Women’s Heart Health: How Heart Attacks and Disease Present Differently in Women
Heart disease is the leading cause of death for women in the United States, yet many women don’t know it or talk about it. Inna Nelipovich, MD, discusses how Maimonides is trying to spread heart health awareness among women.
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Caitlin Whyte (Host): Heart disease is the leading cause of death for women in the United States. Yet many women don’t know it or don’t talk about it. But here at Maimonides, we’re trying to change that. Leading this effort is Dr. Inna Nelipovich, a Clinical Cardiologist, and the Director of Women’s Heart Care at Maimonides. This is my mom Med talk. I’m your host, Caitlin White. So Doctor, to start us off this episode today, what is your specialty and what kind of patients do you see?
Inna Nelipovich, MD (Guest): So my specialties are a noninvasive clinical cardiologist. I do mostly office-based practice. I also consult as a part of my job patients who are acutely ill in the hospital. I’m part of the faculty practice. So we do a little bit of everything, including non-invasive testing, echocardiography, stress tests, event monitors. We deal with all sorts of heart issues, basically anything that has to do with circulation and heart. That’s what we take care of.
Host: Wonderful. So as the Director of the Women’s Heart Care Center, obviously you see plenty of more women. So how is treating heart conditions different between men versus women and what kind of symptoms appear in women? Specifically, that commonly get ignored?
Dr. Nelipovich: So I think it’s best if we start off by talking why is heart disease different than women than in men. I think it has to do with sort of historical bias towards women. And the bias has to do with the fact that women, were not included in as many clinical research studies in the past, as they are now. There is a move towards that now, and women’s care was not accounted for all the different stages of reproductive cycle. Women have an advantage. They have this hormone called estrogen.
It does affect how we approach cardiovascular disease in women, because the ffect of estrogen on the cardiovascular system is significant. It goes beyond that though. It goes beyond hormones. Women’s heart disease, varies during her different stages of her reproductive cycle at at different age groups. And so, what’s important and what’s relevant to somebody who is pregnant is different for somebody who is post-menopausal. We take care, all these women. And a part of my practice, I see a lot of high risk OB patients, as well as women who are postmenopausal. And even to address their cardiovascular risk factors. One of the problems with women’s heart care, is there are multiple layers of biases that are built into the care of the woman.
Sometimes it’s a bias on the side of the women themselves, and sometimes it’s a bias on the side of the care providers.
Host: Now, that’s an interesting point. You’re listing all these variables in women’s care that might not occur in every provider or patient.
Dr. Nelipovich: First of all, women present with a heart disease, acute heart attack later in life. And this has to do something with the effect of the hormones in the woman’s body. Once a woman is post-menopausal and the effect of estrogen is gradually withdrawn, women develop heart disease at about the same rate as men.
And what’s interesting is the trends for overall mortality from cardiovascular disease, over the years has been coming down, but the trend of the overall mortality for younger women has been rising. And this is an alarming trend. There has to be something missing in terms of whether we’re not recognizing or not diagnosing women early enough and not enough prevention is been done for this trend to go down as well as the other trends.
Host: So what would you see as a priority in women’s healthcare?
Dr. Nelipovich: Heart disease awareness is very, very important. I hope, that eventually we can do as good of a job, about heart disease awareness as there is about breast cancer awareness. I know there were studies done in the past and more women think they would die of breast cancer and not heart disease. But in fact, statistics don’t lie. One in four women will die of cardiovascular disease. And only a small percent of women will die of breast cancer. So, we need to do a better public awareness campaign. It’s a part of it.
Host: You’ve mentioned the role of bias in cardiac care for women. Can you talk more about that
Dr. Nelipovich: What’s also interesting is women present differently with cardiovascular risk factors and this has to do with the perception bias.
It’s both a necessity that the woman may not be aware that what she’s having is actually symptoms of coronary artery disease or heart disease, and may not complain about it to seek care early enough. What’s also alarming is the doctor or physician who is treating this woman may not recognize it early enough to be those symptoms.
Host: And can you speak more on how symptoms might show up differently in female patients?
Dr. Nelipovich: So classic symptoms of crushing chest discomfort in the middle of the chest may not be the symptoms that a woman would come to see you in the office. It could be completely different. When I do this educational lectures, I actually have a little poster that shows, well, you know, where are your symptoms? So women most often do not present with chest discomfort or chest pain.
And then when I asked these woman, all what are you feeling to say? Well, I feel something heavy in my chest, but it’s not chest pain. So I have to ask, well, what about neck pain? What about jaw pain? You know, this classic chest discomfort and left arm pain, only a small percent of women may actually have it, but obviously, it’s alarming, you can’t ignore this. Women also complain of pain in the epigastric area. And a lot of times there’s a crossover where a woman may be presenting with a heart attack, but she’s describing not chest discomfort, but pain in he epigastrict area, the area where, where the stomach is. And she would be feeling what feels like, you know, pain in the stomach.
And since they, oh, don’t worry, it’s reflux. It may not be reflux at all. It may be having a heart attack. Some women present with just arm pain and it could be on both sides, both arms. Some women present with pain that goes to the back and pain around their neck and jaw. And some women may not have chest pain at all or any kind of chest discomfort.
It could be having dizziness and rapid heartbeat. It could be difficulty breathing. In fact, more than 50% of the women are complain of difficulty breathing, shortness of breath, a lot of time with physical activity, but it may not be physical activity, but it may be major stress, major emotional stress is something that makes them very upset, will bring on this discomfort, this shortness of breath. Nausea could be a presenting symptom of a heart attack as well, pain in the back and not the pain in the front in the chest, may be a presenting symptom, sweating, dizziness. All of those things have to be accounted for. So whatever it is that a person is feeling, it has to be addressed, but you have to have a high index of suspicion that this is a cardiovascular issue because there’s so much overlap with the lung disease, overlap with the diseases of the GI system, gatrointestinal things like reflux. You know, I have a good number of patients who are getting referred to the ER for what they think is a bad heartburn, it may be a heart attack in fact. You know, so there may be a delay in when the person takes care of, they don’t think that their symptoms so heart a attack. You know, also there is a delay that whoever is seeing the person, you know, the in the medical office or, and in the ER may not recognize that this is in fact a heart attack.
So that’s a big one. And also, there’s also slightly different bias, you know, well you’re young woman, you shouldn’t be having a heart attack at your age. But in fact, we know that the cardiovascular mortality in young women is much higher and there is an alarming study from a few years ago that published that you know, in older women in their sixties and seventies were more aware of having heart attack symptoms than the women in their forties and fifties, you know, but in fact, we know that women in forties and fifties may also be at risk of a heart attack, especially diabetic women. There is also a recent study of cessation of diabetes and early onset of heart disease in these women, what’s interesting about diabetics in general, a lot of the diabetic patients are not having chest pain symptoms.
Host: So with all those studies you just cited, what do you see as the most dire threats against women’s health and what trends are you seeing?
Dr. Nelipovich: Mm. I mean, I, I think, I think diabetes and smoking in terms of the two big things that women have to be very aware of. Those are the two things that increase the risk of cardiovascular disease by a significant amount. I also, you know, we won’t talk about certain things, but it only feels like there’s a war on women in general. So, a woman has to be very aware of what her risks factor are for all the different things and get care regularly. One of the things that has to be on, the woman itself is, you seeking regular medical care, making sure that she is not ignoring her own symptoms and she’s not ignoring her own health, because there’s a million other things that she’s taking care of on a daily basis, you know, taking care of the children, working, sometimes several jobs, taking care of the household, doing all these different things and then ignoring her own health. So I think, you know, women’s preventative care has to be prioritized and a woman’s awareness that these things have to be addressed early on, has to be prioritized. So I think it would be good if we had the better educational campaign about, you know, what are the risk factors for women? When should they seek care? And this is something that we’re doing in our Women’s Heart to Heart program.
Unfortunately, the pandemic put a little bit of damp into it because we cannot do as many in person meetings. But, you know, but one of the things that our Woman’s Heart to Heart program has been doing for years is going out into the communities and doing these educational programs for women and offering screening tests, including cholesterol screenings, high blood pressure screenings, screenings for certain types of cardiovascular disease.
So I think a threat is access to care. I think a threat is knowing what the risk factors are and in terms of medical conditions, so things that I know women could be doing, it’s the smoking. That’s one of the biggest risk factors and also someone who has a predisposition to diabetes or who have diabetes. Those are the biggest risk factors.
Host: Well, let’s talk about aging. How does heart stuff change as women age, like with perimenopause and menopause? How does that affect our hearts?
Dr. Nelipovich: You really have to think of a woman’s heart disease as a spectrum or progression because some of the cardiovascular risk factors are genetic and part of the screening that has to be done fairly early on in life. And sometimes if I see these women in their twenties would be something assessing their cardiovascular risk factors as early as their twenties, including family risk factors of premature heart disease. And this is a woman who would have a family member, you know, a relative by blood, her mother, her father, her grandparents, aunts, and uncles who present with heart attacks or strokes under the age of 65 years old.
And that has to be assessed early on. The other thing is looking at, other cardiovascular risk factors, family history of diabetes, family history of certain types of elevated cholesterol. Some of these things could be familial. And if you address these factors in the twenties, you know, by the time this woman reaches her forties, she may not be in this bad of a shape. have to think of risk factors that come on sometimes are revealed during the pregnancies because reproductive age is very, very important.
Host: Well, what about pregnancy? Why do heart issues sometimes emerge when a woman is pregnant?
Dr. Nelipovich: During the pregnancy a woman’s body undergoes a transformation. A part of this transformation is extra stress on the heart. Sometimes we talk about prognancy as being a type of a stress that’s on the heart.
This is when we start to see issues. Some of the heart valve issues. For example, such as mitral valve stenosis can be unrevealed during the pregnancy and also a woman may be assymptomatic and not even aware she has a heart valve issue. And it will reveal itself during her pregnancy. Another big risk factor that reveal itself initially during pregnancy is a diabetes. There is a very high association of gestational diabetes, something that, you know, a woman if she gets routine care with the OB doctor during her pregnancy, she will be tested for, but gestational diabetes increases risk of cardiovascular issues later on in life, significantly and developing regular diabetes later on in life.
Hypertension during pregnancy is a big deal and there is this medical condition called preeclampsia which is a combination of several different things, including elevated blood pressure, that usually develops after the 20 something weeks of pregnancy, that’s an increased cardiovascular risk factor later on in life, as well as a threat during the pregnancy.
There’s also the medical conditions that are much more, although they’re rare, they reveal themselves during pregnancy. There’s something called SCADs, spontaeous coronary artery dissection. And during pregnancy, a woman presenting with chest pain that has to be in the differential. And even though it’s a rare condition, it’s somewhat under-recognized.
So we were really worried about our pregnant patients when they come in with chest discomfort, you know, they have to be screened obviously. It shouldn’t be ignored just because she’s in her twenties and thirties, for example, or even early forties, you know, and this is during their reproductive age and later on in life after menopause, women develop heart disease, just like men do. There is a small delay in terms of how early an average woman who presents with a heart attack after her menopause, but really the risks are there. So as estrogen is withdrawn, it’s no longer protective and a woman can get heart attacks just like men do
Host: Well talk to us about the Women’s Heart to Heart Program here at Maimonides. Why is something like this necessary and how does it elevate you from other hospitals that see these kinds of patients?
Dr. Nelipovich: The Women’s Heart to Heart Program is a primarily educational program and it’s a screening program for women. We bring this education to the communities in Brooklyn. Part of what we do is we arrange lectures and we have been doing them on Zoom during the pandemic as well. It’s lectures about heart disease, educating women about cardiovascular risk factors, educating women about well and men too. I mean, when don’t exclude our men. We know it’s just, the program is primarily aimed at the heart disease awareness in women and we talk about cardiovascular risk factors. We talk about what needs to be done.
We talk a little bit about prevention, how to diagnose diabetes, hypertension. When we’re able to go out in the community, we bring our nurses with us. And part of what we do is we offer screening programs for cholesterol. We have been lucky to get a couple of grants from major Women’s organizations to screen women for cholesterol problems. We have been bringing carotid ultrasound screenings to some of these programs to check if there is a presence of cholesterol plaques in the carotid arteries, these are big arteries that bring blood flow to the brain. And if there’s cholesterol plugs buildup in them, the women are at much higher risk of stroke. We have been doing echocardiographic screenings.
You know, unfortunately we can’t do during the pandemic because of the issues that have to do with social distancing, isolation. But overall, these are the programs, the very fact about bringing the information, material to the different communities in our area. We’ll also bring a couple of other experts besides heart disease experts, such as vascular surgeons, such as our dieticians to these programs.
And we do part of the, you know, most helpful part for the patients, what can they eat? What kind of food, should they eat to prevent heart disease from developing? We bring to some of these problems, we do in association with our breast center and we encourage screening mammograms. So it’s a big problem where we reach out to the community and we do provide the educational materials and screening tests to the community. And once in a while, we do catch some disease early on, which is very nice because then these are the patients who we wouldn’t have had contact with and patients who would not aware that they have a problem and can be addressed early you know, so they hopefully don’t come in with a heart attack or stroke in the 10 years down the line, five years down the line.
Host: Let’s move on to treatment. What are some of the options at Maimonides and what can patients expect from post-treatment life?
Dr. Nelipovich: Well, treatment really depends on the disease. Here at Maimonides, we do pretty much everything except the heart transplant itself, even though Maimonides was the first hospital in the United States to do a heart transplant, we no longer do heart transplants in Maimonides. It is, but we do everything to prepare a patient for heart transplant. We are number one in heart attack survival in our area. And Maimonides is a top cardiovascular hospital in our area as well. What, we do pretty much all of the heart surgeries that need to be done, including open heart surgery, such as coronary artery bypass surgery. We replace heart valves. We have a very successful transcatheter aortic valve replacement, also known as thr TAVR program. What our interventionalists, these are the people who come in and open a blood vessel during a heart attack, are probably one of the best in the country. We can do different types of mechanical support, including left ventricular assist devices.
These are the pumps that get implanted to the heart, when the heart no longer can pump normally, to bring a patient closer to the transplant, or even as a maintenance treatment, when the person cannot qualify, does not qualify for heart transplant and we have the extra corporeal oxygenation program also known as ECMO, you know, that became quite popular during the pandemic.
So we have all these different invasive options if they need to be done, but we’ll also have an excellent team of doctors, nurse practitioners, and nurses, and support staff that work really well together, including our cardiologists, our invasive and noninvasive cardiologists, and our surgeons. And we work as a team to get the patient, whatever they need. So it really, the treatment depends on the disease. We have quite a big group of doctors that are available to see patients, in our new patient pavilion and we try our best to prevent a person from having a major issue. However, if there is a heart attack or if there’s a heart valve issue or an arrhythmia that needs to be fixed, we also have a very good arrhythmia program here.
We include all different types of you know atrial fibrillation ablations, including hybrid ablation, which is one of the centers in the country, the premiere that, but overall, we have a good number of resources to address pretty much anything that comes our away and even get a person to heart transplant if necessary.
Host: Wonderful. Well, unfortunately the pandemic has of course affected our ability to do things like we used to. So how has the pandemic effected your ability to diagnose and treat patients? Have you seen an increase of severe heart conditions or other issues?
Dr. Nelipovich: Well, there is two different things that happened during the pandemic. The obvious thing is the closures that, for a while, prevented us from seeing patients physically in the office. So all of the usual followup and maintenance had to be postponed, in you know there is a plus to it, for a while we where able to do virtual visits. So at least we’re were able to check in with our patients and provide proper medication, some guidance, but obviously virtual visits can be an add on you know, and it’s much, much better to see a person in front of you and check their blood pressure and examine them and figure out what is going on. So pandemic delayed care for many of our patients, and I think we can speak about it throughout the country during different waves of the pandemic. It happened here in New York, it happened much quicker.
Also the hospital services for a while, or were stretched during the pandemic, a lot more sicker patients are coming in which not having necessarily cardiovascular issues, you know, but require intensive care and require all different types of support from the medical stuff. So, and there is also a delay on the part of the patients. What I noticed a lot of times, patients are afraid to come into the hospital and seek proper care and they are sitting on their symptoms and ignoring the symptoms or postponing coming into the doctor’s office at the fear of getting coronavirus, at the fear of the fact that they would have to stay in the hospital where there arre other patients who are ill with coronavirus.
You know, unfortunately, you know, that delay could be difference between life and death. What we’ll also have seen is there is a delay in terms of how quickly we can get to a patient to address the issues. The hospital have expanded their services, by a significant amount. And we are going out of our way that every patient who comes in for admission gets tested sometimes, multiple different tests, including PCRs to make sure that we do not have, separate our patients with coronavirus, from patients who do not have.
Keep in mind, coronavirus itself has produced a good number of cardiovascular complications that we’re aware of, including heart attacks, including strokes, including pulmonary embolism, including myocarditis and different types of arrhythmias because coronavirus itself is very versatile, unfortunately.
And I think one, you know, there’s many different obstacles the patient may be facing in the moment getting their proper care, but most important part, if someone is having symptoms, they should not be delaying in their care, because the sooner a patient is seen and the sooner they’re diagnosed properly, the faster that they can get the proper treatment and proper care.
And obviously one of the things that we’ll have to emphasize is necessity of vaccinations because the less people, sick people are coming in with coronavirus and needing hospital care, the better overall care we can provide to everybody else. I know including people who are coming in with heart attacks, because ICU availability is very, very important for somebody who is very, very ill, you know, and including people who are coming in and waiting longer time to be seen for chest pain.
And I’m not talking about our hospital. I’m talking about just medical care in general, in our country, you know, including getting into see the doctor in the office, getting those EKGs done if someone’s having cardiovascular issue. Many different ways. But I think there’s a delay, both in getting to the doctor, delay in recognizing or treating the symptoms.
And there’s also a delay in how quickly someone would connect with the proper care, you know, there are some parts of the country over here because they, right now they’re overwhelmed with the ill patients that some of the elective surgeries are getting postponed. This affects cardiovascular surgeries as well.
And that’s scary because we want to be able to provide proper care. Time with a heart and cardiovascular disease is very important. You know, and timing and addressing the symptoms as quick as possible is also very important. As we say, time is myocardium. Myocardium is the heart muscle. So we cannot postpone this type of a care and pandemic does make it more difficult.
So I want the patients to know that if they are having symptoms, they should not be postponing their care. They have to be going either to emergency room right away when they are having this discomfort, where they think may be heart disease related. They should, they have to be talking to their doctors even virtually, and it has to be high index of suspicion that you know cardiovascular disease did not go away just because there’s a pandemic. There’s just the delay and how quickly a person can get to get to get help.
Host: Well, Doctor, we’ve covered a lot here today, but wrapping up on a more personal note, why did you choose to work at Maimonides over any other hospital system?
Dr. Nelipovich: I like Maimonides because it’s a great community. It’s a great community of people who work together. People work here for years. We take care of each other. In general, our staff is very, very friendly. There is a lot of sort of, you know, this feel like you’re coming in, and this is your second family. I actually have been lucky. I have gone through medical school in the beginning of medical school, I ended up rotating through the cardiac unit. And many years later, these are the people who are my partners. These are the doctors that I’m still working with. You know, so it’s a blessing in terms of how good our medical team is, how friendly everybody is. And it’s a blessing because there’s this great community of people who have the same goals.
They work together to get the patients better. And I think what distinguishes Maimonides from other institutions is how we’ve work together as a group. And we’re talking about not just in here in cardiology, but also with our cardiovascular surgeons, with our arrhythmia specialists, with our our vascular surgeons.
And sometimes we’re just a quick phone call away to ask for help. So we work together. We’re not trying to work against each other.
Host: Beautiful, well, Doctor, thank you so much for your passion and your work, caring and advocating for women’s health.
To make an appointment with a heart specialist, call 718-478-2328. This has been Maimo MedTalk. I’m your host, Caitlin White. Stay well.