressed—and continue to address—issues of infection and sanitation as well as reducing cancer. And we’re going to need shared innovative approaches to do that.
Even though the incidence of cardiovascular disease is increasing, the rates of cardiovascular events and deaths are actually going down. So we have more people who are sick, but we’re actually improving survival by hypertension control and cessation of smoking, managing LDL with cholesterol pills, diet, and exercise. So, we’ve had 38 to 50 percent reduction in cardiovascular events, which is one of the incredible stories of cardiovascular disease since the 1940s and ’50s. So, while cancer rates have essentially remained flat—we don’t have cures for many of them and rely on early detection—we have made tremendous headway with cardiovascular disease due to medical research, drug development, and risk reduction.
Rony Shimony, M.D., is a fellow of the American College of Cardiology and the director of Clinical Cardiology at Mount Sinai West Hospital in New York City. As a clinician, Shimony specializes in individualized care for complex cardiovascular diseases. Shimony is on the advisory board of the Mount Sinai Arnhold Global Health Institute and provides patient care and medical training worldwide.
The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.