Decoding Women’s Health with Dr. Elizabeth Poynor Decoding Cardiovascular Health with Dr. Anu Lala

This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions.

00:27

Speaker 2

Cardiovascular disease is the number one killer for men and women, and it increases in frequency and prevalence as we age. There's no magic test to tell you you do or do not have cardiovascular disease. We don't have a mammogram for cardiovascular disease. We don't have a colonoscopy for cardiovascular disease. And so I think of it more as this puzzle that needs to be put together to then inform how we address a woman's health moving forward.

00:54

Speaker 3

Nearly half of all women in the United States are living with some form of heart disease. And yet, women are often diagnosed later and treated later than men. That's especially striking to me because women have certain risk factors for cardiovascular disease that men don't. For whatever reason, heart health is not the sexiest of all health topics. But I am making the case here that it should be. There is so much actionable information for us to get into. I also want all women to be aware of the risk factors and how their personal histories inform their outcomes. so that they can improve their heart health long term. Because a healthy heart is vital to virtually every organ system in the body and to our overall well-being and longevity as women. That's why I am thrilled to introduce you to today's guest.

01:47

Speaker 2

I am trained as a heart failure and heart transplant cardiologist. And so most people see that and want to run the other way. But what that has offered me is a really unique appreciation for the power of prevention and A recognition as my kids grow older, my parents are growing older, of how much is preventable and how knowledge is power, knowing our risk is power.

02:11

Speaker 3

This is Dr. Anu Lala, the program director for the Advanced Heart Failure and Transplant Fellowship at Mount Sinai. She's also a professor of cardiology, population health science and policy, and of obstetrics, gynecology, and reproductive science. I came across her work through my colleague at Atria, Siobhan O'Connor, who's been featured on this show in the past. Siobhan met Dr. Lala through Mount Sinai's health and wellness program for women in midlife, a time when cardiovascular risk can change significantly, even for women who have never had concerns about their heart health before.

02:48

Speaker 2

For many women, midlife is is when cardiovascular risk factors or disease actually suddenly manifests. But that's not when their cardiovascular story begins. It's many threads that have been accumulating across her life that suddenly become visible. You know, I think what's happened is menopause and the midlife transition has become popularized as this cliff.

03:14

Speaker 4

You fall off this cliff and.

03:16

Speaker 2

Then suddenly you have cardiovascular disease. And I don't really think of it that way. I think of it as a window where things are showing up. And in an ideal form, we're able to catch it before things show up and we can be proactive rather than reactive.

03:31

Speaker 3

I wanted to speak to Dr. Lala because of her integrative approach to caring for her patients. chatting with Siobhan after her first appointment. She was absolutely gushing over how Dr. Lala managed to turn a clinical space into such a calming and comforting environment and how comprehensive the intake was. Dr. Lala literally spent an hour with her going over nearly every factor that could inform Siobhan's cardiovascular risk. She refers to this initial assessment as her 14-point framework. So I asked Dr. Lala to walk me through it.

04:07

Speaker 4

This is my framework.

04:08

Speaker 2

I go through it systematically for every single patient. I want to know about their family history. I want to know certain laboratory results are informative in terms of genetic risk, if relevant and applicable. What was her pregnancy journey like? What was her fertility journey like? Did she have any gynecologic surgeries? Has she had fibroid surgeries, etc.? I want to understand if they've had a history of high blood pressure, what their blood pressure is in the office, if they have a family history of high blood pressure, etc. Certainly the cholesterol panel is a good portion of what we discuss. Insulin resistance, inflammation, whatever biomarkers we do have, I like to talk about that.

04:51

Speaker 4

Along those lines, I like to talk.

04:52

Speaker 2

About history of autoimmune disease or inflammatory conditions that can contribute to their cardiovascular risk. I also check a biomarker known as microalbuminuria, protein in the urine, which I think of the kidney as an early spokesperson for cardiovascular health. So I check for that as well. We have healthy discussions around weight. Many women in midlife come in saying that they've experienced a lot of weight gain. A lot of weight redistribution is discussed. We talk about sleep. We talk about movement. I don't like calling it exercise, which can oftentimes feel really daunting for a busy woman in midlife who's juggling a thousand different things. So I like to understand how a woman moves throughout the course of her life and day. We talk about diet, but specifically like the extent to which a woman consumes food processed.

05:44

Speaker 4

Foods, alcohol, timing of food.

05:47

Speaker 2

We talk about tobacco and obviously tobacco cessation, if relevant. We do an EKG as a part of that first visit, which I think is a really helpful initial screening test just to ensure that we're not missing any structural abnormalities at the outset. And then I think perhaps unique to my framework is I really like to talk about the extent to which they incorporate mindfulness and well-being, so to speak, in their day-to-day life. I think traditionally we have, you know, Western medicine on one side and quote unquote Eastern medicine on the other, which, you know, that's an old paradigm, which I think hopefully, thankfully is being broken down. But still we don't in academic medicine where I am, we don't talk about mind body medicine and what that looks like. We don't talk about mindfulness and what that looks like for the individual. So we spend a good portion of the visit talking about that as well.

06:41

Speaker 3

Let's just unpack a little bit of this for our listeners, because you went through a list of factors in a woman's life which are super important. So let's just talk a little bit about blood pressure. Blood pressure just goes up as we age, correct? Is that a correct assumption?

06:59

Speaker 2

It can go up as we age, but it's really not such a singular linear association. What we do know is that it's very, very dependent on your lifestyle, your genetics, your stress levels. Again, this is one of those risk factors, I think, that develops at the convergence of multiple other factors. So we have to take it into context. Blood pressure naturally increases as we exercise, for example, or we can see spikes in blood pressure with stress, you know, especially where in New York City, people are running to get to their doctor's appointment, couldn't find parking, they're rushing in and people take their blood pressure right away. It's kind of natural for us to see spikes in blood pressure in that scenario. You're nervous about seeing your doctor, etc. The extent to which you exercise, I believe, practice mindfulness, have genetic predisposition, have potentially a history of, let's say, gestational hypertension, will determine the extent to which you see it when you're actually seeing that woman in the office. You do develop vascular stiffness as we age. but that doesn't always correlate with hypertension per se.

08:11

Speaker 3

I just want to ask a basic foundation of blood pressure. You know, we go to our physicians maybe once a year, our OBGYNs once a year. We go to our family doctor, our internist once a year. I mean, is that enough for like midlife women, like after 35 to be checking their blood pressure? Should everybody have a home cuff? Should we check it when we bounce into Walmart and you can do that machine right here and there?

08:34

Speaker 2

How often should we be checking our blood pressure? I always say, know your numbers, know your risk. All I'm really advocating for is not a specific frequency with which we check it, provided you don't have other risk factors. But for the average woman who doesn't have risk factors or cardiovascular concerns, they just need to know that number when they had it checked. I think that's where we're missing out. So women are not empowered to know their numbers and thereby know their risk. To answer your specific question, there's no magic frequency. It's being checked probably more often than we recognize or realize. You'll have that once a year appointment or some gyms will do it. And when it is being checked, don't just feel, you know, comfortable saying, oh, it was okay. They didn't tell me anything terrible about it. Empower yourself to know the number and know that top number and know that bottom number, which are the systolic and the diastolic blood pressure numbers.

09:33

Speaker 3

And those should be equal to or less than what?

09:37

Speaker 4

There's a lot of data.

09:38

Speaker 2

The SPRINT trial in particular has kind of informed this. The top number, your systolic blood pressure or your pumping blood pressure when the heart is squeezing, ideally is less than 120 on the top, ideally. And the bottom number, which is your diastolic blood pressure or the quote-unquote relaxation or steadying, state pressure that's in the vessels that the heart is sort of up against should be less than 80.

10:06

Speaker 4

That's just easy framework to remember.

10:09

Speaker 2

That doesn't necessarily, if you have a number above 120, doesn't mean that you definitively have hypertension.

10:15

Speaker 4

Leave a little bit of that to your physician.

10:18

Speaker 2

But I would say know your numbers with respect to those specific cutoffs, and you'll be empowered to at least remember what you generally show up as.

10:26

Speaker 3

And what should a woman know about her family history? Early cardiac disease in her family, aneurysms, what should she know? Really no, because sometimes, you know, medical practitioners won't prod at you a little bit to find out about your family history, other than do you have some high blood pressure or cardiac disease? Like, what are the specifics about what women should be aware of?

10:48

Speaker 2

Women should know what their mother and their father, biologic if they do know, showed up as with respect to cardiovascular disease. So we talk a lot about coronary artery disease and the presence or absence of a heart attack or a stroke. Yes, those are absolutely important to know. So not only, oh, my dad had a stroke or my dad had triple bypass, but what age did he have it at? And if he had the bypass, did he have a heart attack before the bypass that was maybe 10 years prior to it? The age at which it presents has a bearing as to the extent to which we can interpret it as being genetic or not. So for men, that's typically under the age of 55. For women, it's even under the age of 65.

11:32

Speaker 4

To me, it's.

11:33

Speaker 2

Relevant across the age span, but it becomes more relevant when it's at younger ages.

11:39

Speaker 3

And also probably, too, family history of high lipids, right? Important to know.

11:45

Speaker 2

High lipids, high blood pressure, type 2 diabetes, any inflammatory disease for that matter, it's all important to know. So I would say if there's a take-home, know what your parents had, have, and the age at which they presented with, and then the severity to which it progressed to or didn't. And then also your siblings, equally important to know. Many women show up saying, yeah, my brother had a heart attack. That's why I wanted to show up.

12:13

Speaker 4

How old was he?

12:14

Speaker 2

What are his risk factors? What is his weight like, his lifestyle like, et cetera? Try to understand the context in which your parents or your siblings presented with cardiovascular disease if they did.

12:25

Speaker 3

Let's just talk a little bit about obstetric history, which I find gets really ignored a lot when people are taking histories. What do you need to tell your physician about in your obstetric history that's important to your cardiac health?

12:39

Speaker 4

Yeah, I'm so glad you brought that up. So thank you for that.

12:42

Speaker 2

You know, I don't consider pregnancy as an obstetric footnote as a cardiologist. It is very much a part of a woman's cardiovascular history. It's a window to her cardiovascular health. hypertensive disorders of pregnancy, which include gestational hypertension, all the way ranging to conditions like preeclampsia, eclampsia, something called peripartum cardiomyopathy, which is a form of reduced heart muscle function as a result of extreme stress during pregnancy. Now, none of this is meant to scare individuals listening to this podcast right now, but it is meant to really take note of what your pregnancy was like. Did you experience high blood pressure during your pregnancy? That's not insignificant. That is a window into your cardiovascular health. that carries with it a significant increased risk of you developing hypertension during the course of your life thereafter. It may show up again for you in midlife. It's also a significant risk factor for the development of heart failure, which is my subspecialty later on in life. Gestational diabetes is another thing. You know, you'll often hear women saying, oh yeah, I had high sugars during my pregnancy, but then it went away after I had my baby and I never thought about it again. And then it manifests as insulin resistance later on in life, potentially leading to a host of other cardiovascular disease manifestations.

14:10

Speaker 4

And then even preterm delivery.

14:12

Speaker 2

Has associations with increased cardiovascular risk.

14:15

Speaker 4

So I want to know it all.

14:17

Speaker 2

And I think it's really important for women to feel empowered to know their pregnancy history and to share it with their physicians.

14:25

Speaker 3

And early on, you mentioned that you want to know everything about a woman, whether she's had fibroids specifically, you mentioned fibroids and cardiac disease in link.

14:35

Speaker 4

So it's an interesting question.

14:37

Speaker 2

I'm a researcher and I know you have extensive history in this and expertise in this as well. To me, I think we have to frame that connection very, very cautiously. We cannot say that fibroids cause cardiovascular disease. It is More, and I'm sure you'll agree with this, fibroids are another example of why we can't silo gynecologic health from cardiovascular health. I think we're seeing associations between fibroids and hypertension and thereby cardiovascular risk, although we don't fully understand whether it's a causal relationship versus a shared biology. And I think that's an important thing to keep in mind. So at the very least, a history of fibroids should make us think about the whole woman, including her blood pressure, including her metabolic health, and whether, you know, heavy bleeding, for example, has previously caused iron deficiency or severe anemia. So not an established cardiovascular risk enhancing factor at all, but a reminder that women are whole body systems and gynecologic health is very closely intersected with cardiovascular health.

15:51

Speaker 3

I mean, I think this is really, this is where women's health has suffered. Everything has just been siloed and separated. And it's really, it's a whole body, like you said. Endometriosis and cardiac disease.

16:01

Speaker 4

So it's interesting because this is coming up so much.

16:04

Speaker 2

And it's another, you know, as an integrative medicine practitioner, this requires an integrative approach. Endometriosis does have a compelling cardiovascular association. But again, association doesn't mean causation. Women with endometriosis appear to have a higher subsequent risk of cardiovascular disease, namely coronary heart disease, and possibly stroke. There are potential mechanisms, but nothing has been proven to be causal. So there's systemic inflammation in endometriosis. There's what we call endothelial dysfunction. So the lining of the vessels in the body can be inflamed and their function can be disrupted. There's stress in general on the vessels in the body. And then there's also shared cardiometabolic risk factors. And so I think it's important for us to take note of it. Also to keep in mind that some of the association may be relevant to the treatment a woman received for endometriosis. So if they've had, let's say, an early hysterectomy or an oophorectomy where the ovaries have been removed or premature loss of ovarian function, that can be linked to higher risk of cardiovascular disease. So it's not just the endometriosis, but it's also how it was treated.

17:26

Speaker 3

Coming up, what happens to our cardiovascular health when estrogen levels start to decline? And can menopausal hormone therapy help protect the heart or prevent Does it come with risks of its own? Decoding Women's Health will be right back. Let's talk a little bit about endothelial dysfunction and then move into estrogen. What is endothelial dysfunction? First, for our listeners, what are the endothelial cells? Why are they important? What is the link to inflammation and estrogen?

18:06

Speaker 2

Endothelial dysfunction is essentially when the inner lining of our blood vessels doesn't function normally. So normally secrete substances like nitric oxide. This allows for our vessels to dilate and to regulate blood flow, to limit inflammation, to limit blood clots, and really just maintain vascular health. It's actually incredible what happens without even thinking about it. When we have what's called endothelial dysfunction, there is less nitric oxide availability, and therefore there's less vaso, what we call dilation, or vaso meaning vessel, so less dilation of the vessels, less really what I like to call flexibility of the vessels, and then that we see more inflammation and a tendency to develop more what we call a thrombotic environments, which is like a propensity to develop more clotting, for example. It can be an early step in atherosclerosis, the buildup of cholesterol-containing plaque within the walls of our arteries. If that plaque ruptures, a blood clot can suddenly form, and that can be the cause of a heart attack or a stroke. Endothelial dysfunction can also be linked to what we call microvascular disease. And again, this is all happening on a level that's not readily visible on testing. So keep it real simple. Endothelium is the inner lining.

19:42

Speaker 4

Of every blood vessel in our body.

19:45

Speaker 2

A healthy endothelium allows for blood vessels to relax and be flexible. appropriately and maintain tone. When that lining is dysfunctional, the vessels don't respond normally.

19:57

Speaker 3

And what is the link with estrogen and heart health and vascular health?

20:03

Speaker 5

Oh boy.

20:04

Speaker 3

I'm going to go right into estrogen. It's my favorite topic.

20:07

Speaker 5

Yes.

20:07

Speaker 2

I mean, mine too. Mine too, really, especially now. Estrogen is very closely linked to endothelial function, which is one of the reasons why the menopausal transition matters for vascular health. So estrogen, particularly estradiol, supports endothelial function through several different mechanisms. It also promotes... the production of nitric oxide activity. And again, like we talked about, that allows for vessels to relax and to dilate. We have estrogen receptors throughout the cardiovascular system. And I really like to emphasize the fact that it is a cardiovascular system. So cardiovascular doesn't just mean the heart here. It is literally head to toe because our vasculature goes from head to toe, right? So when we have an impairment in... the ability for vessels to dilate or relax. We have increased stiffness. And when we lose estrogen, particularly around menopause, we can lose that favorable vascular flexibility. But menopause isn't just an estrogen deficiency disease. It's the intersection of multiple different hormones with vascular aging.

21:21

Speaker 4

And metabolic change.

21:23

Speaker 3

What are the hormones?

21:25

Speaker 2

There's progesterone, I think less appreciated is the importance of androgens like testosterone. With respect to progesterone and testosterone, the data is a little bit mixed in terms of the direct links that they may have on vascular health. And it's important to recognize that hormonal health is dynamic, right?

21:47

Speaker 4

It's not static.

21:48

Speaker 2

Our throughout the course of the day, let alone during our lifetime. The link with estrogen is a little bit better defined, which is why I focused on it specifically linked to vascular stiffness or lack thereof when there is adequate levels of estradiol.

22:06

Speaker 3

So let's talk about menopausal hormone therapy, which was referred to as HRT in the past and cardiac disease. There's observational data, right, and some data that doesn't reach statistical significance that shows that that estrogen plus progestins or estrogen alone, a little bit stronger, the data helps to prevent cardiac disease. But yet we still don't recommend estrogen at a policy level or a guideline level to prevent cardiac disease. Can you unpack that and kind of tell us your thoughts about that? Do you think women should be using hormone support if they're candidates for it to prevent cardiac disease and maintain good cardiovascular health?

22:48

Speaker 2

I mean, this is so much of what we talk about in our visits. I think it's nuanced. So the pendulum has swung and is swinging, right? It used to be that taking menopause hormone therapy is dangerous for our cardiovascular health.

23:07

Speaker 4

That's where it used to be.

23:09

Speaker 2

Now we're swinging to the opposite end where we're hearing a lot about how menopause hormone therapy works. MHT may actually prevent cardiovascular disease, which is, you know, obviously your question. We are not at the point where we can say that estrogen prevents cardiovascular disease. It should not be prescribed for the purpose of preventing cardiovascular disease. But the cardiovascular disease should be a part of the conversation in deciding whether about hormone therapy and whether it's appropriate for a woman. Estrogen has favorable effects on vascular biology. We already talked about that. If you ask me, the question is, is menopause hormone therapy good or bad for the heart? The real scientific answer is that we don't know. The cardiovascular effect depends on the woman. It depends on the timing. It depends to some extent, potentially, and this needs to be studied, the formulation, the route, and her underlying cardiovascular health. But I think the real take-home as we stand right now is estrogen may behave differently in a relatively healthy artery compared to an artery that already has established atherosclerosis. And so We really need to contextualize MHT for an individual woman, and that's why we spend so much time talking about it.

24:38

Speaker 3

So let's talk a little bit about route of delivery, transdermal across the skin or across the mucosal membrane, and then oral. Do you think there's any difference in cardiovascular risk with oral that undergoes first-pass metabolism in the liver versus transdermal, which doesn't?

24:55

Speaker 4

Yeah, so exactly.

24:56

Speaker 2

I mean, route does matter specifically for thrombotic risk. propensity to develop more clotting. You're exactly right. Oral estrogen goes through the liver first, and so that's that first-pass hepatic effect. That increases hepatic or liver production of clotting factors and can raise, in some women, triglycerides and inflammatory markers like C-reactive protein, which is one of the markers that I check. So as a result, oral estrogen is associated with a higher risk of venous thromboembolism, or DVT. Possibly stroke, but that also depends on the baseline risk, which is why it's important to know family history, prior history, etc. Transdermal estradiol, whether it's the patch or whether it's gel or whether it's the spray, that enters the circulation without that hepatic pass, that liver pass. And so it has a less effect on coagulation factors, has less of an effect on triglycerides and C-reactive protein, which is one marker of inflammation.

26:03

Speaker 4

It's not the only one.

26:05

Speaker 2

And so observational studies suggest that it has a lower thromboembolic risk than oral estrogen. And so that's why transdermal approach is preferred in general when there is a cardiovascular or metabolic or thrombotic concern. What we don't have is large randomized trial data to prove that the patch allows for, quote unquote, fewer heart attacks or strokes than oral estrogen.

26:32

Speaker 3

We just don't have that data. So a question about C-reactive protein. So this is a little bit of an anecdote, right? I'm speaking to a cardiologist a few years ago, and she was like, you know, well, oral estrogen increases your C-reactive protein and inflammatory. And then if you really read about C-reactive protein with oral estrogen, it's just induced by the liver just making more of it. It's not being induced by an inflammatory process. Is that correct? I mean, is that C-reactive protein indicative of an inflammatory process or just what estrogen is doing to the liver? And is it just bad in general to have an elevated C-reactive protein, irregardless of whether it comes from an inflammatory cause or an oral estrogen just impacting the liver? I'm generally confused about that.

27:16

Speaker 2

Yeah, so this is such a hot topic, right? There's inflammaging that we're now hearing so much about.

27:22

Speaker 4

People really want.

27:22

Speaker 2

To understand if there's inflammation. C-reactive protein is one inflammatory biomarker. It's produced, again, by the liver primarily. For cardiovascular disease risk assessment, specifically, we use high-sensitivity CRP, which detects lower levels of inflammation that's relevant to vascular risk. I think we can use it as a window into inflammation. What is fascinating is that when oral estrogen passes through the liver, it can increase CRP, just like you said, where we don't see that effect with transdermal.

27:57

Speaker 4

Whether that's just as a result.

27:59

Speaker 2

Of the liver making more or it actually being prognostically significant, we don't entirely know. Clinically, however, if an HSCRP, that's a high sensitivity CRP, is greater, than or equal to two milligrams per liter, it's considered a cardiovascular risk enhancing factor. It's not the only factor, but we use it in prevention frameworks to try and tailor therapies and management protocols. I think it's just one signal, one flag, and it needs to be taken into the context of the entire person's history.

28:33

Speaker 3

And we've talked a lot about inflammation just in general on our podcast podcast, You know, pretty much we always talk about inflammation when it comes down to like metabolic health. And I mean, almost every podcast we use the word inflammation. Why is inflammation so bad? What does it do to our bodies? Why is it bad? What is the mechanism behind that?

28:51

Speaker 2

Inflammation itself isn't bad, right? Acute inflammation is one of our body's essential repair mechanisms. The problem is chronic inflammation. that means that the immune system is remaining activated really all the time. And that's not how it was intended to operate. And it's similar to how we talk about cortisol a lot. People are like, oh my God, cortisol levels are up and this and that. Cortisol levels vary throughout the course of the day, naturally so. The problem is not a cortisol spike in the morning, which is a natural protective organic mechanism. The problem is when cortisol remains elevated for prolonged periods of time. So we're in this fight or flight mode all the time. time, as opposed to also being balanced by the rest and the digest or the parasympathetic nervous system. So I like that analogy when we talk about inflammation, because we don't want it to be chronically activated. I am glad you brought up metabolic health because this is such an important part of this as well. When we talk about metabolic health, we're really talking about how effectively the body is handling glucose, insulin, lipids, energy storage, adipose tissue. And we know that it impairs endothelial function and nitric oxide signaling. It promotes insulin resistance and other processes. I think of inflammation more as like a fire department. You want it to show up when there's a fire, but you don't want them there when there's no fire. And so I think that's where it becomes problematic. And that's where we see its contributions to poor metabolic health and then ultimately cardiovascular disease.

30:38

Speaker 3

For women who are at elevated risk of cardiac disease, maybe they have a little plaque, maybe they've done a risk calculator and their lifetime risk is over 10%. counsel these women in terms of the use of modern hormone support with transdermal estrogens and natural progesterone? Take it off the table, can't use it, or use it with caution?

31:01

Speaker 2

Again, it's so hard to draw blanket statements. First of all, we need more data. So I think that's really important. But let's say there is a woman who has some mild plaque on a CT angiogram that she's done but she's also experiencing real challenges with perimenopause and was interested in pursuing MHT. There are no direct contraindications from a cardiovascular standpoint with respect to atherosclerosis to her pursuing MHT. Where the conversation changes a little bit is around thrombosis, potentially. And that too, it really depends on the context. So Recently, I saw a woman who had been, you know, 10 years ago had been on a flight, broke her leg, was on oral birth control and developed a DVT or a deep vein thrombosis. And now I'm seeing her 10 years later and she's wondering about whether she can be put on MHT.

32:02

Speaker 4

She had a situation... that.

32:05

Speaker 2

Lended itself to developing a blood clot rather than it being a genetic predisposition or an actual syndrome that would cause her to develop blood clots. And so for me, if she had no other issues, it would be fine for her to pursue MHT. Does that answer your question? It's a complicated one.

32:22

Speaker 4

I think so.

32:23

Speaker 3

If somebody has an elevated risk to develop coronary artery disease, it's not an absolute contraindication. Oh, no.

32:28

Speaker 4

No, no, no.

32:29

Speaker 2

Because what we don't appreciate is that A woman who is suffering from perimenopausal symptoms is suffering with respect to stress, with respect to well-being, with respect to sleep, to weight, movement, diet. So all of those factors that directly play into your cardiovascular risk are being disrupted. And so we need to think about that when we talk about it's not just estrogen linked to cardiovascular disease, but there's so much more that goes along that pathway. It's menopause hormone therapy, how it will impact each one of those different pieces of the puzzle, and how those will impact the development or the prevention of, hopefully, cardiovascular disease.

33:12

Speaker 3

Yeah, I mean, it's really looking at the whole woman, right? Looking at the whole person.

33:16

Speaker 4

100%.

33:17

Speaker 3

I really want to go into stress and emotional health because that is directly linked to perimenopause. I mean, this is a time problem. where women begin to have new anxiety, maybe some depression and obviously societal pressures and family pressures and stuff. So how important are stress and emotional health to overall cardiovascular health?

33:36

Speaker 2

Yeah, this is my absolute favorite thing to talk about because this is where I really think we don't spend enough time. Emotional health is not separate from cardiovascular health. The brain and the heart are in constant communication. through the autonomic nervous system, through our hormones, through inflammation, through our behaviors.

33:57

Speaker 4

So chronic stress.

33:58

Speaker 2

For example, or new stress for that matter, or new depression, it's not something we just feel.

34:04

Speaker 4

It has real physiology.

34:06

Speaker 2

I mean, the connection between the brain and the heart is to me the most obvious, right? When we're anxious about something, like it was my kid's first day of school today, they're anxious. What are they feeling? They're feeling their heart, right? And we all feel that every day. Midlife can be like this extraordinary convergence of stressors. You've got careers, potentially children, aging parents, relationships, now then sleep disruption, and the perimenopause and menopausal transition itself. So we can't tell women to just reduce stress without acknowledging the lives that they're actually living. And we can't fail to ignore the connection between stress and cardiovascular disease. So I'm not saying that the goal is to eliminate stress.

34:49

Speaker 4

That's ridiculous.

34:50

Speaker 2

I can't do that for my own self. But it's what I think as physicians, hopefully we can empower our patients to do is to improve our physiologic response to stress. and our ability to recover.

35:04

Speaker 4

And bounce back from it.

35:06

Speaker 2

And that's where movement, sleep, social connection, mindfulness, I'm a big fan of meditation, breath work, these are not substitutes for treating a high LDL or hypertension, but they are, in my mind, essential components of promoting good cardiovascular health.

35:28

Speaker 4

Coming up.

35:29

Speaker 3

Dr. Lala will break down how she brings stress relief into the exam room with everything from calming music to physical touch and breath work. Plus, what numbers do you absolutely need to know to understand your cardiovascular risk? We'll be right back. So Siobhan also mentioned that you actually play some beats in the office. Tell me about that, actually. I had to look that up, actually, to figure out what she was talking about. Talk to me about what those are and how that relieves stress.

36:09

Speaker 2

Yeah, I mean, you know, this is where it's not necessarily very science-y. There's no clinical evidence that links a specific frequency, for example, or you might see sulfageo frequencies to healing of the cardiovascular system. But To me, this is very personal. This is where it's an art of medicine and not a science in my mind, is that sound can influence your cardiovascular physiology. And that happens through the nervous system. You know, when you go to a spa, for example, why do they play certain music? It directly starts to calm the nervous system down and it allows for you to feel safe. And when you feel safe, your heart rate comes down, right? your blood pressure tends to come down. And so I don't really understand why we only hear healing sounds like that, calming music like that in spas. I think it should be a part of our healing approach as physicians, as clinicians, when we're seeing patients. Why not create an environment that feels safe, that feels healing, that feels soft and calming?

37:14

Speaker 4

I love that.

37:16

Speaker 3

I would also argue for the opposite, doing heavy lifts to classic hard rock and ACDC, getting the cardiovascular system going to do heavy lifts.

37:25

Speaker 5

Right, right.

37:26

Speaker 3

I can't live happy without that music.

37:28

Speaker 2

That's a direct example of how it affects your body's physiology. And it doesn't necessarily work for everyone. I ask people if they like it. And selfishly, it's really great for me. I feel like I'm able to channel more of my healing attributes and really be very present for the woman that I'm seeing in front of me.

37:49

Speaker 3

I love that. I so love that. You also ask your patients about spirituality. What does that mean in a medical context? And why does it belong in a conversation about heart health?

37:59

Speaker 4

Well, I can't speak for others.

38:01

Speaker 2

You know, this is not me coming and saying every physician clinician should be asking about spirituality, but I think it's an under-recognized dimension of health. And I want to make the distinction that by spirituality, I don't mean religion. I mean, meaning and purpose and connection to other people, but more importantly, perhaps to our own selves. to nature, to something larger than our own selves. Understanding a person's sense of spirituality helps me understand their potential sources of resilience to bounce.

38:37

Speaker 4

Back from stress.

38:39

Speaker 2

And there is some data showing that it does allow for better quality of life, greater sense of resilience by measurable resilience scales. And it's also so closely connected with our behaviors, right? We talk about cardiovascular risk in terms of, you know, elevated LDL, blood pressure, and glucose. But being human is, it's so much more of an integrated kind of assessment, right? It's who do you love? Do you feel connected? What gives your life meaning? What brings you peace?

39:15

Speaker 4

It helps me.

39:16

Speaker 2

Understand what does this person need to flourish? and thereby enjoy good health.

39:23

Speaker 3

You have such a unique approach. I mean, for anybody, but especially for a cardiologist, you know, do you see this changing? in medicine? Do you see us being hopefully more integrative?

39:34

Speaker 2

Yeah, I'm glad you asked that because this is where we have to be really, really careful about our words, right? Integrative medicine is not, in my mind, alternative medicine. It's not, quote-unquote, complementary medicine. It's not functional medicine. To me, integrative medicine is not an or phenomenon. It's not acupuncture or statins for high cholesterol. Integrative medicine means maybe acupuncture will help your stress levels, which will help you move better and feel better in your life, and a statin is indicated for your elevated cholesterol based on your genetic risk, etc.

40:12

Speaker 4

etc.

40:12

Speaker 2

So it's really allowing for And again, this word holistic is also overused and misused. It is allowing for a whole mind, body, spirit assessment of an individual. You know, many advocates and proponents of this type of integrative medicine really say that it's not integrative medicine, it's just good medicine, right? And I think that's where we need to be really careful. And unfortunately, social media and other platforms have kind of demonized the And made these different sectors of medicine separate from one another. But really it is, what are all the factors.

40:51

Speaker 4

Influencing your health?

40:53

Speaker 2

And how can we work with them using evidence-based medical therapies?

40:59

Speaker 4

And also know where gaps are.

41:01

Speaker 3

Yeah, it's just like being a great doctor. Back in the day... You know, our family doctors, our doctors in our small towns that we lived in knew everything about us. They knew our family history. They knew where we worked, how we lived. And we got so far away from that. And it's so interesting to see us coming full circle to realize that that art of knowing the people that we care about really makes a difference.

41:26

Speaker 4

I couldn't agree more.

41:27

Speaker 3

At what age should women start really having serious conversations about cardiovascular risk? And does every midlife woman need to see a cardiologist to go over her risk factors and such?

41:40

Speaker 2

I mean, I think there's no magic birthday. You know, it's not like the 45, I get a colonoscopy recipe where your cardiovascular risk suddenly turns on. It's accumulated throughout our lives. But midlife, particularly around the menopausal transition, can be an important inflection point where these hormonal changes that we've talked about can intersect with vascular aging, changes in blood pressure, changes in cholesterol, body composition, insulin sensitivity. I don't want women in general to wait until they're 60, 65 to think about their hearts. I think your 40s are an extraordinary opportunity to understand your cardiovascular baseline and potentially change your trajectory for the better. One could see a cardiologist as early as you know, pregnancy or after pregnancy based on the risk factors that show up or don't show up during the pregnancy. So there's no magic date, but I think prevention is a real lifespan strategy. I think about it as starting for my kids now and what they're eating and how they move and how they show up in their lives. But if we can get the message out there that women should be intentional about knowing their numbers and knowing their risk, in their 40s at least, or potentially earlier if they have risk factors, I think will be doing our society a great deal of service.

43:07

Speaker 3

What numbers do women need to know?

43:09

Speaker 4

Ooh, I love this.

43:11

Speaker 2

You want to know your blood pressure, your cholesterol panel. Every woman should have an LP little a checked, which is a genetic.

43:20

Speaker 4

Marker of atherosclerosis. And you should know whether you had it and it was elevated or not.

43:27

Speaker 2

And I would like everyone to know whether there is insulin resistance. And then one way of looking at that would be a hemoglobin A1c, which would be a marker of insulin resistance, metabolic risk, or diabetes.

43:40

Speaker 4

I think if you start.

43:41

Speaker 2

By knowing those three numerical blood test numbers contextualized with your family history, you'll be equipped to know what your risk profile is like.

43:53

Speaker 3

Um, ApoB, the number of atherogenic particles and cholesterol particles. Yes or no for everybody?

44:01

Speaker 2

ApoB is informative when you have an elevated LDL. For me, it's a part of my routine lipid panel assessment. Coronary artery calcium score.

44:11

Speaker 3

Everybody in their early 40s or only with elevated cholesterol or a family history.

44:16

Speaker 4

So this is tough, right?

44:17

Speaker 3

That's why I'm asking the question because I'm.

44:19

Speaker 4

Sure- I know, I know.

44:21

Speaker 2

So if you look at the latest lipid guidelines, it really encourages the use of something called the prevent equation, which has been put forth by the American Heart Association. So the prevent equation takes into account gender, age, total cholesterol, HDL, blood pressure, hemoglobin A1c as a marker of insulin resistance, weight or body mass index. If you have levels of microalbuminuria in the urine, that can be helpful in terms of predicting risk as well. And based on those factors, it's able to calculate what your risk of developing cardiovascular disease is over 10 years and then also over 30 years depending on your age at baseline. And accordingly, contextualize with your family history, and I try to incorporate in my practice your reproductive history or your hormonal history as a woman, a calcium score can be helpful. So calcium score for everyone?

45:19

Speaker 4

No, I don't think so.

45:21

Speaker 2

Calcium score for individuals at intermediate, high risk, maybe it really needs to be personalized.

45:29

Speaker 3

And then microalbuminuria is protein in the urine, right? Just for our listeners so they know what that is. So your urine should be dipped for protein, right? Yeah. Or looked at for protein. And why is that an indicator of an elevated risk of cardiovascular disease?

45:45

Speaker 5

Yeah.

45:46

Speaker 2

Microalbuminuria, so micro meaning tiny spots, right? Albumin is a type of protein. Urea meaning in the urine is one of my favorite under-recognized cardiovascular risk markers. really because our paradigm of understanding cardiovascular disease has changed. We now think of it as cardio-kidney metabolic health or syndrome if it's deranged. It's another way that shows that we're moving towards whole body interconnected system health. The cardio-kidney access is particularly intimate. The kidney, if you think about it, has this, it's an enormous network. It's like a very fine filter. And if it's leaking across its barrier, it can be due to endothelial dysfunction like we talked about, vascular dysfunction like we talked about, potentially kidney injury itself. So when we see small bits of albumin or protein in the urine, it can be an early signal that the kidney's vasculature is under stress. And remember, this is cardiovascular system. So that's a part of that system. And it predicts not only kidney disease, but cardiovascular events and specific to what I specialize in, heart failure.

47:03

Speaker 3

So yeah, way before creatinine would go up, right? So this is just subtle kidney issues, correct? Right.

47:10

Speaker 2

Just like we talked about the heart and the brain constantly communicating, the heart and the kidney and the metabolic system are constantly communicating. And sometimes the earliest clue is is not in the heart at all. It may show up in the urine.

47:22

Speaker 3

So interesting. Let's talk a little bit about AI. So women are increasingly going to AI, chat GPT, Claude, Fable, any of them. How do you look at this as intercepting with the care of women and their cardiac care? Do you think these tools are good? Do you think they're dangerous? How should we think of them in terms of their utility and to help guide women in their health care when it comes to cardiac issues?

47:47

Speaker 4

Yeah, I love this.

47:48

Speaker 2

I think the promise of AI isn't that a computer or chat GPT is going to replace a cardiologist, but it may allow us to recognize patterns in a woman's health that humans are not able to integrate easily enough. So there are three exciting applications I see for AI. One is earlier detection. So AI can potentially extract information from a surface electrocardiogram or an ECG, from an echocardiogram, which is an ultrasound of the heart, or other types of imaging like a calcium score, CT scan, or even wearable data that could identify disease before it's clinically obvious. We're not there yet, but we're working towards that. And so I'm excited about that. Imagine integrating blood pressure, cholesterol, glucose with your pregnancy history, menopause, sleep, activity, genetics, wearable data. I think that's where AI can actually help us move from individualized prevention. You know, what I'm trying to do is the human integration of all these different factors. I think AI can potentially enable that more effectively on larger scales.

48:59

Speaker 4

It allows for.

49:01

Speaker 2

Continuous rather than just like episodic medicine. And it has the potential to free up physicians to allow them to do what matters most, which is like, Be present. You know, I love touching my patients and holding their hands and connecting with them and looking into their eyes.

49:19

Speaker 4

Rather than a computer screen where I'm writing notes.

49:22

Speaker 2

So those are the things that I'm excited about. The one thing I will say is that we also have to be really careful.

49:29

Speaker 4

So AI is only.

49:30

Speaker 2

Going to be as good as the data that we train it on. So if we have women who are underrepresented, which we do in clinical trials and in the evidence that we use to take care of patients, AI can potentially highlight those inequities. So we have to be really careful on understanding the sources. which is a motivator for us in the scientific world to continue to generate new data, important, relevant data to women so that AI can then incorporate that data into how it helps us take care of women and really correct those inequities.

50:08

Speaker 3

What is the one thing that you hope a woman in midlife will do differently after listening to our conversation today?

50:18

Speaker 2

My prayer is that women will take, myself included, for you too today, for anyone listening, is that we'll take a minute for ourselves to turn inwards. I think we are remarkably intelligent beings who actually know a lot about what is going on with our bodies and our minds, but we put it on the back burner. And I see this day in and day out where women are like, I know I've gained weight. I So we have this internal innate intelligence that we ignore on a regular basis. The body is speaking to us continually.

50:59

Speaker 4

And so while that.

51:00

Speaker 2

May seem like a really obscure prayer, I think a tangible way for us to get there is for us to know our numbers and know our risks. So if we can start by saying, I know my blood pressure, I know the number it was, it will hopefully get us to know our numbers of cholesterol. It'll hopefully get us to know other risks. It will help us talk to our parents and our siblings to understand their risk and how it's shown up in their lives, because that knowledge is power. And with that knowledge, we can influence our behaviors for the better.

51:37

Speaker 3

Before I ended my conversation with Dr. Lala, I wanted to do one more thing. Siobhan had told me about a breathing exercise that Dr. Lala taught her during their first appointment and how helpful she found it. Now, this kind of thing is honestly a little out of my comfort zone, but I thought, why not try it together? So I asked Dr. Lala to talk us through it.

52:00

Speaker 4

I find that breathing can be really, really helpful.

52:03

Speaker 2

One pattern that I use is the 4-7-8 breathing technique. I learned it in my integrative medicine fellowship, which I'm graduating from this month. It can influence the autonomic nervous system through breath, right? So what I do is I'll have some healing frequencies on and I'll prepare patients and I'll say, I'll count for you. I'll ask you to close your eyes so that you don't feel awkward. And I'll ask you to inhale for a count of four, hold for a count of seven, and then exhale really slowly for a count of eight. So the exhale is double the inhale. And that prolonged exhalation can help us shift from sympathetic fight or flight activation to a more parasympathetic, restorative state. So we can do that on the podcast right now. But I start with just kind of a let it all out and a couple of sighs. Then I take some deep, easy breaths. And then we can go ahead and get started. So we're going to inhale, two, three, four. Hold, two, three, four, five, six, seven. Exhale, two, three, four. five, six, seven, eight.

53:29

Speaker 4

Re-center.

53:29

Speaker 5

I'm going to do that again. Inhale, two, three, four. Hold, two, three, four, five, six, seven. Exhale, two, three, four, five, six, seven, eight. Thank you so much for being with us and I wish you the best of health.

54:02

Speaker 3

Thank you so much, Dr. Lalla. Unfortunately, it's rare to find a cardiologist with an integrative 14-point framework and a deep understanding of women's health and women's inner and outer lives in midlife who also wants to hold your hand, play calming music, breathe with you, and really understand how your physical, mental, and spiritual health can affect your lifetime cardiovascular risk. In that way, Dr. Lala is unique. But I hope this episode has given you some of the tools to start putting together your own cardiovascular puzzle, as well as the invitation to take good care of yourself. Know your numbers, especially your blood pressure, cholesterol, and fasting blood sugar. Know your family history and make sure your doctors know about your reproductive and gynecological history, including any complications you experience during pregnancy. And remember that cardiovascular health isn't something that suddenly becomes important when you hit menopause or when something goes wrong. Our risk develops over a lifetime and it's influenced by everything from our genetics and hormones to sleep, movement, and stress. The earlier we understand our individual risk, the more opportunity we have to change our trajectory and protect our health for years to come. Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Rebecca Lee Douglas. It was edited by Amy Gaines McQuaid. Mastering by Sarah Bouguere. Our executive producer is Alexander Gerriton. Our theme song was composed by Hannes Braun. Concept and creative development by Siobhan O'Connor. Special thanks to Vicki Merrick, Alan Tisch, David Saltzman, Dr. David Dodik, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohn.

56:15

Speaker 4

I'm Dr.

56:16

Speaker 3

Elizabeth Pointer. Thanks for listening, and until next time.

56:25

Speaker 2

Thank you.