What every woman should know about heart health

00:00:07: Speaker 1 Kia ora koutou, and welcome to the Heart Foundation podcast, Heart Hub. I'm Justine Munro, Head of Prevention at the Heart Foundation. If I asked you what is the single biggest killer of women in New Zealand, what would you say? It's not something many of us immediately think of as a women's health issue, but the answer is actually heart disease.

00:00:26: Speaker 1 Nearly 3,000 women die from heart disease every year in New Zealand. That's more than 50 women every single week. Yet so many of us, including health professionals, have grown up thinking that heart disease is a man's illness. Today we're shining a light on women's hearts: the myths, the missed warning signs and what new research is uncovering about how women's hearts and risks are different.

00:00:50: Speaker 1 Joining me are two of the people leading that work who are based at Waipapa Taumata Rau, the University of Auckland. We have Associate Professor Katrina Poppe, a health data scientist and previously a clinical cardiac physiologist whose research is helping build better heart risk tools for New Zealanders. And Dr Nikki Earle, the Heart Foundation Hynds Senior Research Fellow, whose work looks at how pregnancy can affect heart risk and how heart attacks differ between women and men.

00:01:21: Speaker 1 Kia ora to you both. Kia ora Justine. Before we dive in, I'd love to hear about what brought you into this work. Nikki, would you like to go first? Yeah, sure.

00:01:30: Speaker 2 So, it wasn't until recently that I really learned about how much of the medical system assumes the sort of typical patient is a man, and how this can lead to blind spots and women can fall through the cracks, including in relation to heart health. Katrina and I are in the really fortunate position to be able to try and do something about this and improve outcomes for women.

00:01:55: Speaker 1 Katrina. Well, yes.

00:01:58: Speaker 3 I'm coming from the perspective of fairness, really. So, you know, I see a number of women around me through life and they have some risk factors in their life that put them at increased risk. And yet they're not really included, and or recognised in everyday kind of standard clinical care. So, I'd quite like to push that message along.

00:02:17: Speaker 1 So, let's start with the main misconception. Nikki, why do so many of us assume that heart disease is a male problem?

00:02:25: Speaker 2 Yeah, that's really interesting, isn't it? I think it's partly because, for decades, most heart research was done on men. So what we knew about heart disease was really what we knew about heart disease in men. And that meant that women's risk was underestimated, their symptoms were seen as less sort of typical. And that myth has hung around, and that's despite heart disease being the single biggest killer of women in Aotearoa.

00:02:50: Speaker 2

00:02:50: Speaker 1 Nikki, what are some of the warning signs that women might experience that might not be immediately recognised as heart-related?

00:02:58: Speaker 2 Yeah, I think it's important to clarify that women still can get that sort of chest pain or chest tightness. It's still actually the most common symptom for women, as it is for men. But women can also get multiple other symptoms and it can be things like nausea, indigestion, pain in other areas, like the jaw, the neck or the back, or just sort of unusual tiredness.

00:03:23: Speaker 2 And because of having those multiple symptoms, they can often be brushed off by women, and sometimes their doctors as well, as being things like stress, potentially menopause or just sort of getting older.

00:03:36: Speaker 1 So not potentially quite as dramatic as we might see on the TV.

00:03:41: Speaker 2 Yeah. And that, you know, can tend to delay people from seeking treatment. And we also know that women are often in caregiving roles, looking after other members of the family. And that can delay people seeking treatment as well. Yeah, but it's important to know that with heart attacks, delays can directly affect long-term recovery and survival.

00:04:03: Speaker 1 So, if you're listening and thinking, that sounds a lot like me - best to go get checked straight away. Yeah. So most of us have heard about the usual heart risk factors like high blood pressure, high cholesterol, smoking, diabetes. But is it true there are some female-specific risk factors that most people have never heard of?

00:04:20: Speaker 3 Yes. Yeah, absolutely. So certainly to start with, women do have those risk factors, as you've said. And can experience them, but they can also have things that are unique to women. So we think of the first thing as pregnancy, for example. And so when a woman is pregnant, the blood circulation changes. You know, you're trying to have enough blood supply to support another human being inside you for like nine months.

00:04:45: Speaker 3 And so sometimes the body can overreact, and so blood pressure can go up during pregnancy. And sometimes it can develop into pre-eclampsia, which used to be called toxemia but that's preeclampsia these days. You can also have an earlier birth, a preterm birth. Or, you could develop diabetes during the pregnancy, gestational diabetes. And all of those things can increase a woman's risk of heart disease in the future years down the track.

00:05:15: Speaker 3 So, that's something to be aware of. And then another time as you think of, women they have their own organs. They have ovaries, you know, and polycystic ovary syndrome can increase someone's risk of heart disease earlier in the future as well.

00:05:30: Speaker 1 I find that really interesting because I think as, as women and as people, you know, we tend to put things into boxes and those things are, you know, reproductive health. And, people may not make that connection between their reproductive health and then their longer-term risk for heart disease.

00:05:49: Speaker 3 So true. It's a really good way of saying it I think. Because, and I think that applies to women, their family, society, but also some of the medical profession. You know, you're kind of okay that's done. Yeah. And now we look at the rest of your life, you know. It's, you know, the body is systemic, everything's interlinked.

00:06:04: Speaker 3 Yeah. And you think of the heart and the blood vessels are a closed system in the body and so anything that affects them at any stage in your life, it's going to potentially have some consequences later in life. Potentially - it's only risk, it's not guaranteed. So a woman's life course is also directed by substantial hormonal shifts. And by here, we can think also of menopause.

00:06:24: Speaker 3 It's quite a big change. And a woman's risk of heart disease, or cardiovascular disease, increases after menopause because you get a loss of estrogen. And estrogen is like an anti-inflammatory and so when that decreases, inflammation increases and that can increase someone's risk of developing problems in their cardiovascular system.

00:06:44: Speaker 2 Yeah, I think it's a really delicate balance, you don't want women who have had a complicated pregnancy to feel anxious in the moment. You also don't want them to sort of put it in their back pocket and think, that's for future me to worry about - heart disease is what happens in older people. So again, as you said, it's that having that awareness and just keeping it somewhere in the back of your mind for when you might need it.

00:07:07: Speaker 1 Nikki, so one of the sobering things from your research is that outcomes after a heart attack are potentially worse for women than men. Why is that?

00:07:17: Speaker 2 Yeah. So that's what we see when we compare younger women having a heart attack to younger men having a heart attack. The outcomes are worse for women. This actually flips when we get to older ages. So above, about the age of 60, men have worse outcomes than women. But thankfully, it's relatively rare for younger women to have heart attacks.

00:07:38: Speaker 2 And those that do, more likely than men of the same age to have multiple other health conditions and this can impact on their recovery and their long-term risk.

00:07:48: Speaker 1 So, are they treated differently when they arrive at the hospital?

00:07:53: Speaker 2 Yeah. Well that's interesting. We know that women, when they arrive at hospital are less likely than men to get certain tests or procedures. And this can be things like angiograms, so looking at the blood vessels that supply blood to your heart muscle, or stents to help clear any blockages. And we don't really know why women get these delays or have fewer treatments, but our research is trying to understand this.

00:08:21: Speaker 2 One of the reasons, we think might be that women tend to have problems in the smaller blood vessels of their heart, and we call that microvascular disease, whereas men tend to have blockages in the larger arteries. And as we've already said, you know, a lot of the guidelines and treatments were based on men.

00:08:41: Speaker 1 Nikki, you talked about a stent - for the people listening at home who might not know what that is. Katrina, are you able to let us know what that is?

00:08:50: Speaker 3 Sure. So, a stent is like a scaffolding that can be placed inside the vessel, inside the blood vessel. And so here we're talking about the arteries that supply blood around the outside of the heart and to the heart muscle itself. And so they can introduce a little tiny thing. It's a bit like the old fashioned ballpoint pens

00:09:09: Speaker 3 with the little spring, it's like that, but not really. It's a bit more fancy, but that kind of thing. And they place it inside the vessel and it just holds the vessel open and kind of yeah, keeps everything all the blood flowing well.

00:09:21: Speaker 1 It's incredible, isn't it? Wonders of modern medicine. Katrina, your work looks at heart disease risk in women, including risk to pregnancy. Can you walk us through what that means and what have you found and why does it matter?

00:09:35: Speaker 3 So some of that work, I mean, a lot of that work for about, cardiovascular risk for women particularly, as Nikki and I are working on it together. But so we looked at women who had pregnancies over 30 years in New Zealand and in the Auckland region, in particular of New Zealand. And of those, about 11% had one of these high blood pressure or preeclampsia during pregnancy.

00:09:57: Speaker 3 So, it's about 10-11% is what we know that that's the rate that it happens. And in those women, so they had their delivery delivered their baby in their late 20s on average about 29 I think was the overall average. And then some women had a three times risk of developing heart disease within ten years than women who didn't have those problems.

00:10:16: Speaker 3 You know, those complications of pregnancy, you know, it's three times and so that's having a cardiac event in their late 30s. So they've got children, they've got at least a ten year old potentially from their pregnancy, and they're living their lives and working and doing whatever. So, that's you know, that was quite shocking - three times the rate.

00:10:32: Speaker 3 It's the highest risk factor for any of the risk factors that we know. And then women who, you know, fortunately didn't have an event, then they might go on, you know, go onto older age without anything, but they're still at about twice the risk of a woman who hasn't had those complications of pregnancy and that carries on through their life.

00:10:49: Speaker 3 And that's just not currently in our standard risk scores that we have. So that's something I'm involved with in my, you know, kind of my day job if you like. And we are going to try and get that in there. You know, to have that as a risk factor that's recognised.

00:11:03: Speaker 1 Katrina, you talked about cardiovascular disease. Can you talk us through what that is?

00:11:08: Speaker 3 Yeah. Good point. Sorry dropping the language in aren't I. So cardio is heart and so, that's where that comes from, and the vascular is all the blood vessels. So, you know, we kind of talk about cardiovascular as a more general term than just heart health because it's a closed system. And so everything - the vessels affect the heart, affect the vessels. And so when someone has, say a heart attack, that is a blockage in the artery that supplies blood to your heart.

00:11:37: Speaker 3 So it's still a vessel, but it's to do with your heart. It's a heart attack. And similarly, if you could have a blockage in a vessel in your brain and that's like a brain attack, but we call it a stroke. So, it just depends which organ in the body's affected. So, that's why we talk about the cardiovascular as the whole system.

00:11:52: Speaker 1 Thank you. So, do men and women develop heart disease at the same age?

00:11:57: Speaker 3 They don't tend to. On average, women will develop heart disease if they do, women will develop heart disease on average seven years later than men. But we need to keep in mind that that is on average, you know, that's a lot of a lot of people swept into one number. So people who have any specific high risk factors themselves will have higher risk than that and so could develop it earlier.

00:12:22: Speaker 3 And so, what we're suggesting and what we started to see in that we were talking just before about the preeclampsia and high blood pressure during pregnancy. And so, you know that could put those women at high risk earlier. And so that age difference tends to disappear. So, it's not just a disease of older people. You know, we can't think of this. It's a life continuum

00:12:43: Speaker 3 that we just need to be aware of heart health.

00:12:45: Speaker 1 So, are there others working in this area in New Zealand?

00:12:49: Speaker 3 There are. And one of them is actually also supported by the Heart Foundation. Which is great. So Dr Sarah Harris at the University of Otago, she has in the past looked at women who have preterm birth and looking at the risk for the woman who has an early delivery and also there's risk inferred in people who have been born early as well.

00:13:12: Speaker 3 So, just looking into some of those cardiovascular risks as well. Which is good.

00:13:17: Speaker 1 Fantastic. So any woman who's listening, who's had preeclampsia or gestational diabetes or a preterm birth, it's about being aware that you're at increased risk.

00:13:27: Speaker 3 That's it. Being aware, and again we talk about this. It's just risk. It's not a certainty. And so being aware helps you have a heart-healthy life you know and to get checked and to get not just leave yourself until you're the last on the list to get viewed by your GP or anything like that to just

00:13:47: Speaker 3 yeah, keep an eye out for yourself as well.

00:13:49: Speaker 1 Being an advocate for your own health.

00:13:50: Speaker 3 Well yeah, yeah.

00:13:52: Speaker 1 So, Nikki, your research zooms in on how heart attacks differ between men and women. So, why is it important to ask those sex difference questions rather than just treating everyone the same?

00:14:03: Speaker 2 It's really important to focus in on these sex differences, because so many of the tests and treatments were built on research that's mainly on men. And this is partly because women were considered biologically complicated to study because of hormonal fluctuations over the menstrual cycle. Partly because of the desire to protect pregnancies in drug trials and this essentially meant, that from about the 1970s to the 1990s, premenopausal women were excluded from all drug trials.

00:14:39: Speaker 2 And partly also there was just an assumption that women were small versions of men.

00:14:44: Speaker 1 But there are biological differences, right?

00:14:47: Speaker 2 Yeah, there are. And as we can understand those better, that's how we can make changes. And it can be small things like, you know, changing the threshold of when you do a blood test for cardiac biomarkers or using different doses or combinations of medications for women after a heart attack.

00:15:07: Speaker 1 So, there has been progress in closing the gap?

00:15:10: Speaker 2 Yeah. The good news is that there has been increased focus on this in Aotearoa and around the world. Research is now expected to have good representation of women. And so that evidence base is now building all the time.

00:15:25: Speaker 1 So, Katrina a lot of this plays out in really practical ways in the GP clinic, like the heart risk calculators for instance. So your work is helping to rebuild these tools. Can you tell us what you're hoping to improve and change?

00:15:38: Speaker 3 So, I'm fortunate to be part of a team of researchers who have been working on this for about the last 15, 20 years. And over that time, we've built a very large data set of people who have cardiac risk assessments done by their GP. So, when that has actually ended up is that we have one of the largest data sets in the world that do this.

00:15:58: Speaker 3 So it represents who was actually here in New Zealand, who was getting risk assessed, who was going to see their GP. And so what that has meant is that we have been able to derive risk scores specifically for the New Zealand population, because before this, you know, we had to use something that was developed overseas, suited - it was actually derived originally in America in the 1970s.

00:16:19: Speaker 3 So, you know, things have changed a bit. It didn't necessarily represent a diverse population, and certainly not our population. So it's been great advance in the last - I think it was in 2018 we published that, and it's been in practice ever since. So we had the sex-specific risk scores, all the S's. And that's something we're able to keep refining and updating and keeping them up-to-date for how the population has changed over time.

00:16:46: Speaker 3 So, it's been great.

00:16:47: Speaker 1 So, Katrina, you're also involved in a major international research push on women's heart health. Can you tell us about the project?

00:16:54: Speaker 3 Well, yes, certainly. So I was fortunate to represent the our Heart Foundation, the New Zealand Foundation, in a global funders group that designed this women's health initiative, women's heart health initiative. And so that was awarded earlier this year. And it's this big grant of about US $10 million that was awarded to a collaborative project about menopause and heart health.

00:17:18: Speaker 3 That was the winner. And so it's great. So, it's a research group that is made up of people from 13 institutes, from about seven countries I think it is. Lots of different disciplines, very much a multidisciplinary, multi-country, multi-institute, big project of work. And they're going to look at changes associated with menopause at the cellular level through to tissues, bodies, you know, clinical treatment, the whole kind of continuum.

00:17:44: Speaker 3 And that's good. And they just got underway. So, it's a five year program of work.

00:17:49: Speaker 1 Oh, that's fantastic. Because I you know, I feel like menopause is finally being talked about, which is incredible. And we've known for a long time that heart disease risk increases after menopause. So it's absolutely fantastic to know that research is going on to find out why.

00:18:07: Speaker 3 Exactly. Yeah. Yeah.

00:18:08: Speaker 1 So if we zoom right out for a moment, what kind of change are you both hoping will come from your research? Katrina.

00:18:15: Speaker 3 Well, I think raise awareness. Really. So raise awareness for women, for their families, like I said before, and GPs and the health professionals generally. Well, most people see their GP. And so at that time, to raise awareness of asking about a woman's specific risk factors, how their pregnancy went. And no matter what age they are now, if they can remember, you know, how their pregnancy went,

00:18:38: Speaker 3 could be 30 years ago. But to ask that and to record it as well. Because one thing from the research side is that if the data is not recorded, we can't develop models from it. You know, it needs to be recorded. And that's something that's quite a stumbling block here as well. It's holding back a lot of research.

00:18:54: Speaker 3

00:18:54: Speaker 2 That's a really good point Katrina. Yeah I think I would like, ultimately, for our research to change the healthcare system so that these sex differences are taken into account automatically. And we're not having to ask women to advocate for themselves to get sort of equally evidence-based care. And I think this is especially important in times of stress.

00:19:16: Speaker 2 You know, you might have just had a baby, or if you're having chest pain, the onus shouldn't be on the woman to be having to navigate the system's blind spots.

00:19:24: Speaker 1 And for listeners, the hopeful part is a lot of this research is underway to help the system catch up. Right?

00:19:31: Speaker 3 Yeah.

00:19:31: Speaker 1 For sure. And to help us all, hopefully, recognise women's symptoms a little bit earlier. So, if a woman tuning in today is feeling a bit off, not quite themselves, what's one piece of advice that you would want them to know? Nikki.

00:19:48: Speaker 2 Yeah. My advice if you're not feeling right, is to go in and get checked. Prioritise yourself. Health professionals would rather that you came in and there was nothing wrong than that something important was missed.

00:20:03: Speaker 3 And, that can't be emphasised enough. People would rather see you than not. Yeah, absolutely. And for me, I think if you're a member of a family or a community that have a history of heart disease, it doesn't mean that you're going to have the same fate. You don't have to have the same fate. You know, it's not a case of

00:20:24: Speaker 3 well, everyone I know, I'm going to have a heart attack. Every one of my family does. So what's the point? You know, why bother doing anything different? It's a case of getting seen, getting seen early, and you can make changes that will change your trajectory. And, I think that's the good thing to keep in mind. It's not a definite thing that you're going to have a problem.

00:20:43: Speaker 1 That's a fabulous piece of advice and hope, which I think is what we all need. Katrina, Nikki, thank you both so much for coming in and talking with us today for what you're doing to put women's heart health back on the map.

00:20:57: Speaker 3 Thank you, Justine.

00:20:58: Speaker 1 Thank you. And to you listening, thank you for spending time with us on Heart Hub. Please share this episode with at least one woman in your life - a friend, a mum, a sister, a colleague. Knowing this information and acting on it could genuinely save a life. If you'd like to learn more or check your own heart risk, visit heartfoundation.org.nz or talk with your GP or nurse about a heart and diabetes check.

00:21:24: Speaker 1 Until next time, ka kite.