What very few people in the past realize is that there’s actually sex specific risk factors that just don’t occur in men. Because most research is done in men, it wasn’t focused on, and it wasn’t explored.
Heart disease in women is on the rise. Doctor Tara Sedlak joins us today to talk about women in heart health and gives us a better understanding of the urgency of gender, health and wellness.
I’m Andrea Gunraj from the Canadian Women’s Foundation.
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May 28 is International Day of Action for Women’s Health, so for the next few episodes, we’ll focus on pressing gender and health matters we may know bits and pieces of but probably need to learn more about.
Dr. Tara Sedlak joins us today to talk about women and heart health. She practices General Cardiology. She is the only certified Women’s Heart Health Cardiologist in Canada. She was awarded the Gold Medal for top graduate from the Doctor of Medicine Program and completed two specialist residencies at the University of British Columbia, where she twice served as Chief Medical Resident.
I was born and raised in Kelowna, BC, and then did most of my training in Vancouver, including my medicine, internal medicine, cardiology, and then, in my last year of cardiology, it became really apparent to me that we needed somebody with an interest in women’s heart health. So I sought out a fellowship, and I went down to California, and trained at Cedar Sinai Hospital, probably the preeminent women’s heart health leader worldwide, Dr. Noel Bairey Merz, and I trained with her for a year, and I did research and education with her for a year and then came back.
The idea behind me coming back to Vancouver was really to try and mimic what they had really done very well in California, which is a very large women’s heart Health Center with the focus on education, and research, and advocacy and we did that. We started that 10 years ago at Vancouver General Hospital and we’ve had lots of great expansions and wins in that department.
What first drew you to issues in heart health and women?
I was in clinic as a student, I was a cardiology resident. I was seeing this patient who had recently been in the emergency department. Her whole story started a few weeks before, when she had actually called the ambulance because she’d been having some chest discomfort. And she was young, she was in her early forties, she had a history of some anxiety in the past, otherwise was fairly healthy, anyways, she was at home, had really severe, sort of what she described as crushing chest tightness and pain and she was highly concerned because it was lasting more than half an hour to an hour, so she called EMS. And the EMS came to her apartment, and within minutes, they sort of made a deduction that she was having a panic attack. And they said to her, you know, we’re the experts and we’re telling you, you’re having a panic attack, go take an Ativan, go have a nap, so they didn’t bring her in.
Thankfully, hours later, just because she was so pervasive about this, and persistent about this, she was still having chest pain four or five hours later, severe, she recalled the ambulance, got a different crew, and they took her more seriously this time, brought her in, and of course the whole time she was having a serious heart attack and by then many, many hours in, she’d suffered a lot of heart muscle damage.
I sort of heard that story in clinic and you know this had all happened a few weeks beforehand. It was really profound to me about what she had to go through, and she certainly wasn’t the first story I’d heard like that, but was one of the more profound stories. And so, I just thought, you know, we need somebody who really takes these things seriously, who researches what are the symptoms and signs in women, what are the types of heart attacks they can experience, and really start sort of an advocacy campaign to really get word out there to EMS, to emerge physicians, to GP’s, to cardiologists, to internists, the lay public about, you know, this is what you need to do for your heart health.
What are the heart issues that women uniquely experience?
The way I think about it, is different stages in a woman’s life, and what kinds of things they should focus on, and what kinds of things they might experience. If we can start with the younger woman who maybe is experiencing pregnancy, or who has had prior pregnancies, or just wants to look at risk factors in their health, things that we’ve really focused on in research in the last five to 10 years is sex specific risk factors in women.
What I mean by that is we’re all aware that, you know, smoking, diabetes, high cholesterol, high blood pressure are all risk factors for both men and women. However, I think what very few people in the past realize is that there’s actually sex specific risk factors that just don’t occur in men. Because most research is done in men, it wasn’t focused on, and it wasn’t explored.
So, in a pregnant woman would be high blood pressure during pregnancy. That alone can double your risk of future cardiovascular disease. Gestational diabetes, where you develop diabetes just in pregnancy but then don’t necessarily go on to develop it long term, that again can heighten your risk. Even premature births, significantly premature birth and other entities that can happen during pregnancy, it’s kind of a window into what could happen to a woman later on.
Other risk factors that people didn’t recognize in the past, but now it’s well recognized, are hormonal changes. So outside of pregnancy, if a woman has a condition called PCOS, which is ovarian cysts and can sometimes go along with hormonal changes, and they can have impaired fasting sugars, and metabolic syndrome and other things, that entity, which is very common, can again, greatly increased the risk of a woman having a future cardiovascular event or future cardiovascular disease.
So I’ve heard that menopause is a factor to consider, but I’ve also heard people saying that the research has been limited about it in the past. What do we need to know?
You know the average age in Canada of menopause is 51. Premature menopause, really premature menopause, is considered more before the age of 40. That definitely is associated with an increased risk of cardiovascular disease, but even having premature menopause, not even that extreme, can be a risk factor. And you obviously may not be able to change those risk factors per se, but just knowing that you’re at increased risk and that you should be checked out. And that some of the modifiable risk factors like high cholesterol and hypertension or high blood pressure, diabetes, you might take them more seriously at a younger age if you were showing trends towards that, you might get into more of an exercise program or change your diet at a younger age, just because you know that you could be at increased risk.
And how about heart issues for middle-aged women?
In the middle-aged woman, we are actually finding that women can of course, just like men, they can suffer straightforward heart attacks where you know you have some heart muscle damage due to an event and it’s due to a blockage in the arteries. So-called atherosclerosis, which is where there’s plaque in the arteries and blockages.
But in women, about 10% of the time, when a woman experiences a heart attack and this is much, much less in men, it’s sort of two or three percent in men, they actually do an angiogram, which is where we put a camera right up inside the artery, put dye in, and actually have a look for blockages. It turns out their arteries are completely normal, not a hint of plaque, blockage, nothing. And we knew about these for years, but we used to kind of not know what it was. We would just say, well geez, you had some heart muscle damage, it looked like you had a heart attack, there was no blockage in the arteries, you must be good, we won’t send you home on any medication and hopefully this will never happen again.
But it turns out now that we do know the causes, most of the causes. So, for example, a woman can actually have a tear in the lining of the blood vessel, an entity called a dissection, and because it can happen abruptly and spontaneously, we call it spontaneous coronary artery dissection, or SCAD, and we’re recognizing more and more that that can happen in young people, it can happen in perimenopausal women can happen in postpartum. Because it’s such a tiny tear, if you’re just putting dye in and looking for big blockages, it’ll be missed. So, a lot of the time these women were told everything was fine and when in fact they would have a recurrent event.
It can be due to spasm of the arteries, so the artery can start off completely normal, a large normal artery, and then under a certain event can actually spasm down, just like a charlie horse where it becomes tight, tight, tight and then can open back up again. And of course, if you, you know, have the procedure done many hours or days after the event, by then it’s opened back up again, and you don’t sort of see anything, and we don’t really know the cause.
Then finally, we know that in women, it’s not only the large blood vessels we need to look at, it’s actually the small micro blood vessels. So, we already have smaller sized vessels and those can become dysfunctional over time, they can become blocked, they can spasm, they can become tight, the blood flow in them can become abnormal, and all of those changes can lead to heart attacks or chest pain in women or a lack of blood supply to the heart. We now know that those entities are more common than we recognized in the past.
And that, you know, if a woman suffers a heart attack and is told everything is fine, let’s look for some of these other causes because there actually is treatment and there’s ways to prevent another cause, and that type of thing.
Actually, in the older women, we are now recognizing that women tend to suffer more from a type of heart failure longer term, the heart doesn’t function well, and blood backs up into the lungs and the legs, and you can get short of breath, and you can get edema, and swelling, and that type of thing. We know in men that typically is due to a problem with the pumping function of the heart, where the squeeze of the heart is very poor, and they can’t sort of output enough forward and everything backs up. Well, in women for the longest time they were experiencing these symptoms and yet they were told that the actual squeeze of the heart was normal. And we actually now know that that’s due to impaired relaxation of the heart, the heart can actually still squeeze fine, but it can’t relax. It’s stiff and then because it’s so stiff, then blood backs up into the lungs and into the legs.
For the longest time, we sort of knew that something like that was occurring. We were kind of unsure about how to diagnose it and now we’ve got lots of new tools to diagnose it. And we actually have new therapy. All the therapy was directed towards the pumping function problem and we would just sort of throw our hands up and say, well, you’re unlucky because you have the stiffness problem.
You can see in all different realms of life there’s different risk factors and different things that occur, and a lot of them can be quite sex specific.
What do you see changing in heart health research lately? Are things changing for the better?
There’s so many things that need to be done in women’s heart health. What I would say is over the past 10 years, there’s definitely been changes. At a very high level, we have created across Canada, a Women’s Heart Health Alliance, an alliance of women, and some of them are women with lived experience, so women whose patients, who have had suffered an event or who have heart disease, some are allied healthcare workers, so nurses, nurse practitioners, physiotherapists, dietitians, and some of them are cardiologists, GPs, internists, etc., and then, of course, researchers. There’s over 100 of us, which is really exciting, from all provinces, that have said, you know, this is something we need to look at, we need to meet regularly and we need to look at all the different ways in different provinces, but also as a nation, how we can advocate for women’s heart health, how we can increase the research output for women specifically because there’s always been a gap with regard to women, and then how we can increase education.
There’s a whole education group within the alliance. They’ve done a lot of amazing work. In particular, they’ve brought a new curriculum to medical school. We used to sort of just talk about heart disease just in general and because most of it was studied in men, it would just be sort of male heart disease. But now we’re saying no, we need to actually have curriculum in medical school that says this is this is very important. Now it’s being instilled into medical schools across Canada.
We’ve actually tried to bring this into high schools. So, it’s really, really preliminary. But what we said is let’s not just start with medical school, let’s actually go back to high school and high school biology and say, you know, it’s all important that we learn about the circulatory system, but FYI, you know the circulatory system is a bit different in women and men, and these are the differences. We’ve had a huge uptake, with that, teachers all across county are really excited, you know.
Advocacy, that’s really my area of expertise. I led the advocacy committee for many years. We have led what’s called the Wear Red Canada campaign. We chose February 13th because it’s the day before Valentine’s Day. We make it all about women’s heart health and it’s a big day where we have, lots of lectures, CME, women wearing red or men wearing red or kids wearing red, trying to highlight women’s heart health. We now have lots of social media campaigns where we’re out getting the message out and of course, February being heart health month, you know is all very much in fit. And we work a lot with Heart and Stroke, who does a lot of campaigns already in February, and so it ends up just being this really great month of advocacy and education.
And where do we need to go from here for women’s heart health?
Number one, we still need more people who are interested in women’s heart health, even though there’s a hundred of us across Canada, that’s not very many when you think of how many people are involved in cardiology and cardiac health, and the more women’s heart health centers, the better.
I’m the director of the Leslie Diamond Women’s Heart Health Clinic, which is unique to BC. We see a lot of women with heart disease or women who are at risk for heart disease, but we’re one of the only few across Canada, and so we’d like to have several in every province, so that women don’t need to travel all the way to BC for advice.
We really need to get more women with lived experience involved in research and then also more researchers in women and heart disease. But we’ve definitely made some strides. For example, both Heart and Stroke and CIHR, which is our main research sort of organization from a Canadian standpoint, when they now look at a grant, they now expect that you have talked about sex and gender in your grant. That is a big change. We need to see more of that. We need to see more research specific to women or on the gender disparities and gender differences.
And then, of course, in the education capacity, you know, we’re now in high schools too, to a small degree, we’re in medical schools, which is great, but we just sort of need to expand that and even really like to get into the education for emergency room doctors and education for internists, and like at all levels just to say, hey, these are the differences, these are the highlights, you know, this is the stuff that you should be looking at.
Alright, now what? Check out wearredcanada.ca to learn more. It addresses things like why women’s hearts are different, how women’s symptoms can be different, how women test differently, and how women can get treated differently. And stay tuned for more episodes on pressing gender and health matters today.
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