← The Dr. Gabrielle Lyon Show
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- [00:00]
Host
Most people worry more about breast cancer than heart disease. But here's what almost no one tells you. You're 10 times more likely to die from a heart condition than from breast cancer. And if you're a woman having chest pain, you'll wait longer in the er, be less likely to get an ekg, and more likely to be sent home undiagnosed.
- [00:25]
Dr. Martha Gulati
You are 10 times more likely as a woman to die from heart disease than you are from breast cancer.
- [00:31]
Host
Heart disease is the number one killer of women, but we're still using diagnostic tools, risk scores, and treatment protocols designed for men.
- [00:42]
Dr. Martha Gulati
First, that every woman needs to be on hrt. That is not true. And secondly, that it will cure heart disease. And thirdly, that it can replace your statin.
- [00:52]
Host
Today, we are setting the record straight. I am joined by Dr. Martha Gulati, a globally recognized leader in women's cardiovascular health, former president of the American Society for Preventive Cardiology, and the mind behind some of the most important advances in female specific heart research.
- [01:13]
Dr. Martha Gulati
The more physically fit you are, the longer you live, independent of all your other cardiac risk factors. So it's an independent predictor of both cardiovascular mortality, dying from heart disease, or dying from any cause. So exercise is medicine.
- [01:28]
Host
We'll talk about why women's heart attack symptoms often get missed. The real link between your first period pregnancy and future heart risk.
- [01:38]
Dr. Martha Gulati
So anatomically, you know, I tell everyone to make a fist, and usually that's kind of the representative sign of the size of your heart. So size matters how?
- [01:49]
Host
Fitness trackers and hormone therapy may not be telling the whole story and the truth behind, quote, anxiety misdiagnoses that are actually silent heart conditions. Whether you're in your twenties or your seventies, this episode could save your life or the life of someone you love. Welcome, Martha Gulati. Dr. Gulati. And I have to tell you, when I first saw you, it was actually at the White House on stage, and you were talking about heart health in women. You were amazing, and I am so lucky to have you on this show.
- [02:30]
Dr. Martha Gulati
Well, I'm so happy to be here, and thank you for having me.
- [02:33]
Host
You really have an incredible reputation. The immediate past president of the American Society for Preventative Cardiology. You are a professor of cardiology at the Smith Heart Institute at Cedars Science. I got that right, didn't I?
- [02:48]
Dr. Martha Gulati
You did.
- [02:48]
Host
I practiced in Los Angeles. And the director of Prevention and associate director of the Barbra Streisand Women's Heart Center. The list of achievements goes on. You are really paving the way for women both for women and as a woman.
- [03:11]
Dr. Martha Gulati
Well, thank you.
- [03:12]
Host
Really, it's. It's truly an honor to be sitting here with you. I have learned a lot going through your research, as my team did as well. I had no idea that essentially women's hearts are different than men's or have differences.
- [03:28]
Dr. Martha Gulati
Yeah, I mean, I think that, you know, women are biologically different than men. And so I only know the heart because that's my organ. But you could literally say that about the whole human body, that there's going to be some biological difference even when we share the same organ. Because something about being xx as a woman is different than being xy.
- [03:53]
Host
You know, I was looking at some of the statistics. Just as how many women die of heart disease, it seems to be the leading killer of women. One in three women will die from it.
- [04:07]
Dr. Martha Gulati
Yes, that's true. I mean, it is the leading killer. And I know when you ask women what they think they're going to die of or what is their number one health concern, the answer is always cancer. And it's actually almost always breast cancer. And you are 10 times more likely as a woman to die from heart disease than you are from breast cancer in the United States.
- [04:28]
Host
Why have we missed that?
- [04:31]
Dr. Martha Gulati
You know, the roots are so far gone. It starts with back, you know, back in the early 1900s, what did women die from? Often childbirth or infectious diseases. And then over time, as we started developing medications. Medications. You know, we had a president in the United States who was a man obviously who died of heart disease while he was in the office in the White House. And that helped men recognize that heart disease could happen to them too. And it brought national attention to it. And when I was in medical school, I remember very distinctly, and everyone who's gone through medical school will probably remember this picture. You remember how we learned from Netter diagrams? The Netter drawings, that drawing of a white middle aged man, you could tell he had just smoked and he was at a business meeting because he had a briefcase. They were so descriptive Netter drawings. And he had dropped this briefcase on the ground. It was a cold, wintry night and it was a man having a heart attack. And we were to remember it because he was clutching his chest and giving us a clear example of the person that what they would look like if they're having a heart attack. And somehow that transmitted even to the medical community that this is a disease of men. And we know that even in our entire medical community, there's still a bias. When a woman presents with chest pain, she gets treated different than how a man is when he presents with chest pain or chest discomfort. And so despite the fact that it's the leading killer of both men and women. And so there's a real problem because we haven't really educated the medical community that well, and we also haven't educated the public in enough ways. You know, women are very good about getting their health screening. When you talk about breast cancer in the pink ribbon campaign, it did teach women to go and get that done, get their mammogram done, and not to belittle breast cancer. They've made the greatest strides in prevention. And that's why the mortality rate from breast cancer is actually quite low. But for heart disease, we have not done the same.
- [06:47]
Host
And part of that is certainly what you're saying. And women were not needed necessarily in research. I don't know another term. They weren't mandated to be in research until 1993.
- [07:01]
Dr. Martha Gulati
Yeah. And it really took even from 1993. It wasn't that day that some tap turned on and women got into research. It was suddenly the observation that women were being left out of clinical trials. And it goes back even a little bit further because if, think remember back in the 60s, which predates us, but in the 60s, there was a drug called thalidomide. And thalidomide was released with no studies, but it was to with a promise that it would reduce morning sickness for women. So without studies, women in Europe started using thalidomide. And much to the negative offset for the offspring was that, you know, we. We saw the abnormalities that were created as a result of that drug almost immediately. The FDA said in the early 1970s, Women will not be included in trials. Women of childbearing ages will not be included in clinical trials. But because of that, it sort of got translated to our medical community, just let's leave women out of it. And part of that was also because they also knew hormones change in women. So they're like, well, we don't know, you know, if they're pregnant or not pregnant, going through menopause or not. How does that affect. Let's just leave them out of it. And so that went on for more than two decades. And then finally, finally, Bernadine Healy, who was a cardiologist and the first woman to lead the National Institute of Health, she was the one that said to the Congress, where are the women? We need to have them here? And she used cardiac examples. She actually gave this beautiful analogy of the story of Yentl. Do you know the story of Yentl? So Yentl was a woman, and she wanted to study the Talmud, but she couldn't because she was a woman. So she disguised herself as a man to be taken seriously. And Dr. Healy used that story to say, do women have to be disguised as a man in order for us to take them seriously? Do they have to present exactly like a man? Why aren't we putting them in research that we find out exactly how they present? And so she talked about it as Yentl syndrome, that we needed to cure Yentl syndrome. So I think I've been spending most of my career, and I remember writing my letter to medical school and to residency and fellowship saying I was going to help contribute to curing Yentl syndrome. And that really was the beginning. But I will tell you, it was 2016 that the NIH finally said that animal and cell studies needed to include female lines. So female animal studies, female cell line studies. That was only 2016. That's not that long ago. And so if our basic science isn't there to lead us to what to do, you know, we don't have the beginning of the information, and we're just getting it. But even our clinical trials, the trial develop the new drugs that we use or interventions that might be beneficial or devices. If we don't include women in those trials, and if there's no obligation that you must include women, it really is affecting what we know about women.
- [10:13]
Host
It is terrifying that one in three women will die of heart disease, and it is the number one killer. And it seems as though we are not getting better at reducing those numbers. Is that true, or have we gotten better and heart disease is this kind of thing of the past?
- [10:35]
Dr. Martha Gulati
It's definitely not a thing of the past. But we did make some strides, I will say in 2001, we started seeing mortality rates in women come down. For men, they had already come down, but for women, they were much higher than men. And then they suddenly started falling. And what happened in 2000, 2001, a big trial that included women. It was a woman only study, was called the Women's Health Initiative. And whether people want to critique Women's Health Initiative, whether it was a good study or bad study, it is the biggest study we've ever done of women. We will never get a study funded from the government in that size ever again.
- [11:12]
Host
How big was that study?
- [11:14]
Dr. Martha Gulati
I'm forgetting right now offhand the numbers, but it was so large, and it overnight changed the prescriptions. The number one prescription in the United States at that time was hormone replacement therapy. And overnight after that study was released, it dramatically reduced. And so we saw at that time that the numbers started declining. Additionally, at that Same time in 2001, we had women's specific guidelines come out. We started the Go Red campaign. That was a national campaign to bring awareness to the number one killer. So things started coming down. But now what's concerning is in the last decade, mortality from cardiovascular disease is increasing and it's actually increasing in both men and women now. And that's concerning us for a couple of reasons. The biggest one being is that it's killing younger people.
- [12:07]
Host
How old?
- [12:08]
Dr. Martha Gulati
So under the age of 55, those people, men and women, but specifically the women, are having higher mortality rates than men. And we know that the younger population, of course has more cardiac risk factors now. Definitely eat differently at from younger ages, they're more sedentary. There's even children now or young teens that are being diagnosed with type 2 diabetes and hypertension. So there's definitely a less healthy population that we need to reverse all the cardiac risk factors that are coming at very young ages. But I think the other thing also is that younger people, especially young women, when they're present with cardiac signs and symptoms, we tend to think it's something else. We tend to discount their chest pain or chest pressure as anxiety and stress for women and we send them away and they're less likely to be treated as aggressively as men. So there is something about being a young woman who may be at risk for heart disease, but you may not get treated in the right way.
- [13:17]
Host
It's a somewhat counterintuitive. In the same vein, in my mind, we would think an older individual 55 and above would be the highest risk for cardiovascular disease. You think a woman has gone through menopause, her low hormone status is going to really put her at risk. But what I'm hearing you say is that it seems as though the younger generation now they have an increased risk, which is again counterintuitive because we're assuming that their hormones are high, that estrogen, progesterone, testosterone in both men and women, progesterone, not so much in men, is cardioprotective.
- [13:59]
Dr. Martha Gulati
And you're not wrong on that too. I mean, women do tend to have about a 10 year delay in terms of the peak of when heart disease starts really being a problem. But it doesn't mean that when you're younger you can't be at risk. Just for an example, we say that when you have type 2 diabetes, you lose that sort of hormone protection that generally we think that's what keeps women from having heart disease at young ages? It's still a disease of aging. Atherosclerotic cardiovascular disease, for sure. It definitely occurs much more when you're older. But if you die when you're under the age of 55, because you are somebody who's unfortunate enough to have heart disease, that's really unfortunate, especially given our life saving medications that we have these days. Our interventions, including medications, but also devices, are better than they've ever been. We have a way to save somebody if they're having a heart attack, but we need to recognize that that person is at risk. And there is still this pervading myth that if you're young, you're not at risk. And that is changing in our US population.
- [15:11]
Host
Colonoscopies start now at 45.
- [15:15]
Dr. Martha Gulati
Yes.
- [15:15]
Host
They used to be 50. Yes.
- [15:17]
Sponsor
Friends?
- [15:19]
Host
Pretty sure you all do cardiovascular screening. Is there a requirement? I'm unaware of an age requirement.
- [15:28]
Dr. Martha Gulati
That's been the hardest thing. What we do recommend is after the age of 18, that everyone be screened for heart disease and that they be screened on a regular basis with their primary care or family physician. The problem is, is that it's often happening. We've created all kinds of tools. We know that of course, blood pressure needs to be checked at every visit. That's without exception, cholesterol at least once at the age of 18 and then perhaps every five years after. Unless there's some abnormality that makes it need to be checked more frequently, or if there's a family history or you already have high cholesterol, then it should be treated. We've created even risk scores where you can plug in people's numbers and their risk factors and it will give you a prediction of not. Not just their lifetime risks. Because especially when you're talking with young people, lifetime risk. Maybe you're saying when you're 90, you're gonna get heart disease. Okay. But we also can give you the 10 year risk. And 10 year risk is more near term and can actually help people understand it both ways. They can be thinking about the future. I don't want to get heart disease, but what's my near term risk for younger people? I think the short term risk, often if you're 20 or something, you're gonna come out as low risk. But knowing that you're at high risk in the future may make you change your behaviors. But I always tell my friends, as a cardiologist who gets a lot of referrals, I've never gotten a letter or a referral by somebody saying this person is at high risk for heart disease, They've done that actual calculation. We've used something called the ASCVD risk score or atherosclerotic cardiovascular disease risk score, where people can plug in their own numbers and calculate their risk. And these are online now. It's. We will be using something called the prevent risk score. So I do think in a new set of guidelines that we're expecting in a few months, it's going to come out with a new risk score. And I actually like that risk score more because it includes other things than just what we usually thought of as risk factors for heart disease. So your age, your sex, whether you have high blood pressure or not, what your cholesterol is and whether you're diabetic or not and whether you smoke. The new risk score, prevent has all of that, but it also has included things like body mass index, socioeconomic status. So where you live geographically may actually determine you're a higher risk. Exposure to pollution, maybe socioeconomic status just based on living in a zip code. But also chronic kidney disease is a risk factor. And we're understanding the link between the kidneys and the heart more than ever now. So I'm actually happy that this new risk score will come out. But my concern is you can make a new risk score, but will people use it? Will art medical community use it and translate it to our patients?
- [18:21]
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- [19:50]
Host
I, I think it's really interesting. The someone turns 18, they get an EKG, they get blood pressure cuff, they get a lipid panel. Cholesterol. I trained in family practice originally. I've done that a million times. And to think that that is an adequate screening. I, I just, as I fast forward to some people that I have seen that have had heart attacks. And then you look at other risk items. For example, let's say all these are normal. But, you know, your friend Christy Ballantyne was on and he was talking about lp.
- [20:27]
Dr. Martha Gulati
I was just gonna say lp, where's the lp? I mean, I think that you, you need to do those things. But actually, if people can remember three things that they should get, because the risk score is if no one's gonna calculate them. I think, you know, my friend Paul Ridker always says if there's three things you can check, it would be your cholesterol. So your LDL cholesterol, particularly your lp, because that's genetically determined. And it's going to be the same pretty much throughout your life. For women, maybe it changes. At menopause, it does tend to increase. So if it's normal pre menopausal, it may increase postmenopausal, and then your C reactive protein. And if you get those three things done, at least those will help us know your baseline risk. Things can change, too, and those numbers can change. So it's important to recognize that and be assessed, because, you know, even in our life, everybody can think of times in their life where they gained too much weight, they were under a lot of stress, they couldn't get their exercise in, their diet change, maybe because they weren't even living in their own home. And so sometimes when you're on the road, as some of our road warriors are, you don't have the choice always to eat the most healthy food. Things can change in our life, and that's why we need it to be screened on a regular basis. But I think that that's different. It's not as easy as a mammogram. And that's the hard part. We can tell women, go get a mammogram. You can empower a woman. And a woman, actually, in the United States, since the Affordable Care act was in place, a woman can request a mammogram. Even when they don't have a primary care physician, they can go and get a mammogram. And that made it easy and accessible. And we need to do the same for cardiac risk screening.
- [22:13]
Host
How does someone know that they're at risk for having cardiovascular disease? Maybe we have a 35 year old female, 40 year old female listening to this.
- [22:23]
Dr. Martha Gulati
Yeah, I would ask them to make sure they get those three things checked, especially the ldl, the LP and the high sensitivity C reactive protein. Talk with your physician about your blood pressure and all those numbers and talk about your family history, because family history at least gives us a clue. Sometimes it's genetic, sometimes it's not. And we need to know more about you. But we would definitely have a heightened risk or heightened concern, I guess, if we knew that there was a family history of early heart disease. I think that's the easiest way to start the conversation. There are things that are unique to women though, that, that in these traditional risk scores, including the new prevent risk score, do not appear. And so we do need to personalize it for the individual. And I think for women it's even more important to personalize it. I need to know about your reproductive history. I need to know about things that happened related to your onset of your period or if your period stopped, Was it early, was it late? On both sides. Those things can put you at a heightened risk. I need to know if you have polycystic ovarian syndrome. I need to know if you had functional hypothalamic amenorrhea, which happens in women who have anorexia or bulimia. I need to know during pregnancy, did you have any of those adverse pregnancy outcomes like preeclampsia or any type of hypertension during pregnancy that heightens your risk for heart disease. Same with gestational diabetes, same with preterm delivery, and same with a small for gestational age. Baby women know all of that. They remember their reproductive history better than their doctors will be able to recall it. But we don't ask about it enough. And those women who have had especially the adverse pregnancy outcomes, we know that their risk for heart disease is high. And we're not talking 20, 30 years down the line, we're talking in the next 10 years that those are the early heart disease that we see. And we are not telling women that because if they had hypertension during pregnancy, often it disappears after the pregnancy. And so nobody's saying to them, hey, you're at a higher risk. You know, we need to control all your risk factors. Do you Know your cholesterol. If you don't, let's check your cholesterol. And that's what we're doing now. We, we call it the field of cardio obstetrics. And we are working much more closely with our gynecology colleagues and really identifying the women that are at higher risk. But I know that we have the fortune at an academic medical center, but we need it spread across the United States and work with our internists and family physicians because they are the ones that are really the ones caring for those women who will know everything about them.
- [25:14]
Host
It is a very noble effort to reach primary care internists. I mean, I do think that that is so important, which again, is one of the reasons why I wanted you on, because there's very few individuals that are talking about, specifically about women, women in menopause, women, perimenopause from the lens of cardiovascular health. And again, the Women's Health Initiative, you said in 2000, was it 2001, 2001, the number one prescription was hormone replacement. We don't know if heart disease was a lower. Imagine it was lower, right? Maybe heart disease, overall, the mortality rate from heart disease or maybe the ability to detect heart disease or the death from heart disease was potentially lower. I only said because I'm assuming people were less obese. You know, the obesity numbers, rates were.
- [26:14]
Dr. Martha Gulati
Quite high back at that time. Actually, that was our height of heart disease. But that was because so many women, I think, across the country were using a medication that had not been well studied. And so, you know, was hormone replacement therapy and high doses, not the type of doses that are out now that women might be prescribed for menopausal symptoms, but high, high doses. What we used in the Women's Health Initiative and what was being used at that time was unstudied. You know, we think about that book called. Did you ever read the book called Feminine Forever? It was where it said hormone therapy for women was the fountain of youth. And it. It in that book it said every woman should be on hrt. And so every woman was taking. Not every woman, but many women were taking it. And this is where we've harmed women. We put people on hormone replacement therapy without studies. We were, in fact, at one time it was unopposed estrogen. So we were causing uterine cancer in women until that we. They started seeing higher rates and they're like, oh, yeah, we should. Should probably make them bleed out and give them progesterone at the same time if their uterus is intact. And so that also, I mean, Women have not been treated well by our medical community, to be honest, in all aspects. We're sort of thought of after we give medication without even consideration for what might be a consequence. And that's the way medicine was and it wasn't that long ago.
- [27:49]
Host
You know, it is unfortunate and I wonder now it's almost as if the pendulum has swung the other way. And now in 2001, everyone comes off hormone replacement. They spend over a decade, really I don't. Almost two decades where hormone replacement seems to be very fringe. It is making a reappearance and wonderfully so because I obviously think there are many benefits. But can you address the, the. I'll start with misinformation and then go to the information of what people need to know about with hormone replacement and heart disease.
- [28:30]
Dr. Martha Gulati
Yeah, I think that's such an important question. And I, I'm told my, by my gynecology colleagues that now we should be calling it menopausal hormonal therapy or menopausal therapy rather than hrt, even though that's what we all had been referring to it as. And the good news, one thing that I can say is in addition to hormone replacement, we actually even have a new medication out that is beneficial, that is non hormonal for, for the hot flashes. So that's good. We're developing new medications. But the big myth out there right now that I see even some gynecologists hopping on this bandwagon without evidence is saying first, that every woman needs to be on hrt. That is not true. And secondly, that it will cure heart disease. And thirdly, that it can replace your statin. And I tell my women, like, if you need hrt, if you need menopausal hormone therapy, I'm not against it. Unless you have heart disease, if you have heart disease, you should not be on it. That data is quite strong and we do not recommend it when you have heart disease. But, but for a woman who doesn't have heart disease, what we tell them is it's not going to reduce your future risk of heart disease. That data is not there no matter what anyone says.
- [29:52]
Host
That is a big, that is a big statement. And there is a ton of information out on the web talking about how the data is very clear that it will protect the heart.
- [30:06]
Dr. Martha Gulati
Yes. And I know where that data's coming from. So there's a very small study that looked at carotid intimal medial thickness and said that some in a small study. And I quite honestly right now don't Remember the exact numbers, but it was a very small study and they did show a statistically significant difference in the women with HRT in terms of the plaque buildup compared to somebody who was not on hrt. It was statistically significant. You can have a P value that's significant, but the amount of plaque was minuscule and meaningless. So it has to mean something clinically. It also needs to be in a randomized trial in a large study to really prove effectiveness. Intermediate endpoints. We never say that plaque is going to be enough for us to say that something's effective, but especially when it was such an insignificant amount of difference in plaque. But to say this, that hormone replacement therapy can substitute for statin, that is absolutely not true. And we tell people like this is one thing that is happening. People are substituting their statin for hormone replacement even when they're not having vasomotor symptoms. Really, this medication should be used for people with vasomotor symptoms. And like I said, we have hormonal medication and non hormonal. And between you and your gynecologist, we need to figure out which one works for you. But in terms of taking away your statin, if you have high cholesterol, there is nothing else that you need but cholesterol lowering agents. It doesn't have to be a statin. I know a lot of people think that's the only thing out there. There's a lot of misinformation about statins online, but I won't get into that. But they're good drugs. We've had them for 40 years. But the good news is if you have any issues or concerns or don't want to be on a statin, and we have lots of LDL lowering agents.
- [32:04]
Host
Right now, things like would that be ezetimide?
- [32:07]
Dr. Martha Gulati
Ezetimide, PCSK9 inhibitors like Repatha and Pralin, we now have something called Inclisiran that we can give every six months. And you come to, you don't even have to remember, we do it in the office for you. And we have another medication called bempedoic acid. And this area is dramatically changed than even about 10 years ago where 10 years ago we just really had statins and ezetimide was emerging at that time. So we can treat your cholesterol, but cholesterol is not getting magically removed by being on menopausal hormone therapy. So I think that we need to work. And then the other thing is that for people with heart disease, they certainly need to understand that they're at higher risk. And that data nobody's ever disputed. And we've never had so many fights about the way we have for people from a primary prevention standpoint. But I love when we work with our colleagues, like when our physicians don't necessarily know for sure, should this person be on it. They have a number of risk factors. What should we do? And ultimately it comes down to the patient. I'm a big believer that we share the information and together it's shared decision making that if somebody really feels that their quality of life is so significantly improved when they're on hormone replacement, replacement therapy, and even if there might be some risks, there is some benefits and we know that, but we work it out together and decide what's best for that individual. But just be careful of the people out there. You know, I, the other thing I'm a, I not a big believer in those bio identical hormones that people are implanting in so many of my patients in la. The pellets there, there's nothing we can't guess yours. The amount of hormone you need versus the amount of hormone I need. Bioidentical is just a marketing tool and the safety of it I would question. But I think that, that these things we should all be questioning about what are people putting into us? Because the one thing about when they implant pellets, you can't get them out.
- [34:21]
Host
Like, we're not, we're not actually a huge fan of pellets for exactly that reason. And it doesn't allow you to adjust the dosage.
- [34:27]
Dr. Martha Gulati
Exactly.
- [34:28]
Host
When it comes to heart disease, we're using this as if perhaps there's a unified term. And I'm wondering, how do you define heart disease? Is it imaging? Is it blood pressure, is it plaque buildup?
- [34:42]
Dr. Martha Gulati
Yeah, you're right. Heart disease means a lot of different things. And when I talk about atherosclerotic cardiovascular disease, I'm really talking about the disease of the coronary arteries that creates plaque in them. So atherosclerosis, having plaque in your arteries, that's just one version of heart disease. Though as you and I know, there's diseases like heart failure that can be connected to atherosclerotic cardiovascular disease, but also can be independent. So heart failure is a common issue. Especially heart failure with preserved ejection fraction for women is much more common in women than it is in men, whereas heart failure with reduced ejection fraction is much more common in men than in.
- [35:26]
Host
And the, would you say the. What is the overarching cause of heart Disease. Is there one? Are they different in men versus women?
- [35:34]
Dr. Martha Gulati
Oh, well, the. Okay, so again, it depends on which form of cardiovascular disease. And I hadn't even finished. There's so many other forms. You can be born with types of heart disease as well. You know, congenital heart disease, you can have arrhythmias and all, all these other things can happen. The heart is one beautiful organ that when things go wrong, can create problems depending on lots of different things.
- [35:58]
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- [37:10]
Dr. Martha Gulati
Atherosclerotic cardiovascular disease or when you have disease in your coronary arteries, the commonest causes of that are, I mean, if you smoke, it is one of the leading risk factors. The good news in America is that smoking has actually gone down significantly. And so that's actually helped with the reduction in cardiovascular disease. But diabetes, hypertension, and high cholesterol, those tend to be the leading known causes and reversible causes. You know, you could have genetic causes of atherosclerotic cardiovascular disease as well. That disease that you Talked about with Dr. Ballantyne, LP. LP is determined genetically how much LP you will make will be different than what I will make. And it's genetically determined. And so, so that is something that may be inherited. If a family member has early heart disease or early stroke, you might be carrying LP around and not even knowing it until Something happens. And right now we don't have a good treatment for lp, aside from lowering your LDL cholesterol and controlling all your other cardiac risk factors. But talk to us in 2026, because we have two really big trials going on that might teach us, can we, by lowering lp, improve outcomes in atherosclerotic cardiovascular disease?
- [38:41]
Host
That would be fascinating. You know, I was listening to as you were talking about statins and the health outcomes. Do we know that lowering hypertension, fixing type 2 diabetes affects long term outcomes if plaque is there? So if someone is, is it fair to say the number one cause of heart disease is atherosclerotic heart disease?
- [39:07]
Dr. Martha Gulati
Yes.
- [39:09]
Host
Or what if we were to say the percentages? Is it maybe 90% of people, if they're going to be suffering from heart disease, would be that kind.
- [39:18]
Dr. Martha Gulati
It's about half of the type of cardiovascular disease that we see. It's the most common thing we see clinically is atherosclerotic cardiovascular disease. And heart failure then is number two. Those are the things that we see the most of. And the reason we see the most of them is because they are so closely linked to particular risk factors that are hugely prevalent in the population, even heart failure. For example, obesity is strongly linked to the development of heart failure. Type 2 diabetes is also strongly associated with, with heart failure. And hypertension as well is strongly associated with heart failure. So we, and we know specifically for, again, for women, if they have obesity, they are more prone to that type of heart failure that we call heart failure with preserved ejection fraction. So, meaning that when you look at the heart function, it hasn't actually decreased. It looks the same or normal, but it isn't able to relax normally and it's not able to pump out the blood adequately and give symptoms like somebody whose heart is actually dilated and failing, but doesn't look like it's failing. And until recently, we haven't really understood HFpEF, partially because it is in women and we haven't studied them. But now we're in an era where we are actually having a few drugs now that have really proven to be effective for what we call HFPEF or heart failure with preserved ejection fractures, the.
- [40:50]
Host
Ability to reverse plaque. Is plaque really soft or hard plaque where the damage from atherosclerosis comes from? Is that really what we're targeting?
- [41:03]
Dr. Martha Gulati
We are so much targeting the hard plaque. The hard or calcified plaque tells us that it's been there for a while and it's already Once it's calcified, when we use tests to tell us if there's calcified plaque there, because we can see it easily on a CT scan, even when you have no contact contrast dye, we can see that calcified plaque. It's not going to go anywhere and it's not even scary plaque. To me, calcified plaque just means you are laying down, you've laid down cholesterol, so you've laid down this plaque in your arteries, but you probably have soft plaque now that we should be worried about more. It's the soft plaque that has the risk of rupturing and causing a heart attack or causing a stroke. And so when we know that there's calcified plaque, it just helps us know that the, that's somebody at risk. And so some of you may be asked to get a calcium score, it's giving us a clue. But I have a lot of patients who always are worried and they want to repeat studies to look if that calcified plaque got worse. And I'm like, don't worry so much about the calcified plaque. Or they expect the number to go down because they're on a cholesterol lowering agent. And I always warn them in advance, that part's not going away, it's going to stabilize. But if we can can get your cholesterol as low as possible, we can prevent soft plaque from forming. And that's really the target of the treatment. We can see soft plaque not with a calcium score, but with something called a CT angiogram, a cardiac cta. And that can be an image that we use to look at both soft and hard plaque. In general, I would say the insurance indications anyway for getting a CCTA is when you're having symptoms. And so we generally won't just order it for someone because they want to know, but you can pay for it out of your pocket. I do have patients who actually will say, can I just have that study anyway? But if you have symptoms, we certainly can. It's a good, good way to really know the anatomy, know what's going on in the heart arteries, in the seeing is believing. And we can really now we can use different techniques with AI and other things that measurements that we can do that we can even tell if the degree of stenosis in this coronary CT is significant or not.
- [43:27]
Host
Is there plaque regression?
- [43:31]
Dr. Martha Gulati
There can be plaque regression and we've seen that in our cholesterol lowering studies, particularly with statins, where they look, looked at people who were randomized to statins versus non statins and saw that the soft plaque did regress. We generally, we don't repeat those studies in our patients routinely and depending on what imaging you had, like I said, if you've had calcified plaque, and that's all you know, you're not going to expect too much regression of calcified plaque. But soft plaque, yes, you would expect it. We don't always measure it, but we have it proven in studies when we lower LDL cholesterol that we can lower, we can reduce or regress plaque.
- [44:17]
Host
From a clinical standpoint, what I'm hearing you say is that hard plaque is seen. That is what you will get when you get a normal ct, a CT angiogram will show. But both soft and hard plaque. The hard plaque is staying there. We don't really care about it. But it's the soft plaque and it's the progression of soft plaque. My question is, are we looking to mitigate it from getting worse by diet and lifestyle and maybe pollution? I can't get out of my head what you were saying in terms of the impact of pollution. Or are we looking to monitor that? So soft plaque, because if we know it's there, is this an impending doom situation? Or are we targeting, say, LDL cholesterol, making sure that is low APOB under 70? These are the things. But the plaque will progress anyway. Soft plaque, no.
- [45:12]
Dr. Martha Gulati
Well, if we see plaque of any form, soft or calcified plaque, it doesn't matter to me once I know there's plaque there. I know you have atherosclerosis. So my initial response to that is get the cholesterol low, get the LDL under 70, LDL cholesterol, so not under 100, get it under 70. No, LDL under 100 is ideal for everybody. But once you have plaque, to me, you have atherosclerotic cardiovascular disease. Now, you know you haven't had a cardiac event, so we wouldn't call you secondary prevention, but would I call you primary prevention? No, I actually like to call you primary and a half prevention because I'm trying to prevent future cardiac events because you haven't had any, but you already have plaque. So at that moment, you have atherosclerotic cardiovascular disease. And we should target your LDL under 70. And if you are already somehow lower than that, then we should target you even lower.
- [46:12]
Host
Okay. Okay, so there's a lot to talk about here. This is a big deal. Most people are not going to know they have heart disease, let's say their EKG their blood pressure, their cholesterol is, quote, normal. They go in and they get a clearly scan or a CT angiogram. They have some plaque, but all other markers are normal. Would that person still want. And when I say normal, they have a CT angiogram score of what, 24, 50.
- [46:45]
Dr. Martha Gulati
Okay.
- [46:46]
Host
Would they. So it's really low. Would you still push that LDL cholesterol under 70 and then. So that's the first part. What about brain function, hormonal function, all the other things that are secondary after lowering cholesterol?
- [47:02]
Dr. Martha Gulati
Yeah. So I mean, we should always be treating all cardiac risk factors preventatively anyway. But once, like you said, once you've identified plaque, that person, that healthy person that you're talking about with absolutely no symptoms but a small calcium score in the 25 or 50 or whatever you want to make up, I still would say that person now has plaque. I'm going to target their LDL under 70. Now, would I give them aspirin? No, if it's under 100, I'm not going to give you aspirin. But we do have some data when your calcium score is above 100, I would give aspirin as long as you're not at a heightened bleeding risk. And that, of course, needs us to talk with our patient and do some shared decision making. I have some patients who choose not to be on aspirin because they bruise or bleed easily or maybe they have something going on that makes us more concerned. I never want anyone to bleed out on aspirin. But we do have a suggestion that date that when your calcium score is above 100, that aspirin may be beneficial. So I see plaque, you know, when I can get that visualization, seeing is believing there's plaque there. And I can do something about that to lower that individual's risk. It always comes down to, of course, the patient in front of me and what do they want to do and whether, you know, some patients will be. I just really don't want to be on a cholesterol lowering agent. Let me see if I can do it with lifestyle. So I often will. And I. Yeah, that too. Does that work?
- [48:34]
Host
500 milligrams of bourbon bid.
- [48:37]
Dr. Martha Gulati
There's no evidence, but we. But I will work with them because I do think it's powerful if you can, you know, especially if somebody doesn't have a very good diet and if they want to try to bring it down. But I still talk to them about what statins particularly do in terms of, you know, plaque stabilization, endothelial function of the arteries. All the things that we also get beyond LDL lowering that are in statins, that could be beneficial. But if they choose that and can really push, choose lifestyle and they can really push it down, I'm okay with that too. We should all try to optimize our diet and our exercise. But I will say that for patients, when they get a calcium score or they get a CCTM way, they are definitely more likely when they, when we look at their images together and they see the plaque, they are more likely to be aggressive about the lifestyle changes but also more aggressively want to lower their cholesterol because once they see that plaque and they see it in their arteries and it's something an untrained eye can appreciate. When you look at that scan, they're like, okay, yeah, that, that's not a good thing. Okay, let's now I'll be on a cholesterol lowering it.
- [49:52]
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- [51:20]
Host
Do you have concerns about the downstream impact on hormones or brain function, any of those things or is the risk benefit. It's too big of a risk to allow that soft plaque again. You know, and this is, it's complicated to talk about because Cases are complex and people are complex. But if we were to lay out a quote, low risk individual with a low calcium score that has some hard plaque, we know they have soft plaque. We expect that soft plaque to develop and we want to move their cholesterol down. LDL cholesterol below 70. Do we have other downstream concerns?
- [52:00]
Dr. Martha Gulati
Not as far as I'm concerned. And let me explain why. You know, if you think about your vascular system, it starts at the heart, but. Right. This whole vascular tree in our body spreads everywhere, so to the brain and to our legs and extremities everywhere, to every organ. Those arteries, you know, the reason we often use the coronary arteries is they're actually bigger than the other arteries that we have difficulty visualizing. If we could do the similar thing to our brain, if we saw plaque in there, we would treat it. And we know neurologically that people on statins are less likely to go on and have stroke or to have even vascular dementia or Alzheimer's disease. And so there's a lot of people who somehow have this misconception that being on a statin affects neurologic function adversely. Actually, it is brain protective as well. And so I think that people need to know that. I know I have patients that describe to me this brain fog with statins and if they can't tolerate a statin, then I change them to some other LDL lowering agent. That's the good news. Living in 2025, we have more than just statins, but statins we have had for now four decades and so we really know them well and the long term risks of them are really not proven. There's a lot of misinformation online about statins. Statins are the like enemy on the Internet. When people bring me in what Dr. Google tells them about statins, I will always counter that we have a lot of evidence. We've been doing very long, large trials that have really taught us the most about statins. You know, there is maybe an increased risk in some people for developing diabetes, type 2 diabetes downstream with statins. But what we do know about that data is a couple things, is that the people who tend to get type 2 diabetes, who have been on statins already had risk factors before for diabetes. So we don't know that it's the statin or is it because they already had risk factors that they were already pre diabetic, for example, or that they were overweight or both that are actually increasing the risk for diabetes. Statins and other LDL lowering agents are held to such A high standard when we study them. These are large population studies. There's no other drugs, except for the cardiovascular field that is held called to doing studies in large populations. And I think people should have some confidence in those studies. But talk with their practitioner, talk with their physician or their team about their concerns, because everyone has concerns. They have a friend who was on a statin that didn't have a good side effect, or they have a family member, or they just have concerns because of what they read. And together we'll work out and find out a medication. I always tell them, I'm never going to put you on something that you're going to hate or is going to affect your quality of life. And I don't care if it's in your head or if it's genuine, it's there. We'll find something that works. And we're lucky to have more than one medication.
- [55:15]
Host
As you were talking, I can't help but think about the female specific. As I filter through all my conversations about heart disease. One of the most common things that comes up, believe it or not, is erectile dysfunction and heart disease. And as we were looking through your research prior to having you come on, you know, there's a difference from the traditional fitness formulas for men and women, which really has been a huge contribution from you, which I'd love to talk about. But also I just realized that the lens that I've been thinking about this, I think about erectile dysfunction as heart disease. Tell me, is there erectile dysfunction and heart disease for women or something similar? Because everyone's listening now, if you weren't before.
- [56:03]
Dr. Martha Gulati
Erectile dysfunction, of course for men is a big issue and we don't have the biological equivalent for women that we can associate with being a warning sign for heart disease disease. The one thing that I will say that we've been really missing, though in women is the fact that women often do have cardiac symptoms. And the thing is, is when they have these symptoms that sound like ischemic heart disease, that sound like there's reduced blood flow to the heart, and we'll do evaluation whether that's a stress test, whether that's a coronary angiogram, and we don't find a blockage in the coronary, unlike men, where we often find blockages in the coronary, until recently, we were just dismissing those women. We were saying, don't know what your symptoms are, but they're not cardiac. Go on your way and this is not your heart. And these same women would come again and again to the emergency room come again and again and allow another angiogram to be done on them or whatever testing was done. And they were often dismissed because they had no blockage. So now we talk about ischemia with no obstructive coronary arteries. It has a night. You can see that cardiologists love names of things. So we call it a noca. But NOCA stands for ischemia with no obstructive coronary arteries. And that happens much more frequently in women. And I think we've often been dismissing women when they had symptoms and not treating them. And a lot of the work we do at Cedars Sinai actually focuses on, on women with anoka trying to figure out how, what's the best way to detect it, but also what's the best way to treat it. We know from some of the early work that I did with some of my colleagues at Cedars, even before I arrived there, I had a normal cohort of women. And we compared them to women with anoka and we found in contrast to what had been told to everyone that these are, you know, this is nothing, do nothing with it. We found using the population called the Wise Women Women Ischemic Syndrome Evaluation study, we found those women with anoka were much more likely to be hospitalized, much more likely to have heart failure, much more likely to have cardiac events. And we found that link again specifically related to heart failure. And now we're connecting anoko with this heart failure with preserved Egypt ejection fraction that they may be along the same pathway. So we are, I think we don't have an equivalent of erectile dysfunction, but I do think that women's symptoms, women are in touch with their bodies. And, and the reason I say that is not being biased being a woman myself, but you know, every month, after whatever age people have menarche, we know our bodies, we know when we're going to have our period. We, we've sort of know our body changes and then it changes again. And so we're in tune with our bodies much more than men. And we know when something's wrong. And I don't think women waste their time in the emergency room or going to the doctor unless they, their symptoms are real. And we, what we have been doing as an injustice for women is discounting their symptoms, discounting their chest discomfort, their palpitations, their shortness of breath, and asking them frequently, are you anxious? Are you depressed? What's going on at home? We're all anxious, we're all tired, we're all probably have Some level of depression with life. But that is not why we're wasting time in the emergency room. People come to an emergency room or come to the doctor because they really have something wrong. And if a man came in with the exact same symptoms, we know he would get evaluated and his heart would be the thing that every doctor is thinking about first and foremost. And for women, it's almost you have to beg to get an EKG before somebody even thinks about your heart.
- [60:04]
Host
We're talking a lot about the difference between men and women. And what about heart attacks? Is there a difference between a woman, her symptoms of a heart attack versus a man?
- [60:16]
Dr. Martha Gulati
That's such a good question. I think that we have somehow misled women to think that they're so different than men, that sometimes when women are having symptoms of a heart attack, they don't think they're having a heart attack because they're somehow told it is different. We have contemporary research that has shown actually that 90% of women and 90% of men actually report chest pain or chest discomfort when they're having a heart attack. So in most people, that's present. But the difference between men and women is this. Women are more likely to have other accompanying symptoms. Chest pain may not be the most important symptom that they actually experience. They have it. But the question is whether us as physicians actually hear it. Because they may actually have more shortness of breath, they may have neck pain, jaw pain, back pain, they may have profound fatigue. I will tell you, women are more descriptive in their symptoms at a time of a heart attack than men. And we know this is true from a bunch of studies. Now, the Virgo study, which was women under the age of 55 who had a heart attack, we have the high stakes data which was the ones that brought us the high sensitivity cardiac troponin. So that was all age, men and women. And then we had this really interesting study called the Hermes study. And the M study used cardiolinguistic technology. So a type of AI it was really a computer that recorded every word that was said. As a doctor and the patients talked and it was men and women. And in that study, so interestingly, just like those other studies showed 90% of men and 90% of women did say the words chest pain or chest discomfort. It's again, though they did find that women had more accompanying symptoms, they were much more descriptive about what they experienced. So if someone's experiencing chest pain or chest pressure, and especially if they have cardiac risk factors, they should be evaluated for heart disease and they should be seen as quickly as possible. They should call 911. They should not delay. And if someone does not evaluate their heart before they leave that emergency room, they should ask, do you think I'm having a heart attack? Because at least then I think an emergency room team would ultimately say, okay, let's just make sure and get an EKG or get the blood work and not attribute those symptoms to stress or anxiety because we're all stressed, and especially when we're having chest discomfort, we're all anxious. But everybody, male or female, deserves to make sure the leading killer is not present.
- [62:54]
Host
Hopefully we're moving in the right direction. I mean, definitely with people like you who are advocating. And yet there are still areas where we're so far behind, particularly fitness. I mean, you walk. How many, how many miles do you walk or jog a day?
- [63:10]
Dr. Martha Gulati
Well, I walk three miles to work and three miles home, so I get always six miles. But I actually run my dogs beforehand before I go to work work, and I do resistance training before I can go to work. So I'm, I try to practice what I preach, maybe to a point of obsession. But I, I really think it is so important that, you know, some of the work that I did do showed that the more physically fit you are, the longer you live, independent of all your other cardiac risk factors. So it's an independent predictor of both cardiovascular mortality, dying from heart disease, or dying from any complex. So exercise is medicine.
- [63:47]
Host
I love that. I definitely believe that to be true. Have there been studies looking at the kind. For example, if someone is really busy and there's a lot of discussion on cardiovascular zone 2 versus high intensity, which actually came out of McMaster University and resistance training. How do you place them in order to of importance for men and women?
- [64:15]
Dr. Martha Gulati
Yeah, I think men and women both need a dose of both. They need aerobic activity and they need resistance training. And it's funny because men tend to be more likely to do resistance training and women, this is a generalization, but women tend to do more aerobic activity and are less likely to do resistance training. And we ever. Everybody needs a bit of both. Our current guidelines all over the world are exactly the same for men and women. It's 150 minutes a day of moderate to intense aerobic activity. And then we say that you need that much 150 minutes per week. And then you need at least two 20 minute intervals of resistance training. So that's a generalization because we know activity is good for you. But I do think that we are Learning more about differences between men and women. And some of the work that we published last year really showed that actually women, for once, we had good news for women, that women. Women got more. Well, they got more bang for their buck. If they did the same amount of exercise as a man, they actually reduced their cardiovascular. Their risk of cardiovascular vas. Vascular death more so than men, and also reduce their risk of dying from any cause more so than men. And so, you know, men really needed to do more activity. And that was true both for resistance training as well as aerobic activity. So maybe women get more out of exercise, and maybe one day we'll have guidelines that say women need to get away with less. The most important thing, though, is that women do exercise and that right now we know that men, at every age there's more, men do regular activity, and women, as we age, we start doing less. And what we need to do is try to build it in at the youngest ages, because if it becomes habit. I think one of my recommendations is like, school should teach and equip our children for their future adulthood. Yes, team sports are great, but you're not always going to have a team. So those of you who played on a soccer team or football team, what do you do after you leave high school or leave, you know, when you in college, maybe you have intramural sports and you find teams to play with. We all need to have an ability to find activities that we love that bring us joy, that we can do alone, too. It's nice if you have other people you can play with, but if you can do it yourself, you're more likely to do it and you do it on your own schedule. And that's what we need to equip everybody with a little bit of training in resistance training and aerobic activity. And when I think of my school and I grew up in Canada, I don't know if it's different in the United States, but I remember even when I played on the soccer team, the men's soccer team would go into the weight room and train partially there. We never were invited into the weight room. And most of our training was running around the track so that we could run after the ball. So they just wanted us to get faster. But nobody ever talked to us about strength training. And I feel like this is something I acquired quite late in age, where I suddenly started seeing the benefit of resistance training, even for my own research work. And then I was like, I gotta start learning how to do this. And at quite a later age, I started picking up Weights, and not that it has to be weights. People can find many different types of resistance training. But that for me is a new thing that I do every day now because I love it, but I wish I had learned it before.
- [68:03]
Host
Is there a difference? Difference from a cardiovascular standpoint, and that's a really broad question. From endurance training or cardiovascular training versus strength training. In my mind, when I think of zone two training, I'm thinking of continuous moderate activity where your heart is pumping continuously versus strength training. It's a spike and then a relax. The long term outcomes. Do we know the difference in cardiovascular impact?
- [68:36]
Dr. Martha Gulati
No, we just know. Really right now from big population studies like the one we did is we know that in terms of cardiovascular mortality there's a reduction. We don't know, we don't have enough data to say what even enough about all the different types of things that constitute resistance training. So there can be if course you can do things like heavy weights or even small weights. But you know, a resistance training is also things like Pilates or yoga and people can do those intensely or not so intensely. When we study from a survey the way that we did, we didn't get to ask, you know, more than that. And so we have small studies where people have done, you know, studies of 20 people doing weightlifting or 20 people doing different types of resistance training. But all we learn about that from that is like the hemodynamic changes, not so much what exactly is changing in the cardiovascular system and how, you know, is there one type of activity that's better than another or is even the duration? I would say we've kind of made up the duration.
- [69:48]
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- [71:16]
Host
Hopefully we will begin to get better at the recommendations again. It's very difficult to make generalized recommendations for entire populations. Yeah, it's the best we can do. Which leads me to this idea of the traditional fitness formula, 220 minus age.
- [71:34]
Dr. Martha Gulati
Oh, that's your heart rate formula.
- [71:36]
Host
What did I say?
- [71:37]
Dr. Martha Gulati
Oh, fitness formula. We have a, we even have a fitness formula.
- [71:40]
Host
But yeah, tell me, is this inadequate for women?
- [71:47]
Dr. Martha Gulati
Yeah. So if anybody on who's listening is ever interested, you can actually find the paper that described 220 minus your age. And the 220 minus your age wasn't even a good formula for men. And it was, if you look at it though, they used five studies of men who were preparing for the army. So they were at the VA and we used to put these men on treadmill stress tests and that's where we learned a lot about normal physiology. But these were young men, right, going off to the army or Navy. Or Navy, yeah. I don't know at the va. Who is it? Everybody. I'm too Canadian to actually fully know, but there were all these studies done at the VA and so they learned a lot about men. But even that formula, they just said most people would fit in this formula. And the person who described that formula never thought that this formula was going to be the most used formula. It's the most used formula in medicine and it's the most used formula actually by lay people because we use it. Many people use it when they exercise. Or if you're like me and you wear a smartwatch and you follow your heart rate when you exercise, when it's telling you you're in the zone. If you use a garment or an apple and you're trying to achieve it, it's all based on that silly formula of 220 minus your age. And for women at least we know that that formula is inaccurate. So I was really fortunate. When I was just finishing my training, I fell into this study called the Women Take Heart Project. And it was a study of just under 6,000 women in the Chicagoland area. We put them all on a treadmill, sort of like the Veteran Men, but they weren't veterans and they, they exercised for us using the same protocol that we had used in those older studies. And we found from that, again, we created our own formula. It's not sexy and it's not easy to remember, but Our formula is 206 minus 0.88 times your age, which I know nobody will remember.
- [73:48]
Host
Are you kidding? Everybody listening is going to remember that. This is, I guarantee you this is the first time that team. Have you heard this, Julia? Matt. Is Matt here? Producer. We've never heard that. And we've never heard it. This is our third year on the show and again, we only select the very best. The best. We've never heard that.
- [74:09]
Dr. Martha Gulati
Yeah, well, we, we need to be using formulas that fit for women because it's important we know that. Of course there's not. When you, whenever you make up these equations, there's some people that are above that number and some people below that number. And it's really a mathematical regression equation that you've created out of a large population so you don't get too worried when people are off. You know, when people are like, my heart rate is 10 beats higher than what it said by the formula. I always tell people, like, how did you feel? How, how was the exercise? You know, that can tell us a lot. The talk test can simply tell us if you're in the right zone of training, depending on what you were trying to achieve. But it's a way to say for a population where your heart rate should be. And it is. This is part one of one is such example of why we need to study women rather than just apply formulas based on men and say women are just small men. We are physiologically different and there is going to be differences in how we respond to exercise.
- [75:12]
Host
It is. I have to pause and think about this. I believe that to be true and I'm grateful to have you say that because right now, with the tools that we have so much in exercise science, from what I see, I struggle to see really well designed studies that show this training is sex specific. And I do believe eventually we'll see that. But even through the lens of something so simple as this, you know, equation, even the analysis of that data of, you know, looking at endurance or heart rate activity is probably going to be, have done through this lens of 220 minutes your age. And I understand, I'm not saying that this makes or changes huge numbers. Again, I don't know. But the fact that it's wrong is a, is a problem. And to the Other thing that you are saying, the other sentiment is that we're clearly different. We might not have the data yet to prove exactly how or how that translates. You know, I just think from a, a resistance training standpoint, a well designed program is going to be a well designed program. But there are probably things that we're not considering that we just don't know yet.
- [76:39]
Dr. Martha Gulati
Absolutely. And I think we, we aren't always. We shouldn't assume everyone knows everything about us. I mean, this is, I don't know.
- [76:47]
Host
My mom does, so she told me, she's told me for many years.
- [76:51]
Dr. Martha Gulati
Yeah, no, we, the research, you know, that's why we do research and that's why science is so exciting and why medicine's so exciting. Exciting because we don't know everything. And that's why we should ask questions about even the data that we use as physicians. Who was it based on? Where did this come from? What ages of people were in there? Did they include people like me, a woman, me, a South Asian woman, walks a lot.
- [77:19]
Host
But you know, every on time, everybody.
- [77:22]
Dr. Martha Gulati
We should know this about it. And I think, think it's the burden a little bit is on obviously us as a medical community to say who does this data apply to? Because our patients don't always know these things and we can debate them in the medical community, but then whether it gets translated to our patients is a completely different question. But I think that there's a lot of things we don't know still. And that's what makes medicine fun. Because every day there's discoveries, there's new drugs, there's new techniques, new interventions, new devices. And we're learning because, you know, not everyone, even when we talk about working out, everyone works out a little different. Everyone's resting heart rate starts out at a different place. If you're somebody who exercises a lot, probably your resting heart rate is a lot lower than somebody who doesn't exercise very often. So even you have to take those caveats even when you make these formulas. But you know, when we make these smart devices and you know what happens is that a lot of patients will come in because they're concerned about what their device is saying. They feel fine, but the device is telling them they should be tired or you're not working out in your zone, or you are, you know, you should back down because your heart rate's too high or whatever the thing is. And these devices that we wear and as smart as they are, have not all been tested. In fact, very few of them have been tested for Accuracy. So I also like devices because they. I like. We all like getting feedback, right?
- [78:58]
Host
But no, I don't wear one because it's going to say your sleep sucks. And I. Yeah, I know that.
- [79:05]
Dr. Martha Gulati
Well, when we have these things though, people should know that very few of them have actually been assessed for accuracy. So they're marketing them to you. But whether they're accurate or not is a complete different question. So don't get too bothered by them. If you're someone who loves the feedback and if there is something concerning, bring it to your physician because they might decide you actually need a more accurate assessment of whatever problem has been identified.
- [79:32]
Host
I have to point something out in. On this podcast we bring in a true trailblazers. Do you know Abe Morgenthaler?
- [79:43]
Dr. Martha Gulati
Nope.
- [79:44]
Host
So Abe Morgenthaler was a Harvard trained urologist for 40 years. They were castrating men because of this idea that testosterone caused prostate cancer. Somehow he figured out, he questioned the status quo. Everyone called him crazy. He went down to the basement of Harvard, he pulled out this paper that was with one person and he proved that it was wrong. One of our last podcast guests, Dr. Larry Lipschultz, another urologist. We joke. I have the number one men's health podcast.
- [80:22]
Dr. Martha Gulati
Just kidding.
- [80:22]
Host
But he was the guy who innovated the field of male infertility. And now I have Martha Gulati on here. And for some reason you thought to say, you know what, we're defining normal with this St. James women take Heart cohort, right? This idea that my metabolic equivalent is the same as my husband's, which is everybody's using 220 minus their age. We said, you know, I don't think that that is right. Was there a reason? Did you have a feeling? It's very unusual for individuals especially trained in the traditional medical system to make such innovations in a moment.
- [81:13]
Dr. Martha Gulati
Well, the reason I asked the question actually started with fitness level. And I came up with that formula for women too, from the same cohort of women. I remember right at the time where I was finishing my cardiology fellowship, we all supervised stress tests and I always knew women didn't go as long as men and their fitness level, because that's how you estimate someone's fitness level when you put them on a stress test. It was clear that there's a difference, partially because of our muscle mass, partially because we were a little bit shorter than men. And when you put them on a treadmill, sometimes it's more. If you're shorter, you don't have the leg spread to Go uphill as easily or it's just much harder, so you end up stopping sooner. So I knew that there was a difference. And I was wondering why in the guidelines there was just this one formula, and it was for men and women. So I went and pulled that paper. Where did it come from? Those same veteran men?
- [82:08]
Host
And I was like, you're not excited?
- [82:10]
Dr. Martha Gulati
I was like, okay, this is for men. What do we know about women? And so when I had the opportunity to take over the women take heart study and realizing they had all had a stress test, that was the first thing. I'm like, I am going to find out if their formula actually works. And I found it did not. And we published in the New England Journal of Medicine actually the formula for women for their fitness level. And then we validated that formula in a group of symptomatic women, showing that it by, if you were under your age predicted fitness level, you were more likely to die from cardiac causes. So that formula now we use in our stress labs and say, this is, you know, what percent of your age predicted fitness level. Then I asked the question actually about the heart rate. Second, I was like, okay, what about that formula? Is that even accurate in women? I think because I had always been in tune that women aren't exactly directly small men, that I wanted to know what we I, what I'd been taught, was it accurate? And I tell everybody that, you know, when I train medical students and residents and fellows like, question, where the data came from, go look sometimes, sometimes 20 years after we've been doing things and we think we're doing it right, and then we suddenly find out, you know, what, we weren't doing it right or we didn't know. And we assume. Assume. When you assume something, you know, there's that expression. But you should also, where did the data come from? Did it come from good, reliable data? Or is it something we can now study and make sure it's accurate? And especially whenever something's identical for men and women, I always teach my trainees ask, are you sure? Make sure it's true. Because the more when you look for sex differences, you often find that.
- [83:57]
Host
Do you think that that translates to dosing both again, dosing and exercise, dosing and medications. Because right now the majority of medical care is not, okay, so your dose of ezetimide is 10, but actually you're a woman, so your dose is 7.5.
- [84:18]
Dr. Martha Gulati
That's such a good point. And I actually think that that's important questions also that we need to ask. You know, when we think about medications, and if you remember in medical school we all learned, but you remember the pharmacology, they would tell us very clearly that medications, how they were metabolized, how they were absorbed, how they were excreted, was differed if you were a man versus a woman and even a pregnant woman. So all we always knew that there was some sort of difference. And yet when we study the drugs, they would put either all men in the study or clump it all together and not analyze if there was a difference between men and women. Women. So think about a common drug that we use for blood pressure. A lot of people might know this or be on it. It's called hydrochlorothiazide. But the problem is, is that when we use that medication, we are more likely to see electrolyte abnormalities in women than men. Why is that?
- [85:13]
Host
Do you know why?
- [85:14]
Dr. Martha Gulati
Well, the distribution is greater for women at the same dose. And so. And it's excreted slower in women. And so it's not surprising that women would have more electrolyte disturbances and as a result have more arrhythmias when they're potentially on that medication. And we should be aware of it. It doesn't mean we can't use the medication, but we need to be aware of those sex differences. Similarly, beta blockers we use a lot for hypertension and also for heart failure and coronary disease. But for women at the same dose, blood pressure drops more, heart rate drops more. We should be aware of those things when we use drugs because then we might understand why women have more side effects than men. And some drugs, we don't have any differences. But you know, we need to find out, we need to study and we need to include women and men in the studies, analyze it by sex so that we really understand is there a difference? Because a lot of drugs, and this isn't just true of cardiac drug drugs, this is true of drugs for every organ system that there potentially could be a difference in how they are metabolized, how they are absorbed, how they are excreted. That might change how long they last in the body and their side effects and dosing. We know even for some of the drugs that we commonly use in heart failure, like ACE inhibitors, women get full effects at lower dose doses compared with men. And that may be why at higher doses we don't need for women, but we've never written any of our guidelines to date have said different doses by sex. And so that's what we need to be looking at in the future. I won't say we're there yet, but I, I will say that, you know, we need, we certainly need to be looking and we are working with our pharma colleagues because we have been pushing them to be more inclusive when they are doing new drug trials, to get more women into trials to make sure that it's representative of our diverse population so that we really know that the drugs work in the people that we care for.
- [87:25]
Host
Very so informative and just really important work. You also mentioned something before we were recording that I had never heard about before. And this is really the environmental impact on cardiovascular health. We spoke a lot about soft plaque as this. Would you say it's an inflammatory agent or process that is happening?
- [87:53]
Dr. Martha Gulati
It is.
- [87:53]
Host
Okay. Soft plaque is driven by poor lifestyle, correct?
- [88:00]
Dr. Martha Gulati
Correct.
- [88:01]
Host
So sedentary behavior, being obese, smoking those.
- [88:08]
Dr. Martha Gulati
Diabetes, high cholesterol, high blood pressure, stress, whether that it's emotional or physical stress can at least accelerate the process when you do have underlying disease process or inflammation in your body.
- [88:24]
Host
And it's safe to say that, that the soft plaque is the outcome, all of these inputs, the soft plaque is the outcome. Right.
- [88:33]
Dr. Martha Gulati
Soft plaque or rupturing of that plaque.
- [88:35]
Host
And I'm going somewhere with this. Those are known entities. We know that if you are overweight or you're smoking or you're eating a crappy diet, that you are increasing inflammation. But one of the things that we don't think about is the environmental influence. We think a lot about the environmental influence on our brain. Am I exposed to mold? Is this heavy metal in my bone? Very rarely. At least I don't think much about it. I think about it in the lungs. I don't think about the environmental impact specifically on cardiovascular tissue or the influence on soft plaque.
- [89:17]
Dr. Martha Gulati
Yeah, I think we need to be thinking more about the environment and its association with cardiovascular disease, particularly with plaque and plaque rupture. We know that if you are living in certain geographical areas where there is higher pollution, that there is more heart disease. We know that after forest fires like the fires we experienced in Los Angeles, that again, there is more heart disease disease than was preceding a forest fire, especially when it occurs in a big city. And there's some. There's studies that are going on right now to really examine that after the LA fires. So we know that environmental pollution is a big risk and we need to be able to capture it. We know from big population studies when we look at zip codes and we see these differences, the EPA actually can gives out what Dale daily exposures are based on Your zip code. And so we, you know, one of the things I talked about earlier with you was how our new risk score does actually have your zip code. And so if you plug in, if, if you're plugging in your prevent risk score and you plug in your zip code, your zip code represents a lot of things, one of which is the pollution that is in our environment. And pollution, you know, we're learning a lot more about it. I, I will still say we have a long way to go to fully understand the pollution effects, but there is the environmental pollution that maybe sometimes you can see, like on a Somagi day in Los Angeles. We all know that it is. There's more pollutants in the air. And the reason that I think a lot of people notice those pollutants is because of breathing. We know people with asthma will have more trouble outside that day and people can almost see that haze. But you know, sometimes the invisible stuff, and we, we talked a lot about this during the LA fires actually, was that things, even when the sky cleared, even when the index that you would get on your phone would say that today was okay. But the part that it was not measuring is the plastics in the air. Because when things burnt, when all these houses burnt down in the air was released all kinds of kinds of toxins, including plastics, that we're probably going to be contending with for a long time, both in our water supply, in our oceans, to our, you know, wildlife, and in the ground that people are rebuilding their houses on. So we have a, we have a lot more to do about understanding it. There's just a paper actually this morning, I didn't even get a chance to read it, but I wasn't surprised by the headline, was that second sound pollution as well is harmful to the heart. And we know that there's all kinds of different pollutions that we need to be assessing and worrying about. Our environment has dramatically changed as we're all experiencing Climate change has affected the whole world. And that climate change is making places hotter, making natural disasters more. And again, even at those times when we have heat waves, we see higher risk of heart attacks. So there's a lot going on right now in our world that I don't think we fully understand. But I do think that there, we're working very closely now with environmental scientists. There's actually a great group here at Houston Methodist, actually looking very specifically at the environmental effects and cardiovascular disease. So they're doing some pretty exciting work right here in your backyard.
- [92:49]
Host
Well, I might be paying them a visit so I'll get those names and probably be wonderful to talk to them. You mentioned earlier that women are not small men. And when we think about cardiovascular health and disease, what is the difference between a woman's heart and a man's heart?
- [93:12]
Dr. Martha Gulati
Well, I mean, to begin with, they're smaller, so anatomy comically. You know, I tell everyone to make a fist, and usually that's kind of the representative sign of the size of your heart. So size matters. But of course, how we respond physiologically to insults differs if you're a woman compared to a man. And so, you know, when we talk about the disease processes that we see that are different between men and women, men are more likely to have those blockages in the coronary arteries that people hear about and seem to be familiar with, whereas women don't have those blockages, but have the small vessels react differently. And that's where the disease actually begins before they get blockages. That's that disease state that we had talked about called Unoka ischemia with no obstructive coronary arteries. And it's the small vessels that we can't see, but we can, can detect reduced blood flow to the heart by certain types of testing, like stress testing. Additionally, even the types of heart failure that we get are different. And there seems to be a difference in the response to stressors or the risk factors that make heart disease more likely. So if a woman has diabetes, for example, she is much more likely than a man with diabetes to develop heart disease. And we don't entirely know why. We know that there's more inflammation, but we don't understand exactly why is a woman's vasculature, why if you are a biological woman, you have a difference in response to being a diabetic than somebody who doesn't, somebody who's a, you know, a man. And that's not entirely clear. We see it even with smoking, so tobacco, you know, a woman smokes the same amount as a man and she will actually have more vascular damage than a man. So there's something about being a biological woman that sometimes these risk factors actually cause more damage and may change the underlying pathophysiology of the disease. We know, even though how women get treated, though, sometimes is different just simply because of our size. So when women get something called aortic stenosis almost at the same rate as men do, it's where the aortic valve gets very calcified and it needs to be replaced. For a long while, women were dying during surgery, so they were less likely to be offered surgery. But now we have a procedure called TAVR where it's a non invasive way or a less invasive way, I should say. It's not open heart surgery where we can replace that aortic valve. But who did they design that aortic valve on? Men. And so the size of it wasn't always fitting most women and that led to less women actually being eligible for a tavr. I will tell you though, the good news is in the last two years we've had some really big studies where they developed a smaller valve replacement that seemed to be the right size for more women. And we showed that women actually have really excellent outcomes. It's the same though, with all our devices. Sometimes we build the device based on a man and we don't even think about even the anatomical differences, the size differences between men and women. We're still figuring out though, a lot of the other things that are different or how sex specific risk factors affect the heart and why they're making women at a higher risk for heart disease. And I don't think we fully have all the answers right now.
- [96:52]
Host
Dr. Martha Gulati, with you on our team, I'm sure that we will continue to improve. And I just have to say I thank you from me personally and I know the audience, but really for all women.
- [97:08]
Sponsor
Thank you.
- [97:09]
Dr. Martha Gulati
Thank you. Such a pleasure to be here with you.
- [97:11]
Host
Heart disease is not just a man's disease and women are not just smaller men. Dr. Gulati's research proves that when we take sex specific science seriously, we can catch heart disease earlier, treat it better, and prevent more lives from being lost. So if you've ever had unexplained fatigue, chest pain, shortness of breath, or were told it's, quote, just anxiety, don't ignore it. Know the tests to ask for, know your risk and advocate for care that sees you fully. If this episode resonated, share it with a woman you love. Want more science backed tools for strength, longevity and prevention? Subscribe now and stay strong.