You know, we talk about heart attacks sometimes happening after stress, after, you know, exertion, or completely out of the blue. So it's not always something we can predict, but the physiology is that that vessel, kind of plaque ruptures.
Hello and welcome to another episode of Uplift For Her. I am your host, Dr Mallorie Cracroft, and we are here talking all things women's health, and we have a really great conversation today that hopefully will be really helpful. We're talking about heart health in women and cardiovascular disease. So we have a special guest, Dr Tanya Wilcox. Dr Tanya Wilcox completed her medical education at the University of California, Irvine, following her undergraduate degree in evolutionary biology at Princeton, she continued her medical training with her residency and chief residency in Internal Medicine with a fellowship in cardiovascular disease at NYU at New York University. Dr Wilcox is a general cardiologist with clinical expertise in preventative cardiology, lipidology, disorders of metabolism and echocardiography. Her academic interests include investigating the association between metabolic risk factors in cardiovascular disease and perioperative cardiovascular outcomes. So thank you, Dr Wilcox, for being here.
Thanks for having me. I'm excited.
I think you're going to agree with me on this, but talking about heart disease in women is a really important topic, of course. Will you just start us off by telling us why?
Yeah, so heart disease is the leading cause of death in women, and I think we haven't traditionally talked about it enough. We traditionally think about heart disease as a male predominant pathology, and that's not the case. And so it's really important that women recognize that they need to take care of their hearts.
Yeah, just some statistics I found. So correct me, if these don't sound right to you, but one in three women die of a heart attack. That's somewhat baffling to me, because I just don't think we think about that like I don't know that anyone would guess that statistic. I also found a statistic that there's actually more women who die of heart attacks than men. Does that sound right to you? Yeah?
Definitely that. You know, one in three women will die of heart disease, which is, yeah, an astounding statistic, but it is kind of a really common disease in humans overall, yes, and so that's why it's so important that we kind of talk about prevention and risk factors.
For sure, one thing that I just wanted to kind of start off the conversation with is, why don't we hear about this more? I mean, one in three women are dying of it. I feel like women hear a lot about breast cancer prevention and right now, a lot about menopause. I don't know what we mean, I think we all see the red come out on the heart elk months, right? But why don't we see this more in women that we know who've had a heart attack or seen that in people that we know? Yeah, well, I think it took a lot for kind of advocacy groups to get people talking about breast cancer, and I think we're just a little bit kind on heart health, but there's great advocacy groups like the AHA and the Go Red campaign that are kind of taking some lessons learned from the community that helped us get awareness about just a lot of marketing, yeah, and I think that's huge. But also there's a tradition and kind of old school teaching and medicine that it is male predominant disease, which is not the case anymore. And then, you know, unfortunately, because of a lot of lifestyle factors that often we, you know, as a society in America, don't have a ton of control over heart disease in general, is just increasing. You know, we have chaotic lives, you have sedentary lives. You don't have access to great food and exercise, and so for all those reasons, I think it typically was thought of as male, but it's just not the case.
Let's talk a little bit. I don't want to focus on it. I don't want this to be a downer episode. You know, I think there's a lot we can do to decrease risk and to prevent but a lot of that starts with education and empowering women to advocate for themselves and to know if it might be an issue for them. So this may seem like it's focused on a lot of things like risk factors and negativity, but I hope people feel very empowered about it. I don't want this just to be like a we're all we're all cursed, you know, like this. This is a terrible situation. There's so much good that can be done, yes, but to start with, let's just talk about a couple of the things that come up in our medical system that may be a little bit complicit in, maybe not preventing as much heart heart disease as we can I think for women, especially, there is, there are some biases that that don't do any favors. I think, as an OB GYN, one of the things that we see is I am the main point of care for women from about 18 to 45. I'm the main person that they see. And I get almost zero training in lipidology and in cardiovascular health and in screening, that seems to be a bit of a problem. Are there any other thoughts you have about that, or other things that you see in the conventional medical system that maybe we could do a little bit better to help women identify and prevent heart disease? So. Sure, yeah.
Well, I think, you know, early in adolescence and kind of early adulthood, people should be screened for metabolic problems like high cholesterol, so a lipid panel and diabetes, so an ANC. But I think specific to women, that a lot of providers might be a little bit wary of starting preventative medications early on in a woman's life because of reproductive potential, and they might even be uncomfortable having the conversation about a woman's desires about reproductive potential, because we're rushed, and it feels like maybe that's not relevant to them. But I think that's a huge like structural kind of barrier to women getting maybe preventative medications or kind of more aggressive interventions because of the presumption that pregnancy might occur, and that may or may not be the case for different women, and it just creates a kind of big time lapse between the typical preventative care that a man of the same age might get.
Yeah, I think that's really true. I think there's a large number of women who don't get screened for metabolic risk or cardiovascular disease, even when they're going to the doctor. And some of that, I think, is because it's not even in the doctor. It's not hammered into doctors enough that this is a really big problem. And so I think if we see people in my position, we'll see people who are 20, 25, maybe 30. The top thing on our brain is not I should make sure her cholesterol is okay. I don't even think it's usually I should make sure her blood pressure is okay. We hit that hard in pregnancy, like we will check your blood pressure every time we see you, and if we can, every time we talk to you on the phone, right? Like we want to know your blood pressure in pregnancy. But outside of pregnancy, I think that even blood pressure kind of is like, Oh, your blood pressure is a little borderline. Make sure you follow that or, Oh, your cholesterol is a little bit high, you should probably diet and exercise. We'll see you in a year. Yeah. And
I think transitions of care is an interesting place to start also with, say, you identify a woman during their pregnancy who does have high blood pressure, preeclampsia or gestational diabetes, and then they're no longer pregnant, they may not see you anymore. There that's a great opportunity to transition care to a preventative cardiologist or primary care doctor who's kind of aware that these are really important risk factors for future disease, and this is someone you should take seriously, and, you know, engage in kind of different preventative strategies. So that, I think, you know, transitions of care are really hard in medicine, as patients and doctors know, and so that's just some a structural thing that we could get better at.
Yeah. Okay, well, let's back up a little bit and talk just through some definitions. So I think when we talk about cardiovascular disease, cardiovascular risk, heart disease, will you just define that and make sure that we're all on the same page with it. So
cardiovascular disease very broad. When we're talking about the most kind of common forms and the forms that cause heart attacks. The kind of typical heart attack is caused by a blockage of the arteries that supply the heart, and usually that blockage is from cholesterol plaque building up in those arteries. Arteries that supply the heart are really, really small, and even a little bit of plaque can cause issues. So that's a traditional heart attack. However, it is important to point out that there's kind of female specific disease states that cause heart attacks that aren't related to cholesterol. They're just much more rare. And I think we might even do a disservice to kind of underestimate the amount that this kind of traditional atherosclerosis is contributing to heart disease in women. Because I do want to mention, you know, things like inflammatory states or dissections, kind of more unusual forms of heart attacks do exist. But primarily the cause of heart attacks is cholesterol built up into those arteries, which is due to a few risk factors. So we can kind of go over family history is a huge one. High cholesterol makes sense. Overall inflammation in the body is a big one, and then diabetes, and of course, high blood pressure and smoking and sedentary lifestyle, and so that always seems like a scary, big, long list, but the positive part of that list is a lot of them are modifiable, and so that's why prevention is a great kind of space to be in, because you can counsel people how to reduce their risk.
So as we're talking about some of the nuts and bolts of this, just so people understand what actually is happening in the biology, I think it's helpful to kind of visualize it. So in the heart, the heart is made up of muscle, right? So it's it's a pumper, and the muscle is supplied by blood vessels. So those are the vessels we care so much about. We think of our blood vessels that are going in and out of the heart. You know, the vessels that are like supplying the rest of our body. Those are important too. But these little, small ones, they're just the ones that are supplying the muscle of the heart. And so if those guys get clots in them, then the muscle doesn't get blood flow, and that piece of muscle dies. And you need all the pieces of your heart muscle you want. You want all of them to be pumping and working in conjunction. And so if you get a blockage, even in one tiny blood vessel that cuts off supply to a piece of muscle, that muscle dies. Now you have a little part of your heart that is not effectively pumping blood. Did I explain that? Okay, perfect. So I. Yeah. What causes those clots? How often is it a blood clot? Like people, especially women, know about pregnancy, you know, blood clots in our legs, yeah. How much do does that type of clot play a role here? Is that a role at all? Or are we only talking about atherosclerotic plaques?
It's more rare that it's a, you know, blood clot that would come from the venous side, blood clots that form in the veins during pregnancy, or perhaps because there's a malignancy or a hyper coagulable state, those should be filtered through the lungs, and so it's hard for those to get into the side of the heart that's supplying the blood. But if you have certain conditions, or like atrial fibrillation or a hole in the heart that can't happen. It's just much more rare. The more common form of clot that forms in the heart is due to that cholesterol plaque and platelets that come to that plaque. And we talk about, you know, plaque is usually, you know, a cholesterol buildup in the wall of the artery, and it's staying there. And our goal is, once it's there, just to stabilize it and prevent it from getting bigger and rupturing, and then once it ruptures, that's a that's a heart attack, and that's when the blockage completely stops blood flow to the heart, like you were talking about, and can cause problems with what we call ischemia. Okay, so
backing up and re reiterating that in in less fancy terms, because it's perfect. So you start with a cholesterol molecule. It's just a little guy moving around the blood, totally benign, correct, nothing wrong with the cholesterol molecule itself. So when we look at our LDL and our total cholesterol and our HDL, those are all different types of these cholesterol molecules, all of which are neutral, to start with, what happens to those molecules then to become a plaque. And also the plaque is, I visualize like a speed bump, right? So you've got these nice, smooth walls of the artery, and then you've got a big speed bump. And the bigger that speed bump gets, the more narrow you have the blood actually flowing through. We don't like that, but especially if that plaque, that speed bump, explodes and ruptures its contents. Then those contents flow down into the narrowest part of the vessel and will completely occlude, will completely shut off the blood flow, right, exactly. And this is where you know your question is, why
do Why does cholesterol going go from kind of a neutral building block in our body to something that's a problem? Yeah, pathologic, and so inflammation is where this really comes in. So those smooth blood vessel walls should not let cholesterol into them. But if there's damage in the walls, or there's kind of particularly high levels of cholesterol or certain types of cholesterol, they kind of weasel their way into the wall, and then your body doesn't like when they're there, and your body's response is to go and send the immune system to go, kind of wall it off and take care of that, usually chew up that cholesterol, try to kind of neutralize it. But when that process happens over and over, they can get bigger to the point where they're called unstable, and that's when we worry about them rupturing and causing acute disease. When they're stable, you can still have some symptoms, but there those symptoms can often be managed, or should be managed with medications so kind of stable versus unstable heart disease. But often what triggers kind of an acute event is a change in the blood vessel wall and the inflammatory state. So, you know, we talk about heart attacks, sometimes happening after stress, after, you know, exertion, so or completely out of the blue. So it's not always something we can predict, but the physiology is that that vessel kind of plaque
ruptures, and what causes that vessel wall to be vulnerable to begin with? What are the things that affect the vessel wall? Because if the cholesterol stays neutral, yeah, well, you mentioned an exception to that, but assuming the cholesterol is just a neutral guy running through the blood, what causes the vessel wall to be vulnerable to begin with? Yeah,
back to those risk factors. So smoking is a huge one. It's really damaging to your arterial wall and in all of your organs, in all of your organs, exactly. So don't smoke. Yes, diabetes is similar. So blood sugar running around kind of unchecked in the blood is bad for the blood vessel wall. What's good for the wall? Exercise. Low inflammation states. So exercise does a great job of decreasing your systemic inflammation. High inflammatory states, so uncontrolled and autoimmune diseases, things like that, damage the vessel wall. So
okay, yeah, so we'll see increased cardiovascular disease in any of those more inflammatory states. So getting inflammation down overall is important. And then if the cholesterol does find a rent in the wall, a vulnerability in the wall, then it's going to partially because of the immune system, and then the cholesterol gets into that rent and starts to build the speed bump. Is that? Right? Yeah, exactly. And if that area then has is exposed to inflammation, then it becomes more of this snowball effect. Yeah, correct. Okay. Now, what causes those plaques to rupture that
sometimes it's just random. So they just get big enough that they, you know. The kind of the inflammatory balance of keeping them under control fails, and then, you know, and so we have a lot of preventative measures, what we call stabilized plaques, with medications, supervised exercise, things like that. And then occasionally it'll be like an inflammatory state. We do see some signal that there's more mis during, you know, acute episodes of like influenza, which is my leaning heart attack, yeah, of heart attacks, acute and acute heart attacks during things like influenza pandemics and things like that. So the other thing I'll say that's kind of more specific to women when we're talking about, you know, really Vascular Biology here, is that your blood vessels, we call them the coronaries, because they're like a crown that goes over your heart. They're the arteries that, yeah, the arteries that supply the muscle, the coronary arteries, the three big ones, are the ones we pay a lot of attention to, but they all kind of go into smaller and smaller and smaller vessels. And we call those like the microvasculature. And it's common for, you know, both sexes, but women, more commonly, can have disorders of actually those even smaller blood vessels. So then we can look at the bigger blood vessels, and they look we don't see too many speed bumps, but there's still something going on. And so we're getting better at testing for those smaller vessels and seeing if there's actually dysfunction in those vessels causing the kind of typical symptoms we see with typical heart disease. And so that's something called microvascular angina and pain in the chest, meaning pain in the chest, yeah, and that's something that was probably ignored in women for a long time. There's also kind of other more common forms of chest pain that, again, we would look for speed bumps, we wouldn't see them. There's something called spasm, where the actual the vessel plants down and then releases and it causes chest pain. And those are things that, yeah, again, we ignored, because we focused a lot on this one kind of physiology that's more common in men. And so those are things that you know, if you're having a lot of chest pain and we have, we look for the lump, the speed bumps, we don't see them, seeking out a specialist who understands kind of some of the more nuanced things that can be going on in the arteries can be really helpful.
And I would add to that, you know, taking all of those preventative steps, even if you don't yet have the diagnosis, like for sure, seek out the specialist, but also, those preventative steps are the same things we do to prevent all disease. Yeah, so seeking out exercise and anti inflammatory foods and anti inflammatory behaviors, I think, is still the way that we should go. Yeah. So one of the things we hear associated with heart disease a lot is blood pressure. What does blood pressure have to do with any of this?
So when the pressure in those vessels? So when we measure blood pressure, we squeeze your arm and we get that big brachial artery, and we use a cuff to figure out how much pressure that artery is actually feeling. And the two components kind of that contribute to blood pressure are how stiff that artery wall is, and then how much fluid there is in the body overall. When there's a lot of pressure on those arteries over time, it causes damage, like we were talking about. So just, you know, that damage in that vessel wall that allows those pesky little cholesterol molecules to get where they shouldn't be. It's important to emphasize that blood pressure, you know, it's a silent problem, so you won't know you have high blood pressure unless you're going to the doctor and being checked. And that's why it's, you know, the Paramount vital sign, yeah, it's a vital sign, and it's really important to screen. It's also important to know that an individual high blood pressure reading is not necessarily harmful. That could just be a physiologic response. It's that a chronically high blood pressure is the problem. And so our bodies are meant to have varying degrees of blood pressure depending on what's going on. You
mentioned that one of the reasons that the blood pressure is such an issue is that the blood pressure is a sign that the artery walls have become non compliant. They become more stiff, I think of like old garden hoses, and they become really brittle and yeah, and not what causes that compliance to get worse? Yeah. So
a lot of blood pressure is genetic, so some people are just prone to get higher blood pressure when they're younger. A lot of it has to do with age. Most you know, as we age, as we age. So the combination of age and your genetics means that some people, you could do everything right, and your blood pressure is still going to be high. So still going to be high. So don't be hard on yourself if this happens. But the same metabolic respecters also contribute to high blood pressure, so things like obesity and smoking, sedentary lifestyle. Another big one that is important to think about, too is sleep apnea. So if you're you know, not getting enough oxygen during the night when you're sleeping, that causes high blood pressure as well.
So some of the main things we've identified so far that we really want as women and as humans, but we say women here, one of the things that we really want to make sure is that we keep those blood vessels compliant as much as we can. So the things that you mentioned, we also want to keep inflammation down, which is a topic in and of itself, but for right now, for those purposes, really living on a lifestyle as much as we can, from a lifestyle perspective of decreasing inflammation is going to help those cholesterol particles be more neutral in the vessel walls, be more healthy and and keep this from becoming that snowball effect that that is problematic. Talk to us a little. It about you mentioned blood sugar. How does blood sugar play a role in all of this? We all kind of know that, like diabetes and blood sugar is somewhat somewhere thrown in there with heart disease. What's the connection there? Yeah,
so it's specifically that when the sugar is high in the blood it's super damaging to the blood vessels, both the large and the small blood vessels, and that's all over the body. And so that's why, you know, if you have diabetes, we need to people to check their eyes, because those tiny vessels in your eyes can be affected, and it just breaks down that what we call the endothelial lining. So it's just the lining of the blood vessel that's kind of keeping the blood cells where they're supposed to be gets damaged directly by the blood sugar. And kind of the blood cells themselves actually kind of get extra blood sugar tagged on to them, and so that's directly damaging to large blood vessels, small blood vessels, kidney blood vessels, nerve blood vessels. So diabetes overall is something that we really need to take control of, and is a very large metabolic risk factor, and then the kind of subsequent inflammatory issues that go along with diabetes, I think, are a little more nuanced, but yeah, yeah.
But like you mentioned earlier, the blood sugar can damage the lining of the wall and also worsen the plaques, right? It also causes that inflammatory cascade of the plaque itself, increasing, decreasing the stability, like you mentioned, yeah. Okay, so we know blood sugar is a problem, so we also want to have the lifestyle that promotes a healthy blood sugar. We talk about cardiovascular disease as the Heart Talk to us about how the blood vessels just briefly, because it's a little bit off topic, but I think it's important to mention how blood vessel disease affects our other organ systems.
So I think I kind of divide in my head when I'm thinking about blood vessels, large and small. And so when it comes to the larger blood vessels, obviously, you know, the blood vessels that supply the brain can also get speed bumps and cause that can cause strokes. So that's a big, big problem. The larger blood vessels that go to the leg can, you can have, end up having problems supplying the muscles in the legs. And so then you get, you know, something called claudication, which is kind of cramping in the legs as you exercise, and problems with wound healing. And then when it comes to the smaller vessels, that's when I think about things like the kidneys. The kidneys filter all of your blood constantly. And so they they need all of these kind of little filtration systems that are lined with this lining that we really want to protect. And so when never we're damaging our blood vessels, that's thereby damaging the kidneys and the brain also has tons and tons of all these little networks of tiny, tiny blood vessels that we want to protect. And so if we're damaging the blood vessels anywhere, we're also going to have problems with the blood vessel integrity in the brain.
Thank you. I bring that up because it's sometimes in medicine, we kind of segregate the organ systems, and we kind of think about this over here and this over here, but, but really it's, it's all one disease state, and it's all, if you if it's affecting the heart, it's also affecting the other organ systems. And so some people it will actually manifest differently. Some people it may manifest in the kidneys before manifesting in the heart, but it's still a vascular it's still going to be a big issue for the heart. And important just to remember the body's one body. Yeah,
I think that's super important to underline when it comes to treating heart disease, though, because I think all of us, you know, want, if we find out we have medical problem, a quick fix. So, yeah, officially say, you know, you do, unfortunately, have a heart attack and you get a stent, the problem, the problem isn't fixed. So I get the question all the time in my clinic, you know, when I'm prescribing medications for the heart, so when, when can I stop this? How long do I have to take it? And the answer is, this is your new, you know, morning vitamin like you need to take this forever because, you know, we've established that your body has kind of an unhealthy, inflammatory, metabolic situation, and we can fix it in a bunch of different ways, and maybe like very aggressive lifestyle, over a long period of time, we could think about pulling things back, but generally, once we have we need to treat a risk factor for heart disease. I tend to just keep the treatment on as long as they're low risk and the patient's tolerating it, because it's a systemic problem. So just because we fixed that one speed bump in the heart does not mean they might not face problems later on, in the legs, in the brain, if we don't go ahead and treat everything aggressively in the whole body.
So tell us, first of all, is this disease state that you're talking about with these plaques? Is this a rapid process or a slow process? Is this like a year or 30 years when? When is this starting and then becoming a problem? Yeah,
and this is like, where I'm afraid to freak people up. It's it starts really early in all of our lives. It's kind of just a consequence of being a human that these plaques will develop at some point in our lives. But we have, kind of the earliest data we have on this is from autopsy studies from young men who died in wars, and they do have plaques forming in their aortas, in their arteries in their 20s. So they're there, but the fact that they are there doesn't mean they're going to cause problems, but it just emphasizes that, you know, everybody should kind of adopt these. Healthy measures, because we're all at risk. Some people are much higher risk than others, and you talk about who those people are, yeah, I
think on the flip side of that, though, we can see, you know, you see that in that age group, but bodies are pretty resilient, you know, I think what we see when we get to major disease states in the body, the body will age right? The body will go through changes where certain functions aren't working like they used to, and we can do lots of things to slow aging or to minimize aging, and there's fun stuff that a lot of scientists are doing looking at anti aging, and that's all wonderful. But even as we age, the body can tolerate a lot of change. It's when you get one thing piled on top of another, piled on top of another. And so as you get a lot of these risk factors together, is really where we see the worst outcomes Correct. Yeah. I mean, if you take someone who has multiple risk factors, like a family history and they're a smoker and they're overweight or have struggled with with being obese for most of their lives, that's going to be a harder situation than someone who's doing most things pretty well, they're going to have a much lower risk because our bodies are so resilient. Yeah, absolutely.
That's why I think a lot of our risk scores, or when you kind of see a doctor in clinic, they'll ask you a whole lot of questions about, kind of, yeah, your family history, kind of, especially when we talk to women, I think we need to focus more on, you know when their menu was, and if they've had complications in pregnancy. So all these things that you think might not be related, that your doctor's kind of hounding are actually really important, and you want your doctor to be asking all those questions to get a better sense of your overall risk. Yeah, and that's why, yeah, certain risk scores that that we'll use are helpful. And then I think also definitions, like the definition of metabolic syndrome is nice because it takes into account a lot of different aspects of your metabolic health, not just you know, your LDL, cholesterol is this, so this. So
let's define that. So we use that term a lot metabolic health, and metabolic syndrome, will you just define that for us? So metabolism
overall is how your body uses food and the building blocks of proteins, fats, carbohydrates to make energy. And so metabolic syndrome happens when, for complicated reasons, our body does not do so well with using those building blocks appropriately, and they get stored in unhealthy ways. And so, you know, metabolic syndrome has multiple components, but it's an elevated blood pressure and elevated triglycerides, elevated blood sugar, low HDL cholesterol and an elevated waist circumference, and those having at least three of those will constitute metabolic syndrome.
Hey, there listeners, just a quick break to tell you about something that could make a big difference in your life or the life of a woman you care about. Here at uplift for her, we specialize in integrative women's health, offering comprehensive support for every stage of life, whether you're navigating menopause and need expert HRT advice looking to shed those stubborn pounds or seeking for help with your mental well being, we've got you covered. We combine the best of traditional and functional medicine with personalized health coaching and dietitian support. Here at our salt lake city based clinic, we ensure that your unique needs are met with the care and expertise you deserve. At uplift for her, we're here to help you feel your best inside and out, ready to take the next step in your health journey. Visit us at uplift for her.com or give us a call. Today, we have services available for those of you living in the state of Utah, and some services available for those of you outside of Utah. Now let's get back to the episode so that constellation of findings in a human has been shown to increase the risk for cardiovascular disease and other disease states. So when we talk about metabolic health or metabolic syndrome, we're talking about like you just said, the way that the body takes in energy, breaks down that energy, stores that energy for right or for wrong, and then whether that promotes inflammation and promotes balance in the body, or whether it throws the body out of balance. So that's that's what we're talking about when we say metabolic health. So how should this look in a perfect system? How should a good cardiovascular risk prevention routine look for a woman, what age would she start having screening, what types of screening, and how would that change throughout her life, her reproductive life, and so on. What would that's gonna be a long answer, yeah. But walk us through what that looks like in a woman's life to in a perfect world, help monitor for cardiovascular health. Yeah,
so blood pressure should be checked every time we go to the doctor, no matter what age, no matter what age. And so, you know, you should get your, you know, your yearly checkup and your blood pressure should be checked there. As soon as we're around 20, we should be screened. And I think in pediatric literature, probably, I won't speak to but, you know, talking about women, once they're about 20, we should screen everybody with a lipid panel, and then an A, 1c which is the marker for diabetes. And. Just
a plug there, because so many people are going to their gynecologists. I don't know that it's, it should be standard of care. I don't know that all gynecologists are routinely screening for, you know, a lipid panel and an hemoglobin a 1c I think it's perfectly appropriate to say, can you check my lipid panel and my hemoglobin a 1c I think that should be if you're gynecologist, I will say, some of them push back and say, I'm not a primary care doctor. You need to go to your primary care doctor. You know, you've got to deal with that as it comes. I think it's really appropriate to say, will you order these blood tests and if they're abnormal, I will go to my primary care doctor, or go to your primary care doctor. But that is perfectly appropriate to ask. Oftentimes, gynecologists, ob gyns, bless their hearts, oftentimes, we are very, very busy and and inappropriately. Sometimes our focus can turn towards the pregnant mamas, right? And it's not inappropriate, but like, we should care about all of our patients, and it's really appropriate if they're rushing out the room to be like, hey, could I get my yearly screening labs? I know I'm supposed to have my cholesterol and my blood sugar that that should be really easy for all of them to do, yeah. And insurance pays for it, yes,
yeah, absolutely, always yes. And then the other kind of more advanced lipids that are coming around are can be considered as well. So I think definitely, like an A, 1c and a lipid panel everybody should get but a something called like an LP, little a lipoprotein. Little a European guidelines now recommend that everybody gets that once in their life as well. Here, I think it's more for the high risk individuals. But say you do have, you know, family history where people have had heart attacks in your family in their 40s and 50s. It's something to talk about with your doctor that I could understand a gynecologist or an OB may be saying, go to a primary care cardiologist. But there is kind of, there is data that that might be a good thing to look at, because we will have it just it's a very strong enhancer of risk, and so it might make us take other kind of small changes in what we see in your blood pressure and your cholesterol, might make us start treatment a little
earlier. And I've seen some recommendations for the LP little a to have it once in your pre menopausal life, and then once in your post menopausal life. Is that what you recommend for
women? Yeah, for women, I do. And then other thing I'll say that's female specific, that I'm kind of just learning about, is that actually your lipid panel will change during your menstrual cycle. And so having that in mind, it's a small change. So if you're just getting screened and then comes back pretty normal, that doesn't mean you need to check again. But for somebody who we're treating for, you know, something like a familial hypercholesterolemia or has had a heart attack, we're really trying to be aggressive and get a target. You might just take note of that and do a couple throughout, like, at different points in the cycle, just kind of know where you're at, yeah, I
think that are just comparing apples to apples. Like, if you get it done at the first part of your cycle, always get it done in the first part of your cycle. Yeah, it's not always very easy, but, you know, and if you're on a birth control pill, or you're on a, you know, IUD, and you don't know, just wing it, it. It doesn't change it too much, but it is interesting to see how much it can affect it. And I think, like you're saying when, when it matters for treatment, then you can coordinate that,
but and then so going back to kind of the like, like, stages of a woman's life, so they're going to re engage with the healthcare system around if they are going to become pregnant, always a good time to recheck your blood pressure. I know you guys do screening for diabetes at that stage. Checking a lipid panel during pregnancy is probably not necessary,
because, in fact, it will be abnormal, will be very abnormal,
and it's not going to get us one way or another. But the next point that you know, you would want to continue to get your routine care, get your blood pressure checked, and then after menopause, your cholesterol levels can change hugely because of the change in hormones. So you know, the traditional, you know, protective effects of estrogen that we talk about, you know, change during menopause. So that's really important to not be surprised that all of a sudden your cholesterol is high and it was fine your whole life. It's not your fault. It's just, it's norm gonna happen. It's gonna happen. You mentioned
earlier, the waist circumference. That's not something.
I don't think it's done at most clinics, including mine, actually, and I believe it, and I honestly just don't, there's just a lot of things and you don't do it. So that is definitely something that people can track themselves, especially if you're starting to worry about about risk factors there. Some people do a waist circumference. Some people say waist to hip ratio, but, but both of those can be helpful. So let's take sort of a little branch away here, talk about pregnancy specifically. Let's maybe first talk about, as we're leading into pregnancy, what do we do if we are already at increased risk of cardiovascular health? You mentioned that a lot of people are pretty nervous to use statins, and a lot of people, I think it's easy to be like, well, you're so young, so yeah, your cholesterol is a little bit high. We'll deal with it later, right? Tell us about your approach to that pre pregnancy cardiovascular risk for those, those who are at risk,
yeah. So I think we should just recognize that, you know, we just mentioned this protective effect of estrogen when it comes to the atherosclerotic like speed bump disease. So that goes away in patients who have diabetes or patients who have familial hypercholesterolemia. So then their risk becomes the same as their male counterparts. So that's really important to know, and so they should be treated exactly the same. And we say the protective effects of estrogen also, you know, it just means that if you don't have these increased risks, you're you still have that risk. You're just about 10 years behind a male counterpart, so the risk is still there. It's just a little bit delayed, however. So
you're saying so for people who are diagnosed with familial high cholesterol, then they should be treated before pregnancy, before
Yes. So that's my that is yes, my approach. So and familial hypercholesterolemia can be diagnosed in childhood, and often is so I guess we can kind of take an aside there and talk about that. So familial hypercholesterolemia is a genetic disorder. How common is it? It's very common. Yes, about one in 250 people. So very common. It's autosomal dominant. So 50% chance that if your parents have it, you will have it, and it's basically, you know, our bodies are really good at kind of recycling cholesterol and grabbing it from the bloodstream so it can be used for other purposes. People who have this genetic problem are missing some of those receptors, and so the body just can't grab the cholesterol out of the blood, so it sits in the blood and causes the problems we've been talking about. Luckily, if it's treated, your risk kind of goes back to baseline. So as long as you're on treatment for this disease, you can really prevent a lot of the downstream issues.
So that's usually diagnosed to start with, just with the lipid panel in childhood or teens. Yes, typically.
So that's why I say a lipid panel is so important. And I would have a pediatrician guide when in childhood it should be done, because during puberty, there's going to be changes too. But the usually pretty obvious, though, yeah, yeah, so screen, but that's one of the things that we're looking for with screening with a lipid panel. That's huge, is just make sure that this patient doesn't have this kind of genetic problem, and if we do see usually, it's defined by an LDL cholesterol that's greater than 190 milligrams per deciliter and a family history. You know, I recommend genetic testing for patients if they're interested, but I always send them to a genetic counselor so they can talk about, you know, what that really means. But when this is diagnosed, and usually it's diagnosed, young women are often under treated because of this pregnancy consideration. So statins were previously category x by the FDA for pregnancy that has been removed as of four or five years, 2019, I believe so, which is great, because
that meant before that it was considered in my training, we said, oh, you cannot, under any circumstances, take a statin during pregnancy because it will cause a birth defect, right?
And now we have, you know, great data, but we have some data that it's not causing birth defects. So I think because once a drug is category X, people are really afraid to prescribe it to anybody with reproductive potential, which is not right. I think if you are actively considering conceiving, that is when you should can have a conversation about maybe stopping the drug, or kind of how high risk you are, and go through it with, you know, a cardiologist or an OB who's comfortable with that, but if you have, just because you're 20 doesn't mean you shouldn't be on the statin, because this, this was a previously considered, you know, a potentially harmful drug, because it's it's not, it's probably Not, and it's even safe to be prescribed in children. So we know that this is a pretty safe medication. And
I think also there was the thinking of like, well, you're 20 and you might have a baby in like, eight years. So why would we bother? Because we don't want to start it and then stop it. And the fact is that if you if you're 20, and you have high cholesterol, number one, that's different than a 60 year old who has a little bit of elevation in cholesterol, right? Like you've got 80 years potentially to run around with, potentially a big problem. So we have to look at this at a more macro view, and say, okay, you've got a lot of years. How do we do this? And that does take, you know you may need to advocate for yourself and say, I want to have a bigger conversation about this. It's okay to say, like, can I see a cholesterol specialist? Can I see a cardiologist and really get my risks better? I do think in medicine, when you get to the specialist, like, like a cardiologist, they want to prevent that heart attack. They see heart attacks all day, every day, they want to prevent the heart attack, and I think it's easier for those of us more in the screening side of medicine. It's easier for us to downplay it and be like, Well, I don't see heart attacks in your age. I just don't see that. So let's not worry about it. So just a plug to advocate for yourself and and to recognize that we as women need changes in our health care that address before pregnancy and then during pregnancy and then after pregnancy and then after menopause. Like, we can't have these sweeping like, this is how you treat women, because our bodies are going through these massive changes. So it's really okay to say, Okay, I'm not pregnant. Let's do this thing. Let's, let's optimize my health now, yeah, and. Then to say I'm planning to get pregnant, I should talk to a specialist, optimize it again. I'm now pregnant. Let's figure it out, do it and then postpartum, do it again. So, yeah, it may take your own advocacy, though,
absolutely, yeah. And so I think that's, that's just an important thing. And sorry, I think we didn't even clarify what medication I'm talking about, talking about, yeah, statins. Statins are the, are the kind of first treatment. And the good thing about statins is, you know that we've been around a long time. They're safe, but if people don't tolerate them, we have other options now as well. Yeah,
Okay, wonderful. Tell me about pregnancy conditions that we won't go into this too deeply, but pregnancy conditions that people should have, at least doctors should have on the top of their list, but that people should know. Okay, this is worth knowing. This is not an isolated pregnancy thing like morning sickness. You could argue, okay, like once you're not pregnant, don't worry about it. But for people who have certain issues during pregnancy, they need to know that that changes their potential for problems outside of pregnancy. What are those conditions? I
think the one that's probably under recognized the most is preeclampsia, yeah, because it doesn't have diabetes or hypertension in the name, but it is a vascular problem, a pretty complex vascular problem that you probably understand even better than I do. But it's, it's a huge risk factor for developing hypertension and then subsequent heart attacks and heart disease,
yeah. And I think along those lines, it's, it's a weird disease, and it's a massive spectrum. And so there's people that say, Oh, I got preeclampsia at 37 weeks, and they had to deliver me early. And then there's people who get preeclampsia at, you know, 24 weeks or 30 weeks. I think that severity, we don't understand exactly why that severity is different, but the severity needs to be you need to attend to it. And then I also think some people's blood pressure will just normalize within hours of birth. That's probably that's good. There are some people who need blood pressure medications for a week or a month or six months after and I think the higher the severity, the more you need to say, like, okay, there's some underlying thing that made my body vulnerable to this severe situation. So
that's one I think, like you should if you were just talking to a cardiologist for the first time and they didn't talk, you know, ask about your OB history. Bring that up. Bring bring up gestational diabetes, and bring up hypertension during pregnancy, even if it was just isolated during pregnancy or before, or before, for sure. Yeah. And then the other thing that I think is kind of we talk a lot, a lot, when we see women who have known cardiovascular disease, a congenital disease or otherwise, it's something called like the fourth trimester. So after Oman gives birth, there are still a ton of hormonal changes and fluid shifts and all these things that are happening that. So if you had a complication right after your pregnancy, and you know, maybe you didn't categorize that as a pregnancy complication, but you were in the hospital for any reason after the pregnancy, I would definitely bring pregnancy, I would definitely bring that up. That's an important thing for your cardiologist to know.
Is it worth commenting just about why pregnancy? Like pregnancy and the heart like, why does that expose vulnerability? So maybe it's the easiest way to say it. Do you want to comment on that? Yeah,
it's a huge topic, yeah, so your blood volume massively expands during pregnancy. And so the things, you know, we worry about a lot are obviously the lumpy, bumpy disease, if it's caused any problems with the heart pump, pumping function. But you know, we haven't talked as much about the actual diseases, just of the muscle themselves. But there are problems with the heart muscle, and there's a lot more demand on the heart during pregnancy. There's issues with the heart valves. There's a lot more demand on those during pregnancy. And then, you know, your blood pressure should go down during pregnancy, because this expanded volume, your vessels should relax. And so if you have a predisposition to not allowing those blood vessels to relax, and then the volume expands. You know, that was the definition of the two things that contribute high blood pressure. Obviously, that's pressure. Obviously, that's putting double the pressure on those vessels that already have an issue. And so it's just a huge change in your physiology. So it's obviously going to affect all your organs, but your heart has to accommodate all that extra volume. I just want
to pause for a second and bring it back to I don't want this to be too much of a downer. It is a bummer talking about the body the way the body doesn't work. But I think if we went back in time and just saw people like dying for no reason, and like what happened, like that person was alive and then they died, like what happened. And now we have so many risk factors. We have so many things that can help us understand and empower us as individuals to say, okay, you know, my family member had heart disease, or my, my family member, my dad, had a heart attack when he was, you know, 50 or my, I have eight met family members who have had heart disease, or I have had cholesterol for a long time, or I've had blood high blood pressure. Those are tools that we get to use to say, okay, yeah, well, let's live. Let's take care of me. Let's figure out how to best live for me. Now, the end of this conversation is we really all should be doing all the things, you know. We should just be eating a diet that's healthy for our blood sugar, and avoiding, you know, smoking, and we should all be doing these things. But if you have, once you start spotting. These risk factors. It is like, early warning, right? We get these early warning signs of body's not happy. You better change something, because the body's not happy with it. We get to do that. And that can be annoying, because we wish that it wouldn't, yeah, but it is also empowering. So I do hope, I hope it's not a downer. I hope people will feel like, okay, now I know. Now I know, like I had preeclampsia. I've struggled with blood pressure off and on. Every time I go to the doctor, they tell me my blood pressure is high. You gotta, you gotta know that you you want to address that, because that's a sign that your body is feeling some wear and tear or feeling some struggle to do its regular daily activities. And that's the time that we want to start, even if it's a medication, even if it's lifestyle change, like get the help that you need so that you don't have that issue pile up over time. Yeah,
and we can kind of take you through in the clinic too. Once you you know, we have identified that there is some risk factor, we can kind of lay out what that means in terms of even numbers. We have risk scores that can do that. And then we can see when your blood pressure comes down with either a lifestyle change or medication, usually both the that you know, we went from a higher risk situation to a lower risk so that can be really empowering to to just, I think, you know, not be down on yourself when these kinds of diagnoses come up, because being hard on yourself is just going to make it harder to do the next step that needs to happen. And then when you do the next step and you see that it's working, it can be really gratifying. So that's knowing that you do have control over a lot of these situations is Yeah, should be empowering.
Yeah, yeah, wonderful.
Tell me a little bit more about some screening tools that people will have heard of you. Think about an EKG, a stress test, an echocardiogram, and one that people may not hear as much about is the coronary calcium score. When? At what point do those? Should those come into play for women? The calcium
score is one that I think is very useful. Unfortunately, the so and I can kind of explain what a calcium score is. We talked about the speed bumps. I love this analogy, obviously using it. And we talked about how your body's response to the cholesterol getting into the blood vessel wall is to kind of send the immune system to neutralize it. The result of that immune system, kind of walling it off is literally creating some calcium there, and so the calcium shows us that your body has recognized there's cholesterol there and is walling it off. So it's a indirect marker of cholesterol in the artery. But if it's fluctuating, going up and down, it could just mean that you're kind of are doing what we call, like positive remodeling, so you're making that, yeah, healing the cholesterol situation. So focusing a ton on the number isn't, is somewhat helpful, but really it's just, is it there, or is it not there? Zero or non zero, non zero. When it gets really high, we talk about other tests. But when it's, you know, somewhere between 03 100 ish, we kind of just say, Okay, we know that the cholesterol is being pesky, we should lower it. And so that's when, when I use a calcium score, is when I'm considering starting cholesterol medication, and it kind of helps us make that decision. So I wouldn't call it a screening test, I would call it a decision aid, and that's when it's really helpful. Unfortunately, the calcium is a slow process for that to happen, and so people under 40, it's pretty unlikely for them to have any calcium buildup. So it's not a useful test in younger people unless they're very high risk.
So just to go back, it's a CAT scan of the vessels of the heart, and it's looking for calcium buildup. So it's a coronary calcium score, so it's looking for calcium buildup in the vessel supplying the muscle. And if there's calcium there, then that means there's some plaque there, mostly, unless it's pretty modeling. But yeah, pretty much, yeah, pretty much, that means there's plaque there, yeah. And that means that it tells you you already have some amount of cardiovascular disease state. So that can be helpful, but not too young, because the it takes a while for the calcium to actually build up. Yeah, go back, because you mentioned this a couple times, the unstable versus stable plaques.
What tell us more
this is kind of comes into play a bit more when it when we know somebody has a lot of those lumpy, bumpy and disease, if you and they can, you know, it's so severe that the blood vessels are kind of constantly not getting enough blood flow. And so when they do exercise, they get constant they get chest pain all the time. If that chest pain is kind of constant, we treat it with medications called stable disease. If it's unstable, that means it came out of the blue. It's much worse than it's ever been before. And you're really concerned, that's probably unstable plaque, so that means it ruptured. How do we identify that early? That's what, that's the you know, what we need to figure out in cardiology. So we have more invasive tests where we can do, you know, give you contrast and slow your heart rate down, and take really good pictures, and try to figure out which plaques are the bad ones and which ones through the vessel, yeah, where the dye goes through the vessels and and I think that's kind of the frontier. That's where we will be in the future for screening, but right now, that's a bit of an invasive test. So it's radiation, it's people can have allergies to the dye agent, and we need more data to know that it's helpful. But if you're. Having chest pain. We're trying to figure out why. It's a great test if you don't have any symptoms, but we're just concerned something might be there. We're not quite to the point of using that. We are using the calcium scores for people who we just want to see if there's anything there, because it's a quick no contrast, so no dye. It's very low radiation dose. It's pretty inexpensive. Not a lot of kind of incidental findings, although there can be some, which we can talk about too, and why we don't just scan everybody's whole body all the time, right? But that is kind of what I'll say about screenings. I think in the future, in select patients, we will be able to look at those plaques really closely. We're not quite there yet.
What about a yearly EKG? The
US Prevention Task Force doesn't say that we need that there's insufficient data. I don't think it's bad idea. It's another one of those non invasive, cheap tests that can give you some information. I but you know, it can any kind of testing can cascade into more unnecessary testing, and so there can be a lot of abnormalities on EKG that are not concerning and but often it can lead to an echocardiogram and kind of more medicalization of normal, healthy people.
Yeah, I want people to have an idea of, like, my doctor didn't order that for me. Like, I think that's okay, yeah. I think just a reminder, as we kind of talk about this, that the cardiovascular disease is best viewed from the macro level. It's best viewed from we're looking at all of these factors, and it's some people are going to have more of factor A and less of factor D, and some people are going to have tons of factor D and none of A, and some are going to have A, B, C and D, right? Like you want to look at those people can all end up with the same disease state. So what we're looking at is, we're looking for all of the things that factor in. And how do we minimize the lowest hanging fruit. You know, the ones that are easiest to minimize, like stop cessation of smoking, right? That's an easy one. You should stop smoking. Some of them are harder, like genetics. So we're kind of looking at all of these pieces that contribute and say, Could we lower this one a little? Could we lower this one a little? So if a woman has, I think we'd be remiss if we don't talk about the presentation of heart disease in women compared to men all over the like warning posters in hospitals, it'll always say, like, chest pain and left sided arm pain, right tell us what, what the difference is with women. So
often women will present with like, gi so gastrointestinal symptoms, so like, nausea, vomiting, sometimes anxiety, things like that that can be ignored. And so that's a big problem. And so obviously, you know, if you having these new acute symptoms, and you're very concerned, asking for an EKG is not unreasonable, and should it show up on an EKG, if it's an acute heart attack, almost always there. There are, you know, depending on the severity of the heart attack and the location. So to
put that in perspective, because we don't want to create a bunch of panic and women every time they have a stomach ache, right? I think the first step is to say, what is your underlying risk, right? Are you overweight? Do you have high blood pressure? And your your doctor told you to take a statin, and you're not taking it. So you know your cholesterol is high, you should have a higher threshold for paying attention to weird symptoms. Is that anything you want to add to that? Yeah, I
think also kind of if you have uncontrolled inflammatory disease, yeah, I've seen that more commonly in people who don't have other risk factors, but that should be on your radar too. Yeah,
so and so. Then, how does a woman tell a difference? If she has these high risk factors, she's going to be more apt to pay attention. But I think one of the keys to these symptoms is they should kind of be coming out of the blue and or related to exertion. Is there anything you would say to clarify that
these symptoms can't are caused by not enough blood flow getting to an area of the heart so that can be because you've just done something that kind of made your heart work a little bit harder, and so then the blood flow doesn't get there, or all of a sudden the blood flow stops without you working hard so it can come out of the blue. And typically it's going to be something that lasts like 30 minutes, and it's going to be something pretty concerning the symptoms. But so it's not just going to be a little tummy yeah and then, but if it is coming with exertion, sometimes after a large meal, and then sometimes with stress, it should be the kind of thing that comes on and gets better if you rest or that kind of goes away. So you know, constant pain for multiple multiple days should be evaluated, but just It's usually more periodic.
Yeah, and you hate to do that, to say this too much, but I do, again, with advocacy, I do think it's missed a lot. So if you feel like I'm really worried, I think something could be wrong. And you go to the ER and they say, you know, like, well, take some Imodium or something, you know, I think it's okay to say, Would you mind doing an EKG? I don't I say this sensitively, because it's a it's a complicated thing, right? You go to the hospital and they say, like, Stop telling me how to do my job. But I think, by way of advocating for if you know, you have done your research, you've listened to this, you know you're at high risk for a heart attack. You're having symptoms that are really concerning, out of the blue and EKG is not that big of a deal. They can do an EKG. Like, if you're there, they can do it. Yeah. So it's okay to kind of push and be like, Can you roll out a heart attack? Because I've heard that these symptoms can, you know, be different. To in women, and they might glare at you, they might be rude, but like, get the EKG and call it good, and then if it's normal, then you can go home knowing, like, maybe it is heartburn, that's fine.
And if they did a blood test too, if they if they do look for heart damage in the blood, and especially if they took it twice, really, really, really sensitive tests for ruling out an acute heart attack doesn't mean that there wasn't an episode of low blood flow to the heart that kind of recovered and could come back. So I don't want to completely dismiss people who come in and get negative, what we call troponins, or negative blood work. That doesn't mean they don't warrant further workup, but it does mean you can probably go home, yeah, and get at it with your with your cardiologist in the office.
And if you're having a somewhat new symptom that's coming with exertion, then that's something,
yeah, I would definitely need to work that out. Talk to your talk to your primary care,
especially if you know that you have high cholesterol, you know you have high blood pressure, that's pay attention to that. This is why, I mean to be fair, like, this is why it's missed all the time. Is because it's, it's not a super obvious thing. I mean, if blood is coming out of your arm, then it's easier to be like, well, I know what that is, right? Yeah, I think when you have these vague symptoms, you don't want to make every woman who has a symptom feel like she's having a heart attack, but it sure makes it hard to differentiate, like, Who's the one who's having a heart attack and who's the one who's not. So that's why it's empowering to women to I mean, I talk about this all the time, but like, be in tune with your body, understand your body, know where you're at in your cycle, know your risk factors, know your blood work, know your you know, educate yourself, because you will take better care of yourself, and you will help your doctors take better care of you. If you know these things, yeah,
absolutely. It's really important, and I think, but it's also good to know that you know if, yeah, if you cut yourself you have a lot of nerves, you can know exactly where that happens, yes, and you're inside your small, little body. It's very it's just a whole different nervous system. So it's, it's really, can be very hard to locate. There can be referred pain. It's a whole different kind of mind body connection when it comes to our internal organs. So that's why it can be
really tricky. And if you go to the ER, they may be thinking, Oh, your lungs, do you have wheezing? Do you have pneumonia? Like, it's okay to be like, Could you check my heart? Yeah, I think that's okay. Okay. We're just in the last couple minutes here, and we haven't covered nearly what I wanted to cover, because I really wanted to cover a lot of the prevention and the lifestyle. So we'll talk about the lifestyle and the prevention another time. But will you help us just understand is the last question. Help us understand a lipid panel? Because you said we should go get a lipid panel. What does that mean? So we kind
of talked about the building blocks of, you know, what we take from our food and use into to make energy. Lipids are one of those chunks that we talk about, like fats, proteins and carbohydrates. Fats are what we measure on the lipid panel, and they're what's kind of in the blood at any given moment. But I think what I wanted to kind of emphasize is that there's two big categories of lipids that we're looking at on the on the lipid panel. One is your cholesterol, and the other is your triglycerides. And triglycerides are different than cholesterol in a big way. So cholesterol has kind of more of a structure, and it's used for making hormones and it's used for making cell walls. Triglycerides are really great sources of energy. And so your triglycerides right after you eat are basically most of the fat in your food will end up being triglycerides in your bloodstream, and your body will take those and use them. Your muscles use them for energy, your brain like they're just great energy sources. And then the cholesterol is kind of stored away and used for very specialized purposes, and usually it's neutral, as long as it's not too, too too high, and getting into the blood vessels, when you're looking at your lipid panel and kind of in your mind, just kind of separate those two things, and think about the cholesterol levels, and then think about the triglyceride levels. Triglycerides have more to do with your diet and your metabolic health and your cluster and blood sugar, yeah, and your insulin resistance, where, if your cholesterol is high, kind of that often is genetic, especially if it's very high, and it's a little bit harder, it's not impossible, but it is harder to control with diet, and often requires if it's very high in medication. But the biggest thing I think I talk about in clinic all the time with my patients, because, you know, I'm gonna do a lot of lipid consultation, if you're and I'm just going through their lipid panel. I think everyone's heard LDL cholesterol is the one that we should worry the most about. If your triglycerides are high, a typical lipid panel uses the triglycerides to calculate your LDL, so it's not directly measured. So that LDL level in your lipid panel is not really what you want to look at if you have high triglycerides, meaning over, meaning over 150 and especially if they're in like the hundreds. So then you just kind of look right down. It's usually right underneath the LDL. There's something called the non HDL cholesterol. I think we've heard a lot about HDL cholesterol being kind of this good cholesterol. It's basically just not it's probably neutral. It's not bad cholesterol. We want it to be higher. It's bad when it's low. But anyway, so, so taking a look down there and just knowing that that's kind of another thing that you and your doctor should be paying attention to is that LDL cholesterol is one data point, but that non HDL cholesterol is probably a more important data point in. Predicting kind of how much of your cholesterol is like the problematic kind. So let's
go through that really quick, because one of the things I hear most from my patients is thank you for going through my labs with me. Because usually I just get an email that says it's normal or abnormal. So let's just, let's let people go through it, get a pen. Yeah, so total cholesterol is usually at the top, and total cholesterol we're aiming for,
yeah. I mean, it's really less
than 200 probably generally less than 200 and then usually triglycerides are right after that. And triglycerides less than 150 less than one less than 100 would be great,
yeah. And that does depend on if you're fasting or not, yeah. So I don't make my patients get fasting lipid panels. But if we have a triglyceride issue, I do, oh, nice, yeah, I do. Because I just need, I just want to know kind of what's going on on a day to day. Because the triglycerides, if they're really high and they're not fasting, it tells me something, yeah. But so, yeah, so under 150 is it's considered kind of goal, if we're, if we're looking to lower triglycerides,
and then HDL greater than 40 typically, is considered protective or neutral. Yeah. And then LDL. Is it same for non LDL is still the same target of I
add 30 to non LDS to LDL to get your target for each for so if your LDL goal is like under 100 your non, non HDL would be one less than 130
and these are usually on the lab. So if someone gets their own labs, they're usually there. Except I find that LDL ranges are all over the place. A lot of them will say less than 130 still. And I usually tell them less than 100 is that what you're Yeah.
I mean, it really that's I like to tailor your LDL goal, or your non HDL goal, to the person. But if we're talking about about risk and cholesterol, just as a general, yeah, screen, we do like it, you know, some around 100 or less, and then you've already had an event, or your high risk lowers that different
story, yeah. And then LP, little a you're aiming for,
yeah. That one, it depends on if it's millimoles for deciliter or milligrams, but it becomes a risk factor when it's in the like, 60s or higher for milligrams per deciliter. And that's that's above normal, but, like, there's a kind of a gray area with LP little a, we don't have targets for LP little a yet, because we don't have anything targeting it
yet. And then for hemoglobin A, 1c that's the diabetes marker, and that lab range is usually correct. On there, less than 5.6 is considered less than pre diabetes. So 5.6 and above pre diabetes, I like 5.4 I get a little picky with it. Anything else, any last final words of like, shout it from the mountain tops to women for their heart health. Anything that you want to end with? Oh,
yeah, um, I mean, I think we were kind of talking about this before we went live. But don't be too hard on yourself, because I think, you know, there's so many factors, there's so many factors, and a lot of us, a lot of things you can control and work with your doctor, find somebody who you you know, like and trust and but you know you can't make positive changes if you're feeling bad. So this is what you and I were talking about, is even knowing all of this and being around all of this, it's still really hard to do all the things. So we do our best. We do our best. Fortunately, we have medications and medical support to help us sort of hopefully make up the difference. Yeah, possible. Yeah, absolutely, awesome. Well, hopefully we'll have you back, because we still want to talk about menopause and hormonal changes and a couple other things. So thank you so much for being here. Thanks for having me.
Thank you so much for tuning in to today's episode. A huge thank you to our guests for sharing their insights and time with us. We are grateful for the incredible support from our sponsors and to all of you listening. We couldn't do this without you. If you enjoyed this episode, please consider subscribing on your favorite platform. You can find us on our website, uplift for her.com, YouTube, Apple podcast, Spotify, or wherever you love to listen, and if you found value here today, please share this episode with someone who would benefit from it. Leave us a comment or give us a review. It really helps us reach more listeners like you. Thank you for being part of our community. Stay tuned for our next episode. This information is for educational purposes only and not intended to be medical advice. You.
