Women’s heart health at midlife — a discussion with Dr. Emily Lau

Heart health at midlife — Transcript from an interview with Dr. Emily Lau

Nina: Welcome to Interviews with Experts. Today, we’re talking to Dr. Emily Lau. Dr. Lau is a cardiologist and researcher, and I will let her introduce herself, and then I will ask her a few questions.

Dr. Lau: Well, thank you so much for having me. I am the co-director of the Mass General Brigham Women’s Heart Health Program and a physician scientist focused on women’s cardiovascular health.

Nina: Excellent. So, our work at Women Living Better is related to investigating whether changes associated with perimenopause begin earlier than we previously thought, and just to say, we believe they do. So, one of the benefits of thinking about perimenopause or the changes associated with menopause earlier is it gives women a chance to start thinking about a new phase of life and their health at an earlier time point, both, you know, individual risks and just generally healthy behaviors. And so, from your perspective, let’s talk about midlife heart health.

You know, I don’t know what the right age is, people say 35 is way too early, maybe it’s 40, but in that given timeframe, what should a woman in this age range be thinking about with respect to her heart health?

Dr. Lau: Well, I would first say is that it’s never too early to be thinking about one’s heart health, and that is even before midlife. But I do think that the midlife provides a really important opportunity for women to be proactive about their cardiovascular health. And that’s because a lot of things happen during this important life transition that influence your risk of developing heart disease later on in life.

For example, we know during midlife and during the menopause transition that our cholesterol profiles change quite dramatically. LDL cholesterol, which we sometimes refer to as the bad cholesterol, will rise precipitously. And we know that HDL cholesterol, often referred to as good cholesterol, actually becomes a little less cardioprotective during this period of life. There are other changes. We see, that insulin resistance changes body composition. Women start to put on more visceral, adipose tissue, which is really the fat that surrounds our internal organs, which is much more inflammatory, much more related to cardiovascular disease risk.

All of these things actually go up quite precipitously during the menopause transition and in midlife. So this is the time for us to be proactive. We should be talking with our female patients in midlife or even before midlife, what they should be looking out for.

Nina: Excellent. And so, following from that, what should a woman do about all of those things? What are the behaviors that have the greatest impact in your mind?

Dr. Lau: Well, I’d say the first things are just really know your numbers. You know, when you go see your primary care physician, well, I’d say the first thing is go see your primary care physician. And when you do go see your physician, ask to be screened for the traditional cardiac risk factors. Ask for a cholesterol panel.

Check your blood pressure. What is your weight? These are what is your sugar control, your hemoglobin A1C. It would be, you know, many, many people actually don’t even know what their basic cardiac risk factor profiles are. So it’s really important that we as patients advocate to our physicians.

Dr. Lau: checking and screening for these important traditional risk factors because it is not too early to know these numbers. And the midlife is a really important time period for us to be looking at these important risk factors. And then I would say that really adopting a heart healthy lifestyle throughout one’s entire life, but especially at these important trajectory points in life and transition points in life are important.

So of course that includes things like diet, exercise, healthy eating, but I think we have to be a little bit more specific about each of these recommendations. What does exercise look like? Well, the American Heart Association recommends 150 minutes of moderate intensity aerobic exercise across a week or 75 minutes of vigorous or heavy intensity exercise. And something that many patients don’t realize is that the American Heart Association also recommends resistance exercise. We think a lot about getting our heart rates up, but what about developing skeletal muscle, building lean muscle mass? That’s actually a really important component of cardiovascular health. And then when we talk about diet and healthy eating, I really think about this, of course, in the concept… in sort of, like, in a holistic viewpoint. Really trying to integrate healthy eating habits into one’s life overall life habits in their day to day lives. Of course, this means trying to reduce processed foods, processed sugars, and really emphasizing fruits, vegetables, lean meats, proteins, that sort of thing. But really trying to think about this in a holistic approach rather than in a punitive way. I think those lead to the most sustainable results.

Nina: Excellent. When you say moderate, is that the can or can’t… can’t have a conversation? Because sometimes these terms, like, moderate, vigorous, I wonder, what does that mean? If I’m gonna go for the 150, you know, 3 times a week, what does that mean? [Or 5 times 30]

Dr. Lau: Yeah. Yeah, yeah, it’s a great question. I would say moderate intensity exercise is that you are getting your heart rate up, but that you probably still are able to have a conversation with a partner. Say if you’re doing some brisk walking, light jogging, vigorous intensity exercise is really important.

Nina: Okay.

Dr. Lau: The type of exercise where you probably can’t have a conversation with somebody.

Nina: Okay. So, if I’m biking, I can still sing along with my playlist. Okay, and then the last thing, so, you and I have been working on some new content for the Women Living Better site, and, you know, I think one thing stands out for me that is both informative and a little scary is that women’s heart disease, we’re learning, shows up differently than men’s heart disease.

Dr. Lau: Yes, exactly.

Nina: And following from that, women’s heart attacks show up differently from men’s heart attacks, correct?

Dr. Lau: That’s right.

Nina: So, when I look at the things that we are soon to publish on the site, I worry that women are going to be like, oh my gosh, is this, you know, do I need to go to the emergency department? And is there a way, or, you know, I want everyone to be cautious and go if there’s any risk, but is there a way to help women understand when it, when it, when it’s time to go versus, you know, I know heartburn is similar.

Dr. Lau: Yeah, yeah. It’s a great question. I mean, the 1st thing I will say is that chest pain is still the most common symptom of a heart attack in both men and women. So I think that is actually really important. 90% of patients with acute heart attacks actually experience chest pain. And that’s both men and women. So I think that sometimes we, you know, we’ve spent a lot of time trying to highlight that women often will present with many other non-chest pain symptoms, which they do, but we don’t want to disregard the still the most common symptom of heart attack, which is chest pain.

Nina: Okay, that’s great. I need to update that. Okay, that’s great.

Dr. Lau: Yes, absolutely. And then the other piece is that it is true that women are more likely than men to experience non-chest pain symptoms of heart attack, like shortness of breath, nausea, fatigue, you know, sweating. And those can be a little bit difficult to discern, as you’re right, and you don’t want every single symptom to send our patients to the emergency room. That’s no way of living. I think that creates a lot of unnecessary anxiety.

Nina: Mmhm, yes.

Dr. Lau: But I really fundamentally believe that women and all patients really know their bodies the best. And you sort of know when something isn’t right and it’s really nagging at you and you’re saying, I’m feeling more short of breath than I usually am. I could I used to be able to do this hill and something’s not right. I’m so breathless or I’m really nauseated and there’s no real reason why I’m so nauseated.

Dr. Lau: I think it’s worth a conversation with the physician and potentially coming in to be evaluated. If there’s something sort of nagging you, saying something doesn’t feel quite right, I think it’s worth a checkup.

Nina: Okay. Great. And this is, do these symptoms need to be with exercise or not necessarily?

Dr. Lau: Not necessarily. Of course, I think the most classic sign of the beginning symptoms of some sort of heart issue is that the symptoms come on with exercise, and that’s because when your heart’s not getting enough oxygen, that’s what precipitates the symptoms.

Nina: Yeah, yeah.

Dr. Lau: And that’s what we call ischemia, where your heart muscle is not getting the oxygen that it requires. And so when a patient is exercising, your heart oxygen demand increases, which is why the early symptoms often can be with exercise.

Dr. Lau: But some heart attacks really come on quite suddenly, and don’t… it’s not necessarily a… patients may not necessarily have symptoms with exercise, they may have it all of a sudden and at rest. And so when there is a question, you know, if you’re having chest pain and it’s at rest you never had it with exercise, came on suddenly, something’s still not right, I still think it’s worth coming in to be evaluated.

Nina: Fantastic. I love the listen to your body because I think that’s just a general theme across many areas of women’s health. And also don’t let anybody sort of make you doubt. I mean, again, this is certainly in the heart health area, but same with mood and other things. If something isn’t right, like listen to yourself because we know our bodies best. I think it’s easy to sort of feel sheepish or shame and be like, is this real or is this just me? And I’m finding that to be a constant theme across topics in women’s health, which is, you know best, listen to your body, seek help and, and sort of, speak up. So, this has been, yeah, this has been so great. Any other things that, um, you know, based on research that you’re, um, doing or finding that are kind of new interesting findings, with respect to women and heart health that we, that I didn’t ask about?

Dr. Lau: Absolutely. Well, you know, I think more and more we’re realizing and recognizing that events across a woman’s lifespan are actually important signals for future cardiovascular health. For example, what age did you start your periods? Did you have a diagnosis of now what we call PMOS, or previously PCOS? What happened during your pregnancy? Did you have trouble getting pregnant? What age were you when you went through menopause? All of these things that we never used to associate with heart disease are in fact, I think more and more we’re discovering they are in fact risk factors for cardiovascular disease development later on in life.

Um, so I think as a… as a women’s cardiovascular specialist myself, I always ask all of my women patients, you know, let me ask some questions about your reproductive history so that it can help me better inform the way I take care of my patients. We should be asking all of our women patients these questions, just like we ask about family history, smoking, etc.

Nina: Wow. So let me just one quick follow on and then I know we’re just about out of time. But so do you think primary care providers are probably not making those associations with kind of reproductive health history? Should a woman just voluntarily share that? I mean, what’s a way for a woman to make those links, you know, for herself right now. Does she need to see a cardiologist to do it, I guess, is my question. Would a primary care be like, uh, that’s not… I’m not gonna order you any different tests because of that. I mean, how can we incorporate that kind of new research now?

Dr. Lau: Yeah, well, certainly I would say that prevention, of course, the primary care physician is the centerpiece of all prevention. And so it’s not that you need a cardiologist to be able to link reproductive history with cardiovascular health, but it’s true that perhaps some of that literature is not always getting to our primary care colleagues. So one of our missions, of course, in the women’s cardiovascular space is to educate our colleagues, our patients, the community about the new research that we are discovering.

But I would say that patients are their best self-advocate. So if a physician, if your primary care doctor gets through your whole visit, never asks you about these things, you say, “Hey, you know, I read that, you know, reproductive life events may influence my cardiac health and might actually change the way you may think about the types of treatments you are gonna prescribe me. Can I share a little bit about the specific life events that might be important for you to know.

Nina: Fantastic. Excellent. Well, thank you so much for taking the time. I’m excited to get this up on our new page and get this information to women. And again, it’s so fun to work with you as always.

Dr. Lau: Okay.

Nina: I really appreciate your expertise and time.