[Dr. Michael Konstan] Good afternoon everyone it's 12:00 so we're going to get started Welcome to our Cardi-OH webinar primary and secondary prevention of cardiovascular disease in women. I'm Dr Michael Konstan the principal investigator of the Ohio cardiovascular and diabetes Health collaborative also known as Cardi-OH and I'm joined by Dr Shari Bolen co-principal investigator of Cardi-OH. Founded in 2017 Cardi-OH’s mission is to improve cardiovascular and diabetes Health outcomes and eliminate disparities in Ohio's Medicaid population cardio brings together Ohio's seven medical schools to identify produce and disseminate evidence-based cardiovascular and diabetes best practices to Primary Care teams to learn more about the collaborative and to access our online repository of best practices please visit our website cardio. org and download our web app next slide.
I would like to acknowledge and thank our sponsor the Ohio Department of Medicaid and our administrative partner the Ohio colleges of medicine government Resource Center I would also like to recognize the partnership of Ohio's seven medical schools who contribute to make the cardio collaborative success Dr Bolen will now provide some Logistics regarding today's webinar.
[Dr. Shari Bolen] Thanks Mike good afternoon everyone just some brief Logistics um if you um are on Zoom if you could put your name as your first and last name so we can see who you are if you're joining as a group um please use the chat feature to record the names and emails of everyone that is with you at the group we want you to ask questions so please the Q&A feature to submit questions at any point and we'll answer those during the Q&A portion at the end of the webinar and we do want to hear um how we can make improvements in the future so there will be a survey afterward that we hope to have you fill out and share with us your thoughts on this webinar today.
These are our disclosures. Really no disclosures that affect this uh presentation if you are interested in CME when you registered um you clicked a button so that we would send you an email from cloud CME afterward within the next week if you didn't register um just make sure you use this QR code here to register and click that you want CME if you do want that. And with that I will introduce Dr Amy Zach who will be moderating today and we'll introduce our speaker but Dr Zach is a family medicine physician Vice chair of Education at Cleveland Clinic and faculty at the Case Western Reserve University School of Medicine she is um serves as the head of education and dissemination for cardio so thank you Dr Zach for moderating.
[Dr. Amy Zach] Thanks very much Shari um it's my pleasure today to introduce our speaker for our Statewide webinar Dr Leslie Cho is the director of the Cleveland Clinic women's Cardiovascular Center she is also section head of preventive Cardiology and Rehabilitation and the Chief quality officer in the department of cardiovascular medicine at the Cleveland Clinic she's a profess a professor of medicine at Cleveland Clinic learner School of Medicine um with Case Western Reserve University Medical School. Dr Cho is board-certified in Interventional Cardiology cardiovascular medicine and internal medicine she earned her medical degree at the University of Chicago completing residency at Johns Hopkins and fellowships in cardiology and Interventional Cardiology at the Cleveland Clinic. Dr Cho’s specialty interests include heart disease in women cardiovascular prevention microvascular disease and Hyper lipidemia. She has both been a researcher and a shaper of our national landscape in cardiovascular prevention and particularly in women through committee committee participation, publications presentations and talks like we have today so it's um our pleasure to introduce today Dr Leslie Cho.
[Dr. Lesli Cho] Well, thank you so much for having me and it's really my pleasure to be with all of you today to talk about something that's very near and dear to my heart which is primary and secondary prevention of cardiovascular disease in women and I'm so glad you're um you think this is an important topic because we think it's a crucial topic. And so these are objectives identify cardiovascular risk consideration unique to women. Talk about evidence-based patient education on prevention and risk management and screen and treat cardiovascular disease risk factor in women.
So let's get started so I don't have to tell you that the leading cause of death for both men and women is cardiovascular disease and so let's just dive right into it and talk about are there gender differences in risk factor, clinical manifestation, cardiac testing and treatment and an outcomes. So let's talk about risk factors obviously we know these risk factors these are drilled into our head even from Medical School hypertension, hyper lipidemia, diabetes, smoking and family history. But you know these risk factors while we know them they affect women and men very differently and so I'll show you some of the datas about hypertension.
So for example we know that women have hypertension women get hypertension later than men but when you look at the trajectory of blood pressure increase uh throughout their life that Delta change is much faster for women. The risk factor for women this is based on the nurses health study around 89,000 healthy women. The number one risk factor is BMI greater than 30 and of course not following the DASH diet physical inactivity and excessive alcohol for women that uh salt is really a four-letter word it's really important to maintain good body weight but also uh women are exquisitely salt sensitive. It's also important to uh understand hypertension and how the Circadian rhythm so for women especially postmenopausal women they're less likely to have nighttime uh dipping of blood pressure.
We know that that dipping actually is very important and because women are less likely to have uh the lowering of blood pressure in their sleep they're more likely to experience cardiovascular events at nighttime. The other unique thing about hypertension is of course fibromuscular dysplasia. 90% of women uh 90% of patients with fibromuscular dysplasia are women and if you look at fibromuscular dysplasia patients 75 to 80% of them have renal artery involvement it's really important to think about this diagnosis when you look when you see young women with hypertension. First line of treatment is medical therapy if resistant then we talk about intervention but really most patients are quite responsive to medical therapy and the time for diagnosis is in their 40s.
You know as I get older um the young age changes but 40 is the time for diagnosis is now we've seen as young as 30s with fibromuscular dysplasia having hypertension so it's important to think about it and keep it in your background. So hyper we talked about hypertension how women are non- dippers they're they have a increase in hypertension uh later on in their life especially after menopause. Let's talk about diabetes. 26 million people in the US with diabetes half of them are women women have higher rates of type two diabetes in their youth women with type 2 diabetes they don't have the protection of estrogen so they are actually um having heart disease at the same age as men in their 40s and then 50s and having diabetes for women is a particularly potent risk factor um and I'll show you the risk factor um for heart failure but it really is a potent risk factor for women.
So when you look at the meta analysis of 49 studies these are 5 million patients with diabetes it increases uh mortality CVD mortality heart disease mortality these are this is a really potent risk factor this is women compared to men so much higher risk if you are a woman with diabetes you're much more likely to have cardiovascular event. This is from the Stockholm heart epidemiology epidemiological study and when you are diabetic and you're a woman you're more likely to have nonfatal myocardial infarction. It's pretty sobering to look at these uh data if you're uh as you know many of you um in this audience are Family Medicine doctors you know that if you're a uh Hispanic or black uh baby girl born in America in 2020 your risk of having diabetes is 50%. That means 50% of those kids are at increased risk for having heart disease um for having non-fatal Mi and then of course having heart failure as well.
This is the UK biobank study looking at how diabetes increases the risk for heart failure in women it's around half a million uh patients follow up for nine years look at this hazard ratio. 1.73 higher rates of uh heart failure heart failure mortality is also increased um in women. Smoking in women is associated with half of all cardiovascular events it's actually a much more potent risk factor for heart attack in women than it is in men and it shows a strong causal relationship uh with stroke as well in women.
But are there unique risk factors and of course we wouldn't be having this talk if there weren't so the answer is yes and there are and this is a a paper that uh we published um in the American College of Cardiology looking at unique cardiovascular risk factor in women and those have to do with adverse pregnancy outcomes and I'll go through that with you. Autoimmune disorders um and so let's dive into sort of the unique risk factors.
They are preeclampsia or or hypertension during pregnancy, gestational diabetes, polycystic ovarian syndrome and early menopause and whether that early menopause is natural surgical or chemically induced as in the case of breast cancer early menopause you know there's a lot of controversy about 45, 40 but you know I think 45 is a reasonable number that increases your risk for having early having heart disease.
So let's look at the hypertensive disorders of pregnancy if you have hypertension forget preclampsia if you have hypertension during pregnancy and I and you know I mean even talking about the fourth trimester especially postpartum hypertension which we're learning a lot about if you have hypertension during pregnancy or postpartum you're at 2.3-fold increased risk for developing hypertension in your life. This is like a risk fact like a a stress test so you've flunked the stress test so you are at an increased risk for hypertension you're at 1.6-fold increased risk for having coronary artery disease and you're at 1.8-fold risk increase for having stroke.
It is an incredibly potent risk factor for developing cardiovascular disease later on in your life. Heart failure aortic stenosis risk for arhythmia and of course this incredibly potent risk factor for developing chronic kidney disease. Gestational diabetes again another potent risk factor if you have gestational diabetes you go on to develop diabetes but also hypertension ischemic heart disease as well.
And that is the reason why the American College of Obstetrics and Gynecology along with the American Heart Association and the American College of Cardiology considers these adverse pregnancy outcomes a potent risk factor and if you have that then you’re really should be screening these people um for heart disease and and it's not to start people on medications but it's really to get them on the right pathway um getting their medical history, doing a good physical exam, getting lab testing and really trying to uh change their um risk factor change their diet, and their lifestyle so that they don't develop hypertension so that they don't develop diabetes go on to have CKD um heart attack or heart failure.
Premature menopause of course as we know estrogen is a is a wonderful thing to have um unfortunately it's hard to replicate this um exogenously but estrogen withdrawal from the body there is an increase in blood pressure changes in your lipids you reduce your glucose tolerance there's a gain weight and of course there's a endothelial dysfunction component and vascular inflammation component. As uh the earlier the menopause as you know most women in America go through menopause at age 52 so earlier the menopause less than 40 increases your risk uh more than less than between 40 to 45 but early menopause actually is a very poent risk factor for having heart disease as well.
Other risk factors are PCOS and then of course autoimmune disease you know we think of autoimmune disease as something very gender neutral but it's actually not gender neutral it's mostly in women. And we think that actually things like mitro stenosis is a a form of autoimmune disease as well um and so autoimmune disease 80% of people with autoimmune disease are women rheumatoid arthritis a very potent risk factor for having heart disease, lupus, psoriasis, um and and the reason for is is that when you're when you have autoimmune disease the whole inflammation milieu starts the artherosclerosis cycle.
So there's been a lot of talk about clinical manifestations that men and women have different clinical manifestations of heart disease so let's dive into the data and see so this is the uh patient registry around half a million uh patients. Women are less likely to have the typical chest pressure chest tightness they have it 70% of them have it but 30% of them actually have atypical symptoms so they have nausea as their symptoms just shortness of breath extreme fatigue as a symptom.
When you look at um the most interesting thing I think is is uh from the registry is is that younger women and we know from the registry data the national uh database now that younger women are having heart attacks because of diabetes because of obesity younger women tend to have silent MIs the sort of unrecognized MIs because they have atypical symptoms so the younger you are the more atypical symptoms you have and the older you are um they have more typical symptoms of chest pressure chest tightness um that we associate with heart disease.
There is actually a fundamental difference between men and women in terms of atherosclerosis you know women's heart is not just smaller men's heart there's actually a fundamental difference there is some difference in in uh plaque as well. So plaque erosion that's when the cholesterol uh plaque erodes back into the vessel wall is more in women than it is in men. Now obviously women uh have plaque rupture majority of women have plaque rupture but plaque erosion where the plaque erodes back into the vessel thus causing uh clot formation that actually is much more common in women.
The other thing that's very very common in women is spontaneous coronary artery dissection. That has nothing to do with plaque that has to do when the artery dissects and of course there's now an increasing awareness because now we have great modalities to um diagnose it but it's the number one cause of MI in young women less than 60 years of age in certain registries. 30% of these uh occur in patients with fibromuscular dysplasia so it's really important in young women they come in they have this spontaneous coronary artery dissection to check for fibromuscular dysplasia the recurrence rate is around 30% it's really important to control their blood pressure and heart rate because we think that's the mechanism the um of the dissection you have an endothelium that's not healthy it tears and so controlling blood pressure and heart rate is really critical.
The other uh the other important thing to remember is that peripartum or postpartum third trimester to fourth trimester lots of times we see spontaneous coronary artery dissection also in women on hormone replace therapy as well um so it's important to think about these things um in women presenting um with heart attacks after that after the peripartum time.
The other um unique heart attack that happens in women is something called myocardial infarction without obstructive coronary artery disease. So I’m an interventional cardiologist I spend a lot of time um in the big epicardial artery putting stent in but that actually is only one half of the of the issue the micro vessels the small arteries we can't see with our eyes we can't cap we can't bypass we can't stand they can become dysfunctional and in the past there was really no way for us to diagnose this um microvessel disease and now there it is a very um a good way to diagnose microvessel disease.
So we're learning a lot about [inaudible] which is this microvessel uh disease that causes heart attack and this actually occurs mostly in women as well. Microvessel disease actually is not benign so when you look at the the some of the microvessel uh studies that have been done women with microvessel disease do come in uh with heart attack similar to the rates of people with epicardial coronary artery disease um with to the hospital with recurrent um non stemies.
Treatment for microvessel disease because we think it's an endothelial dysfunction uh problem we treated it with aspirin, statins, ace inhibitors and the most potent treatment for endothelial dysfunction which is cardiac rehab exercise. Treating the symptoms, we uh treat it with either ranolazine or nitroglycerin beta blockers we particularly like nebivolol because we think it has a a very good endothelial um effect as well and then of course calcium channel blockers.
As I was saying to you there is fundamental difference between coronary structures and function between men and women and if there is one message I want you to remember when you come out of this that is the unique risk factor and that men women's heart and men's heart are fundamentally different. When you look at women's heart it's smaller so um women's arteries are smaller and what's fascinating is when we take a woman's heart out of a woman's body and put it into a man's heart like we do in cardiac transplant the arteries actually become bigger.
And the other interesting thing is women's arteries have more stiffness they have as I told you more sort of erosion when they have a heart attack but they have more fibrosis and there there is actually differences in the microvessel function between men and women. The other diagnosis that are unique to women are stress induced cardiomyopathy so this is a broken heart syndrome that we have all heard about when either when they're super happy or super sad or just very surprised they could have this uh incredible surge in their stress hormones which uh causes a heart attack.
That's 90% in women. It's a very much a female phenomenon when we talk about diastolic heart failure diastolic heart failure is you have heart uh that are normal in function but you have uh nevertheless um heart failure that heart failure preserve dejection fraction that is a disease of ladies because their heart muscles become stiff with hypertension. Again predominantly a female um issue and of course [inaudible] cardiomyopathy is a uniquely female phenomenon.
This is a stress induced cardiomyopathy where the entire sort of anterior wall of the heart is not working. Many uh majority of these patients recover the interesting thing we're learning is that besides 90% of them being women this is a recurrent problem in some patients and that's sort of a fascinating um new disease entity.
So are there differences and how we test women with heart disease and there are and I will give you sort of my bias and so my bias is you know we talk a lot about cardiac testing, EKG, exercise stress testing, whether we should do stress echo stress nuclear and and I'll give you some of my uh thoughts on that cardiac CT and then cardiac catheterization. So you know the EKG stress test obviously it's super easy to do. I like EKG stress test you know just to see function it cheap it's it's cheap works well in people.
It has lower sensitivity and then for women it's particularly lower sensitivity in women because of breast tissue and there's some changes that occurs during menstrual cycles and so this has sort of fallen out of favor uh for most part. Now you know we think lower accuracy because low prevalence lower QRS but but because mainly because this ST segment abnormalities vary by menstrual cycle.
Now for older um patients you can certainly think about doing EKG but I actually like uh stress testing with imaging modality. And my preference for women is stress echocardiogram and the main reason for that is that you get um good sensitivity good specificity but you assess the valves and I really like assessing the valves and you know shortness of breath is never normal and I want to say it's you know I like I sometimes hear women they're like yeah I'm getting short of breath but I'm getting older okay that's not the reason you're short of breath.
Um and I think you know valve disease are very is are underdiagnosed in women valve disease are a little different in women so I really like stress echo. Stress echo for to look at valves as well as pressures and then I like the fact most importantly for younger women I like the fact that it has no radiation and you know I see sometimes women from outside where they come in with yearly nuclear um stress test.
Nuclear stress tests can have anywhere from 500 to 1,000 chest x-ray. I mean that's that's a lot of radiation to the breast um obviously if you are a very large patient it's the image quality for stress echo is not that great it's very much reader and technician dependent but and then in patients who've had multiple heart attacks it's not such a great test a stress echo but in a good center with good readers and good uh technician I think you know you can do okay.
Now I think the true minus to stress echo is the multiple resting [inaudible] abnormality that actually is a very difficult uh patient population. Nuclear study it's a great uh study safe in patients good for people who are overweight um and I think it's also you know there's a lot of nuclear test uh centers out there so it's easily available. The thing I don't like is that uh because women have smaller hearts you know sometimes it's difficult the radiation issue and then of course of course it's very important to correct for this breast artifact.
The number of people who have quote unquote abnormal stress test when it's just a breast tissue artifact is huge and so you have to your nuclear study um if it's in a good center should be correcting that breast uh tissue attenuation. I really like cardiac CT and and the reason I like cardiac CT I think cardiac CT has a very good role and the and the role for cardiac CT I'm not talking about the calcium for the role for cardiac CT that's really important is for people who come in to hospitals recurrently with stress test um that are normal um that you know you think their probability is low this is a great test to sort of rule out CAD now some of these people you have to think about microvessel disease but for lot of sort of atypical symptoms cardiac CT is a great test.
This is not same thing as a calcium score which is very different. Now obviously cardiac cath which is how I uh spend Tuesdays and Fridays is the gold standard but it's invasive um and you know even though it's incredibly safe to do it's still an invasive testing it has its you know 28:53 risk. The reason I like to do cardiac cath especially for uh women with recurrent chest pain who've come in multiple times um is the physiology uh testing that now that we can do now for microvessel disease and I'll show you how we do that in in a couple of slides.
So when we talk about microvessel disease for years we've uh said oh you have normal coronary arteries you have chest pain that's not your heart maybe it's something else but it actually turns out it may in some of these patients be the micro vessel so we're not talking about large vessels but we're talking about tiny tiny uh capillaries and and the microvessel dysfunction so microvessels should dilate when you exercise when you're under stress but these microvessels constrict there's also this thing called microvessel spasm as well that we also test for.
So how do we do that the way we do that is we put a a wire down um we uh we do adenosine and we measure the microvessel physiology we measure the resistance. We also give medicine acetylcholine to test for vasil reactivity to look for um epic cardia large vessel coronary spasm as well as microvessel uh spasm as well and it's a great test and I think for people who've had multiple uh admissions for heart uh chest pain been ruled out for everything this is a sort of a a great test in a last resort.
Now are there differences in treatment uh between men and women. Well let's talk let's start with the good news for secondary prevention aspirin and statin both men and women derive great benefit and so let's go now talking about for primary prevention. So aspirin for primary prevention well um it's really important to think about the risk versus the benefit so the absolute benefit of cardiovascular reduction versus the bleeding.
So how can we sort of think about that as you know there's been three sort of pivotal primary prevention aspirin trials the ARRIVE, which is moderate risk ASCEND, which was in diabetic primary prevention a SPREE greater than 70 primary prevention and really mace was kind of you know um neutral is uh except for ASCEND which they did show decrease in mace but there was consistently increase in bleeding and in the elderly population not just bleeding but mortality.
So you know for sure if we look look at all the sort of metaanalysis of aspirin use you know that it does aspirin definitely lowers adverse events it lowers heart attack it lowers you know stroke by around 11%. But what it does consistently is it increases bleeding so CBD prevention the number needed to treat 265 number needed to harm for um for with aspirin 210 so that's a fairly you know that sort of gives us but there are patient population in whom aspirin for sure works and so let's talk about who that is and I think this is where calcium score becomes very important and and so calcium score can be used to guide who should get aspirin.
So let's just look at this which is very interesting. So calcium score of zero you should not be doing aspirin calcium score of greater than 100 look at this incredible uh in terms of number needed to harm and number needed to treat you actually have a benefit so the bleeding risk compared to the benefit is low so you should be treating these people with aspirin therapy.
The other group that actually would benefit from aspirin therapy is women with elevated lipoprotein a so as you recall the Women's Health Initiative looking at hormone replacement therapy as well as aspirin um there was a substudy of women with elevated lipoprotein A . Women with elevated lipoprotein A had 200% increased risk for having heart attacks and they're the ones who derived benefit from being on low dose aspirin therapy.
The other um thing is that in people who are not well controlled so you have primary prevention population but their blood pressure is not well controlled their diabetes is not well controlled their cholesterol level is not well controlled or their smoking aspin actually makes a lot of sense. But for most patients you have to really sort of grapple with the number needed to harm and the number needed to treat and I think that this sort of uh for sure aspirin in secondary prevention but I think it's really important if you have ASCVD risk greater than 10% you're not well controlled with your risk factor um and your bleeding risk is low that we still use aspirin therapy.
So uh yes for secondary prevention, no if you're um you know healthy and no risk factors or greater than 70, or have bleeding risk but really consider in people who are smokers, elevated CAC score, strong high lipids uncontrolled risk factors and and uh Lp(a) with low bleeding risk.
Now what about cholesterol. Obviously um it's important to treat secondary prevention patients and there is no difference between men and women for secondary prevention and cholesterol lowering it's a main stay of therapy. The question is is in primary prevention what about women and there's been lots of controversy and this is I think where using risk enhancers reproductive history autoimmune disease Lp(a). Lp(a) is a genetic determinant uh risk factor and then coronary calcium score really makes a lot of sense in when to start uh cholesterol lowering medication.
So the way we think about it is obviously for secondary prevention for primary with their LDL is super high for diabetes because as you know the American Diabetic Association says that if you're diabetic even if you don't have CAD your LDL should be less than 70 if you're high risk obviously and then with risk enhancers with intermediate risk no for primary prevention um if you're low risk um but maybe for people who are on borderline with risk uh enhancement.
Now the sad thing is is that women still don't get statins and when they do get statins they're less likely to take it. You know I think this is where shared decision making it is important this is I think where risk enhancing factors become really crucial. I think this is where CAC scores are really important because patients like to see their own bodies and it's a really good sort of conversation starter um to talk about how to treat aggressively and when to treat.
You know the good news and the is that women derive similar benefit as men in terms of hypertension you know this notion that we don't treat older women with blood pressure um and so you know we're less aggressive on that this is how they go to have diastolic heart failure we should aggressively be treating to target. Women derive just a similar benefit with SGLT-2 inhibitors GLP-1 receptor uh agonist but they do they still get less aggressive care.
The under treatment I could have 10-20 slides just talking about under treatment women. This is from uh United Kingdom but I can show you our [inaudible] data too women are less likely to be on guideline directed therapy and you know uh it's critical that we keep on talking to them about it it's critical that we drive home that women don't die of you know most women die of heart disease and it's important to also uh emphasize that vascular dementia is a leading cause of dementia and it's as women get older older because they they live to a late age you know that's one of the potent risk factor, treating risk factor uh vascular risk factor is good for your brain too.
The good news is that women and men derive similar benefit with bypass um but they have more uh complications because of smaller size um and it's important to when we talk about revascularization therapies to sort of think about you know um some of the medications we give as an interventional cardiologist uh it's crucial that women have radial access uh instead of femoral access to prevent that bleeding complication.
Women are older when they have heart disease they have more comorbidities and it's still very sad even in 2024 that they come to the hospital later with heart attack even now even after all the American Heart Association the ACC all our campaigning they still come to the ER later with stemi and of course myocardium is you know is dies and once it dies it doesn't recover and minutes and seconds are crucial um and so it's really important that we continue to educate our patients on symptoms.
So in one of my final slides here, do women have more side effects is that like a thing or is that not a thing. Women absolutely have more side effects you know uh some sometimes people say to me oh women have more side effects they just complain more. You know what that's not the thing because women have you know babies and it's very painful to have babies so that's not a thing like women just complain more.
Women definitely have more side effects and that's because the pharmaco kinetics are very different between men and women because of water distribution and fat and the other uh important thing for us to remember as physicians and as scientists is that most clinical trials are done in men. If you look at the basic rat studies that initially start these drug trials they're all done in male rats because they don't want to you know have to they don't want to deal with the menstrual variation and so most of all animal studies are even done uh with male animals and so if when you look at 86 drugs most common drugs that we use higher blood concentration and longer elimination time is seen women.
So that's why it's crucial absolutely crucial because of smaller body size, higher body fat content, all the stuff that we enroll women in clinical trials. It's really important that we you know make sure women have participation in clinical trials. So in conclusion um risk factors yes they're similar between men and women but women have unique risk factors and even traditional risk factors.
It's really important to aggressively treat them because the adverse events that happen are different between men and women. We need more awareness and of course and of course once you get diagnosed it's really important to aggressively treat women so that they don't get heart disease thank you for your attention.
[Dr. Amy Zach] Thank you very much Dr Cho for addressing this really important topic I invite anybody who has questions to ask them in our Q&A um as opposed to the chat function if you are able um and we have a few minutes to answer some questions.
The first one is would um folks that have chest pain related to microvessel disease present with elevated troponin and or more typical EKG findings like we might expect in perhaps a male MI patient.
{Dr. Leslie Cho] So most people with microvessel so it is definitely they definitely present with MINOCA which is myocardial infarction non-obstructive coronary artery disease they have nonspecific ST changes on their EKG so not the traditional ST elevation um they have troponin elevation and then they all get sent to the cath lab and then they're like oh no um arteries are blocked so you you know who knows what this is and they maybe it's a demand ischemia or something and they go home and they continue to have chest pain.
You know the the troponin elevation troponin is a marker and so you know we it's really important if they have non-obstructive coronary artery disease that we look for the cause whether it's myocarditis, whether it's you know um microvessel disease. It's really important to look for a cause. Majority of people with microvessel disease come in with recurrent chest pain they don't leak enzyme they come in with recurrent chest pain they get stress tests negative or they even get a stress test that's positive they go to the cath lab, everything's fine so then they get sent home but they keep on having chest pain.
The interesting thing after having treated these people for 20 years is either they have chest pain with exertion or with psychological stress or some of these people after they exercise they have tremendous amount of chest pain and it like you know hangs on for a while. But it is sort of that you know related to that and they have tremendous benefit on nebivolol. I really like nebivolol um and I but the most important thing is to treat the underlying endothelial dysfunction which is aspirin, statins, ACE inhibitors and of course exercise because exercise releases nitric oxide which then vasil dilates and helps train the endothelium.
[Dr. Amy Zach] And for those patients that you would recommend exercise for especially if they have chest pain related with exercise do you recommend starting with a like cardiac rehab or it's okay just to send them to walk what would you recommend.
[Dr. Leslie Cho] Well I think it's really important if they get diagnosed with microvessel disease um uh angena is actually paid for is one of the diagnosis that can pay for cardiac rehab. Patients are frequently scared to exercise you know because they're having chest pain so they're like oh I don't want to exercise but you know if you have the firm diagnosis of microvessel disease what we do in cardiac rehab at the clinic is we put them on the treadmill, they exercise they get chest pain they stop, and they exercise once the chest pain goes away so to build that tolerance.
But it's nice to do it in a control setting so you know it's it's reassuring for the patients, it's reassuring for the family you know.
[Dr. Amy Zach]  I guess the next question is on um ARB versus ACE and do you have thoughts about the effectiveness or um what would be your go-to.
[Dr. Leslie Cho] So I I mean I think ACE and ARBs are pretty much the same you know ACE inhibitors because of the I like ramapril uh because of the endothelial uh function dysfunction uh I think it helps with endothelial dysfunction I like ramapril um if you're going to if they can't tolerate ACE inhibitors because they have a cough I like um any ARB as you know valsartan is the weaker of the blood pressure um uh ARBs medicine so a lot of these uh microvessel disease ladies they don't need a big time lowering of their blood pressure so sometimes I will choose losartan but if they do need lowering of their blood pressure I go with valsartan.
[Dr. Amy Zach] Next question is around the LDL goal for patients with autoimmune disease and I would even expand that to say we know these patients have a higher risk um what is the LDL goal but are there any other preventive measures or actions that should be taken in folks who fit that profile.
{Dr. Leslie Cho] It's a great question so I think autoimmune disase especially rheumatoid arthritis, lupus is a incredible risk enhancer, incredible risk enhancer so if you look at some of the different guidelines the ESC guidelines if you know it actually is almost like a CAD equivalent that's how much of a risk enhancer it becomes and so I you know we at Preventive Cardiology at Cleveland Clinic we treat them to an LDL goal of less than 70.
We're very aggressive about about rheumatoid arthritis or lupus. Now the problem here is is that many of these patients there are three problems many of these patients are on ton of medicines they don't want to take it they don't want to take another medicine like that's not you know they don't want to take it and that's where I think it's really important to sort of discuss the benefits of being on lower cholesterol medicine.
People that worried me the most with autoimmune disease are people with frequent flares and that there's actually great data that if you have frequent flares um you have an increased risk for cardiovascular disease and so people with frequent flares we actually are more aggressive about getting their cholesterol down I um like getting apolipoprotein B uh for some of these patients um I think I think because it's such a potent risk factor um I think having that discussion really showing them the data it is really critically important.
[Dr. Amy Zach] In terms of recommendations for screening if you are using lipoprotein A or [inaudible] lipoprotein B, what is your uh what would you recommend for treatment for patients who have elevations in these markers.
[Dr. Leslie Cho] So lipoprotein is a a risk determinant like a genetic risk determinant and currently there's no medicine that lowers lipo protein a level there's three phase studies that are ongoing. If you look at the E uh European atic Society consensus paper the national lipid guideline consensus paper everyone sort of recommends treating their LDL down to less than 70. There is no consensus on [inaudible] B level which I'll talk to talk about in a second but but everybody sort of you know says you you should aggressively risk modify them.
So aggressively get their cholesterol down aggressively you know make sure their blood pressure and everything else is controlled. You know APO lipoprotein B is better um as a determinant of all the [inaudible] particles so apolipoprotein be measures sort of all the [inaudible] particles for diabetic patients and for people with metabolic syndromes apolipoprotein B actually is a better measure I think than just LDL alone.
You know if if there was like peace in the Middle East and there was you know um if I could have anything I want and order anything I want I would get Apo B on everyone if I could get it and if it was no cost issue I I would get it because I think it's actually you know a better testing. Like for example people with LP(a) that's very high their LDL is always going to be high because LDL measurement the way we measure LDL currently is it it also counts LP (a) and so because of that if I could do it on everybody I would do Apo B but since we can't and we're cost contained um I do Apo B on people who are diabetic metabolic syndrome and people with uh elevated LP(a).
[Dr. Amy Zach] Thank you um I the next question is around your thoughts on hormone therapy um and cardiac risk and I I think that this would be you know hormone therapy for symptoms of menopause.
[Dr. Leslie Cho] Yeah so um so there are or five societies that have come up with guidance on hormone replacement therapy the menopause society the endocrine society the American Association of clinical endocrinologists, ACOG and AHA and ACC and we recently published a paper that basically states that you should you can take hormones for postmenopausal symptoms for the shortest amount of time no society zero society recommend you take it for prevention of cardiovascular disease.
There are people in whom you know now we have all these celebrities sort of pushing hormone replacement therapy and it's become sort of like call to action. There are people who are genuinely at an increased risk and those are uh people who are so people who with secondary prevention should not so people who've had stent people who had a heart attack, stroke, none of these people should be on hormone replacement therapy none of them people with spontaneous coronary artery dissection should not be on hormone replacement therapy.
But for primary prevention if you're low risk you just started menopause you can be on hormone replacement therapy. The people that are at risk the in intermediate risk are people um who have uh uncontrolled hypertension, uncontrolled diabetes uncontrolled cholesterol I think those people are kind of you have to talk to people like this but the but the um but the most uh potent risk is people who are overweight they have a they have an incredible risk of developing DBT and PE and regardless of whether you start hormone therapy at the time of menopause or not the risk of DBT and PE is greatly increased you can look at every study.
There was recently a study that was just published in BMJ looking at the Swedish uh registry and I think it was just published in BMJ this week um and looking at different compound of hormone replacement therapy and the increase in DBT is undeniable really undeniable so it's really important to assess your risk.
[Dr. Amy Zach]  Thank you we have a couple follow-up questions on the autoimmune disease topic and that is um do you use high sensitivity CRP and at what age would you start to look at risk coronary risk factors in women with autoimmune disease.
[Dr. Leslie Cho] So um at the Cleveland Clinic everybody with autoimmune disease rheumatoid arthritis um lupus etc they get a preventative cardiology consult and you know the CRP we love getting HSCRP and there's a a great study that came out uh by Paul Ritker’s group out in Boston were measuring HSCRP LP(a) and LDL at one time predicted your 30-year risk for having heart disease.
Isn't that amazing 30-year risk for having heart disease we like to measure HSCRP. Now in patients with autoimmune disease that's kind of tricky right so because you know CRP is going to be elevated in that patient population but we do like measuring CRP HS CRP in general in women. Now HSCRP as you know is kind of a tricky thing if you're obese your HSCRP is going to be elevated ,if you have chronic gingivitis your HSCRP is going to be elevated you know HSCRP is kind of a a marker that you have to sort of understand when you order because sometimes it can go up with just a viral infection.
The other thing about um HSCRP is that it always increases in uh hormone replacement therapy and it has to do with sort of this one pass um phenomenon but nevertheless um I like getting HSCRP I'm not sure what to make of it with autoimmune disease patients because we treat them so aggressively.
[Dr. Amy Zach] Wonderful thank you um well we have lots we have lot of other questions and I apologize to everybody we won't get to all of them but I have one more minute and time for one final question and that is um what is your um viewpoint on covid and the increased cardiovascular risk especially in women.
[Dr. Leslie Cho] You know that's such an interesting uh question and and you know I don't know I you're right I mean there is a this increased risk and and um I'm not sure what to make of that and I don't know um there there is a hypercoagulable aspect to it too um which I'm not sure if that and I don't there's a hypercoagulable aspect there's like sort of almost an autoimmune aspect to it and as we said autoimmune disease is particularly prevalent in women but it is an interesting question and I also am kind of um you know there's also this huge thing about long covid and whether that long covid is chronic fatigue syndrome and and why it affects more women I don't know there's so much to be done and you know one of the things that I think is really important for our audience is we have to you know men and women are fundamentally different um and it's really important to continue to study the sex differences.
[Dr. Amy Zach] Thank you very much we really appreciate you being here today and for this fantastic talk so thank you very much Dr Cho and um I think Dr Bolen.
[Dr. Shari Bolen] Thank you thank you Dr Zach for moderating and Dr Cho what a wonderful talk so thank you so much um we will just wrap up with a few um a few announcements um if we can't thanks um just a reminder if you want CME um you need to have registered and actually clicked that you're interested in CME so you can use this QR code or the URL in the chat if you have not done that yet next slide um we just a reminder that we do want to hear from you and find out if what things you liked or what things we could change for um future webinars that we do and that will link will come to you very soon to um complete your evaluation next slide and then just a thank you for um to to everybody today for attending and we look forward to many wonderful great uh events in the future if you want to learn more about cardio. org you can uh go to our website and um if you're interested in getting our monthly newsletter you can subscribe to that there or follow us on social media so thank you everyone and have a wonderful afternoon.