The Truth About Women’s Heart Health | Dr. Martha Gulati

26:50It was where it said hormone therapy for women was the fountain of youth. And in that book, it said, every woman should be on HRT. And so every woman was taking, not every woman, but many women were taking it. And this is where we've harmed women. We put people on hormone replacement therapy without studies. We were, in fact, at one time it was unopposed estrogen, so we were causing uterine cancer in women until that we, they started seeing higher rates and they're like, oh yeah, we should probably make them bleed out and give them progesterone at the same time if their uterus is intact. And so that also, I mean, women have not been treated well by our medical community to be honest in in all aspects we're sort of thought of after we give medication without even consideration for what might be a consequence and that that's the way

27:45Dr. Gabrielle Lyon:medicine was and it wasn't that long ago you know it's it is unfortunate and i wonder now it's almost as if the pendulum has swung the other way and now um in 2001 everyone comes off hormone replacement they spend over a decade really I don't almost two decades where hormone replacement seems to be very fringe it is making a reappearance and wonderfully so because I obviously think there are many benefits but can you address the I'll start with misinformation and then go to the information of what people need to know about with hormone replacement and heart disease? Yeah, I think that's such an important question and I'm told by my gynecology colleagues that now we should be calling it menopausal hormonal therapy or menopausal therapy rather than HRT, even though that's what we all had been referring to it as.

28:45And the good news, one thing that I can say is in addition to hormone replacement we actually even have a new medication out that is beneficial that is non-hormonal for for the hot flashes so that's good we're developing new medications but the big myth out there right now that I see even some gynecologist hopping on this bandwagon without evidence is saying first that every woman needs to be on HRT that is not true and secondly that it will cure heart disease and thirdly that it can replace your statin and I tell my women like if you need HR if you need menopausal hormone therapy I'm not against it unless you have heart disease if you have heart disease you should not be on it that data is quite strong and we do not recommend it when you have heart disease but for a woman who doesn't have heart disease.

29:42What we tell them is it's not going to reduce your future risk of heart disease. That data is not there no matter what anyone says.

29:51Dr. Gabrielle Lyon:That is a big, that is a big statement and there is a ton of information out on the web talking about how the data is very clear that it will protect the heart. Yes and I know where that data is coming from. So there's a very small study that looked at carotid intimal medial thickness and said that some, in a small study, and I quite honestly right now don't remember the exact numbers, but it was a very small study and they did show a statistically significant difference in the women with HRT in terms of the plaque buildup compared to somebody who was not on HRT. It was statistically significant.

30:36You can have a p-value that's significant, but the amount of plaque was minuscule and meaningless. So it has to mean something clinically. It also needs to be in a randomized trial in a large study to really prove effectiveness. Intermediate endpoints, we never say that plaque is going to be enough for us to say that something's effective, but especially when it was such an insignificant amount of difference in plaque. But to say that hormone replacement therapy can substitute for statin, that is absolutely not true. And we tell people like this is one thing that is happening. People are substituting their statin for hormone replacement, even when they're not having vasomotor symptoms.

31:23Really, this medication should be used for people with vasomotor symptoms. And like I said, we have hormonal medication and non-hormonal. And between you and your gynecologist we need to figure out which one works for you but in terms of taking away your statin if you have high cholesterol there is nothing else that you need but cholesterol lowering agents it doesn't have to be a statin I know a lot of people think that's the only thing out there there's a lot of misinformation about statins online but I won't get into that but they're good drugs we've had them for 40 years but the good news is if you have any issues or concerns or don't want to be on a statin we have lots of ldl lowering agents right now

32:08azedamide pcsk9 inhibitors like repatha and priolent we now have something called inclicerine that we can give every six months and you come to you don't even have to remember we do it in the office for you and we have another medication called bambadoic acid and this area is dramatically changed than even about 10 years ago, where 10 years ago, we just really had statins and ezetimide was emerging at that time. So we can treat your cholesterol, but cholesterol is not getting magically removed by being on menopausal hormone therapy. So I think that we need to work, you know, and then the other thing is, is that for people with heart disease, they certainly need to understand that they're at higher risk.

32:54And that data, nobody's ever disputed. And we've never had so many fights about the way we have for people from a primary prevention standpoint. But I love when we work with our colleagues, like when our physicians don't necessarily know for sure, should this person be on it? They have a number of risk factors, what should we do? And ultimately it comes down to the patient. I'm a big believer that we share the information and together it's shared decision making that if somebody really feels that their quality of life is so significantly improved when they're on hormone replacement therapy and even if there might be some risks there is some benefits and we know that but we work it out together and decide what's best for that individual but just be careful of the people out there you know I the The other thing, I'm not a big believer in those bioidentical hormones that people are implanting in so many of my patients in LA.

33:53The pellets? The pellets. There's nothing. We can't guess the amount of hormone you need versus the amount of hormone I need. Bioidentical is just a marketing tool. And the safety of it, I would question. but I think that that these things we should all be questioning about what are people putting into us because the one thing about when they implant pellets you can't get them out like we're not we're

34:21Dr. Gabrielle Lyon:not a huge fan of pellets for exactly that reason and it doesn't allow you to adjust the dosing when it comes to heart disease we're using this as if perhaps there's a unified term and I'm wondering how do you define heart disease? Is it imaging? Is it blood pressure? Is it plaque buildup? Yeah, you're right. Heart disease means a lot of different things. And when I talk about atherosclerotic cardiovascular disease, I'm really talking about the disease of the coronary arteries that creates plaque in them. So atherosclerosis, having plaque in your arteries. That's just one version of heart disease, though, as you and I know, there's diseases like heart failure that can be connected to atherosclerotic cardiovascular disease, but also can be independent.

35:10So heart failure is a common issue, especially heart failure with preserved ejection fraction for women is much more common in women than it is in men, whereas heart failure with reduced ejection fraction is much more common in men than in women. Hmm.

35:26Dr. Gabrielle Lyon:And the, would you say the, what is the overarching cause of heart disease? Is there one? Are they different in men versus women? Oh, well, the, okay. So again, it depends on which form of cardiovascular disease. And I hadn't even finished. There's so many other forms. You can be born with types of heart disease as well. You know, congenital heart disease. You can have arrhythmias and all these other things can happen. The heart is one beautiful organ that when things go wrong can create problems depending on lots of different things. Newborns don't get coffee to wake up unless you drink a ton and you're breastfeeding.

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36:44Dr. Gabrielle Lyon:I also love that they are third-party tested, so you can trust that what they have on the label is also what's in the product. And they've got a special offer just for my audience. Get 15 % off your first order at tryamra.com slash drlion. That's T-R-Y-A-R-M-R-A dot com slash drlion. But when we talk about atherosclerotic cardiovascular disease, or when you have disease in your coronary arteries. The commonest causes of that are, I mean, if you smoke, it is one of the leading risk factors. The good news in America is that smoking has actually gone down significantly, and so that's actually helped with the reduction in cardiovascular disease, but diabetes, hypertension, and high cholesterol, those tend to be the leading known causes and reversible causes.

37:44You know, you could have genetic causes of atherosclerotic cardiovascular disease as well. That disease that you talked about with Dr. Ballantyne, LP little a. LP little a is determined genetically. How much LP little a you will make will be different than what I will make. And it's genetically determined. And so that is something that may be inherited if a family member has early heart disease or early stroke. you might be carrying LP little a around and not even knowing it until something happens. And right now we don't have a good treatment for LP little a aside from lowering your LDL cholesterol and controlling all your other cardiac risk factors.

38:26But talk to us in 2026, because we have two really big trials going on that might teach us, can we, by lowering LP little improve outcomes in atherosclerotic cardiovascular disease?

38:40Dr. Gabrielle Lyon:That would be fascinating. You know, I was listening to, as you were talking about statins and the health outcomes. Do we know that lowering hypertension, fixing type 2 diabetes affects long-term outcomes if plaque is there? So if someone is, is it fair to say the number one cause of heart disease is atherosclerotic heart disease? Yes. Or what, if we were to say the percentages, is it maybe 90 % of people, if they're going to be suffering from heart disease, would be that kind? It's about half of the type of cardiovascular disease that we see. it's the most common thing we see clinically is atherosclerotic cardiovascular disease and heart failure then is number two.

39:29Those are the things that we see the most of and the reason we see the most of them is because they are so closely linked to particular risk factors that are hugely prevalent in the population. Even heart failure for example obesity is strongly linked to the development of heart failure. Type 2 diabetes is also strongly associated with heart failure and hypertension as well is strongly associated with heart failure. So we and we know specifically for again for women if they have obesity they are more prone to that type of heart failure that we call heart failure with preserved ejection fraction.

40:09So meaning that when you look at the heart function it hasn't actually decreased it looks the same or normal but it isn't able to relax normally and it's not able to pump out the blood adequately and give symptoms like somebody whose heart is actually dilated and failing but doesn't look like it's failing and until recently we haven't really understood half path partially because it is in women and we haven't studied them but now we're in an era where we are actually having a few drugs now that have really proven to be effective for what we call HEF-PEF or heart failure with preserved ejection fraction.

40:49Dr. Gabrielle Lyon:The ability to reverse plaque, is plaque really soft or hard plaque where the damage from atherosclerosis comes from? Is that really what we're targeting? we aren't so much targeting the hard plaque the hard or calcified plaque tells us that it's been there for a while and it's already once it's calcified will we use tests to tell us if there's calcified plaque there because we can see it easily on a ct scan even when you have no contrast dye we can see that calcified plaque it's not going to go anywhere and it's not even scary plaque. To me, calcified plaque just means you are laying down, you've laid down cholesterol, so you've laid down this plaque in your arteries, but you probably have soft plaque now that we should be worried about more.

41:38It's the soft plaque that has the risk of rupturing and causing a heart attack or causing a stroke. And so when we know that there's calcified plaque, it just helps us know that that's somebody at risk. And so some of you may be asked to get a calcium score. It's giving us a clue, but I have a lot of patients who always are worried and they want to repeat studies to look at that calcified plaque got worse. And I'm like, don't worry so much about the calcified plaque, or they expect the number to go down because they're on a cholesterol lowering agent. And I always warn them in advance, it's that part's not going away.

42:13It's going to stabilize. but if we can get your cholesterol as low as possible, we can prevent soft plaque from forming. And that's really the target of the treatment. We can see soft plaque not with a calcium score, but with something called a CT angiogram, a cardiac CTA. And that can be an image that we use to look at both soft and hard plaque. In general, I would say the insurance indications anyway for getting a CCTA is when you're having symptoms and so we generally won't just order it for someone because they want to know but you can pay for it out of your pocket. I do have patients who actually will say can I just have that study anyway but if you have symptoms we certainly can it's a good good way to really know the anatomy know what's going on in the heart arteries and seeing is believing and we can really now we can use different techniques with AI and other things that measurements that we can do that we can even tell if the degree of stenosis in this coronary CT is significant or not.

43:26Is there plaque regression? There is there can be plaque regression and we've seen that in our cholesterol lowering studies particularly with statins, where they looked at people who were randomized to statins versus non-statins and saw that the soft plaque did regress. We generally, we don't repeat those studies in our patients routinely. And depending on what imaging you had, like I said, if you've had calcified plaque, and that's all you know, you're not going to expect too much regression of calcified plaque. But soft plaque, yes, you would expect it. We don't always measure it, but we have it proven in studies when we lower LDL cholesterol that we can reduce or regress plaque.

44:16Dr. Gabrielle Lyon:From a clinical standpoint, what I'm hearing you say is that hard plaque is seen. That is what you will get when you get a normal CT. A CT angiogram will show both soft and hard plaque. The hard plaque is staying there. We don't really care about it, but it's the soft plaque and it's the progression of soft plaque. My question is, are we looking to mitigate it from getting worse by diet and lifestyle and maybe pollution? I can't get out of my head what you were saying in terms of the impact of pollution? Or are we looking to monitor that soft plaque? Because if we know it's there, is this an impending doom situation?

45:00Dr. Gabrielle Lyon:Or are we targeting, say, LDL cholesterol, making sure that is low, ApoB, under 70? These are the things, but the plaque will progress anyway, soft plaque? No. Well, if we see plaque of any form, soft or calcified plaque, it doesn't matter to me. Once I know there's plaque there, I know you have atherosclerosis. So my initial response to that is get the cholesterol low, get the LDL under 70. LDL cholesterol. So not under 100. Get it under 70. No, LDL under 100 is ideal for everybody. But once you have plaque, to me, you have atherosclerotic cardiovascular disease now. You know, you haven't had a cardiac event, So we wouldn't call you secondary prevention, but would I call you primary prevention?

45:47No. I actually like to call you primary and a half prevention because I'm trying to prevent future cardiac events because you haven't had any, but you already have plaque. So at that moment, you have atherosclerotic cardiovascular disease, and we should target your LDL under 70. And if you are already somehow lower than that, then we should target you even lower.

46:11Dr. Gabrielle Lyon:Okay, okay. So there's a lot to talk about here. This is a big deal. Most people are not going to know they have heart disease. Let's say their EKG, their blood pressure, their cholesterol is quote normal. They go in and they get a clearly scan or a CT angiogram. They have some plaque, but all other markers are normal. Would that person still want, and when I say normal, they have a CT angiogram score of what, 24, 50. So it's really low. Would you still push that LDL cholesterol under 70? And then, so that's the first part, what about brain function, hormonal function, all the other things that are secondary after lowering cholesterol?

47:02Yeah. So, I mean, we should always be treating all cardiac risk factors preventatively anyway. But once, like you said, once you've identified plaque, that person, that healthy person that you're talking about with absolutely no symptoms, but a small calcium score in the 25 or 50 or whatever you want to make up, I still would say that person now has plaque. I'm going to target their LDL under 70. Now, would I give them aspirin? No. If it's under 100, I'm not going to give you aspirin, but we do have some data when your calcium score is above 100, I would give aspirin as long as you're not at a heightened bleeding risk.

47:42And that, of course, needs us to talk with our patient and do some shared decision making. I have some patients who choose not to be on aspirin because they bruise or bleed easily, or maybe they have something going on that makes us more concerned. I never want anyone to bleed out on aspirin, but we do have a suggestion that when your calcium score is above 100, that aspirin may be beneficial. So I see plaque, you know, when I can get that visualization, seeing is believing, there's plaque there. And I can do something about that to lower that individual's risk. It always comes down to, of course, the patient in front of me, and what do they want to do?

48:23And whether, you know, some patients will be, I just really don't want to be on a cholesterol lowering agent. Let me see if I can do it with lifestyle. So I often will, and I, yeah, that too. Does that work? 500 grams of berbering? the ID there's no evidence but um we but I will work with them because I do think it's powerful if you can you know especially if somebody doesn't have a very good diet and if they want to try to bring it down but I still talk to them about what statins particularly do in terms of you know plaque stabilization endothelial function of the arteries all the things that we also get beyond LDL lowering that are in statins that could be beneficial, but if they choose that and can really push, choose lifestyle and they can really push it down, I'm okay with that too.

49:12We should all try to optimize our diet and our exercise, but I will say that for patients when they get a calcium score or they get a CCTA, they are definitely more likely when they, when we look at their images together and they see the plaque, they are more likely to be aggressive about the lifestyle changes, but also more aggressively want to lower their cholesterol. Because once they see that plaque and they see it in their arteries, and it's something an untrained eye can appreciate when you look at that scan, they're like, okay, yeah, that's not a good thing. Okay, let's now be on a cholesterol lowering agent.

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51:27Dr. Gabrielle Lyon:It's too big of a risk to allow that soft plaque. Again, it's complicated to talk about because cases are complex and people are complex. But if we were to lay out a quote, low risk individual with a low calcium score that has some hard plaque we know they have soft plaque we expect that soft plaque to develop and we want to move their cholesterol down um ldl cholesterol below 70 do we have other downstream concerns not as far as i'm concerned and let me explain why you know if you think about your vascular system it starts at the heart but right this whole vascular tree in our body spreads everywhere, so to the brain and to our legs and extremities, everywhere, to every organ.

52:17Those arteries, you know, the reason we often use the coronary arteries is they're actually bigger than the other arteries that we have difficulty visualizing. If we could do the similar thing to our brain, if we saw plaque in there, we would treat it. And we know neurologically that people on statins are less likely to go on and have stroke or to have even vascular dementia or Alzheimer's disease. And so there's a lot of people who somehow have this misconception that being on a statin affects neurologic function adversely. Actually, it is brain protective as well. And so I think that people need to know that, that, you know, I know I have patients that describe to me this brain fog with statins and if they can't tolerate a statin then I change them to some other LDL lowering agent that's the good news living in 2025 we have more than just statins but statins we have had for now four decades and so we really know them well and the the long-term risks of them are really not proven there's a lot of misinformation online about statins.

53:26Statins are the like enemy on the internet. When people bring me in what Dr. Google tells them about statins, I will always counter that we have a lot of evidence. We've been doing very large trials that have really taught us the most about statins. You know, there is maybe an increased risk in some people for developing diabetes, type 2 diabetes downstream with statins. But what we do know about that data is a couple things, is that the people who tend to get type 2 diabetes who have been on statins already had risk factors before for diabetes. So we don't know that it's the statin, or is it because they already had risk factors, that they were already pre-diabetic, for example, or that they were overweight, or both, that are actually increasing the risk for diabetes.

54:18studies statins and other LDL lowering agents are held to such a high standard when we study them these are large population studies there's no other drugs except for the cardiovascular field that is held to doing studies in large populations and I think people should have some confidence in those studies but talk with their practitioner talk with their physician or their team about their concerns because everyone has concerns they have a friend who was on a statin that didn't have a good side effect or they have a family member or they just have concerns because of what they read together we'll work out and find out a medication I always tell them I'm never going to put you on something that you're going to hate or is going to affect your quality of life and I don't care if it's in your head or if it's genuine it's there we'll find something that works and we're lucky to have more than one medication?

55:14Dr. Gabrielle Lyon:As you were talking, I can't help but think about the female specific. As I filter through all my conversations about heart disease, one of the most common things that comes up, believe it or not, is erectile dysfunction and heart disease. And as we were looking through your research prior to having you come on, And, you know, there's a difference from the traditional fitness formulas for men and women, which really has been a huge contribution from you, which I'd love to talk about. But also, I just realized that the lens that I've been thinking about this, I think about erectile dysfunction as heart disease.

55:53Dr. Gabrielle Lyon:Tell me, is there erectile dysfunction and heart disease for women or something similar? Erectile dysfunction. Because everyone's listening now. Yeah, yeah. If you weren't before. Erectile dysfunction, of course, for men is a big issue. And we don't have the biological equivalent for women that we can associate with being a warning sign for heart disease. The one thing that I will say that we've been really missing, though, in women is the fact that women often do have cardiac symptoms. And the thing is, is when they have these symptoms that sound like ischemic heart disease, that sound like there's reduced blood flow to the heart.

56:32And we'll do evaluation, whether that's a stress test, whether that's a coronary angiogram, and we don't find a blockage in the coronary, unlike men where we often find blockages in the coronary. Until recently, we were just dismissing those women. We were saying, don't know what your symptoms are, but they're not cardiac. Go on your way, and this is not your heart. And these same women would come again and again to the emergency room, come again and again and allow another angiogram to be done on them or whatever testing was done. And they were often dismissed because they had no blockages. So now we talk about ischemia with no obstructive coronary arteries.

57:12It has a night, you can see that cardiologists love names of things. So we call it a NOCA, but NOCA stands for ischemia with no obstructive coronary arteries. And that happens much more frequently in women. And I think we've often been dismissing women when they had symptoms and not treating them. And a lot of the work we do at Cedars-Sinai actually focuses on women with ANOCA, trying to figure out what's the best way to detect it, but also what's the best way to treat it. We know from some of the early work that I did with some of my colleagues at Cedars, even before I arrived there, I had a normal cohort of women and we compared them to women with ANOCA and we found in contrast to what had been told to everyone that these are, you know, this is nothing, do nothing with it.

58:03We found using the population called the WISE women, Women Ischemic Syndrome Evaluation Study, we found those women with ANOCA were much more likely to be hospitalized, much more likely to have heart failure, much more likely to have cardiac events. And we found that link, again, specifically related to heart failure. And now we're connecting Enoka with this heart failure with preserved ejection fraction, that they may be along the same pathway. So we are, I think we don't have an equivalent of erectile dysfunction, but I do think that women's symptoms, women are in touch with their bodies. And the reason I say that is not being biased being a woman myself, but, you know, every month after whatever age people have menarche, we know our bodies, we know when we're going to have our period, we sort of know our body changes and then it changes again.

58:59And so we're in tune with our bodies much more than men. And we know when something's wrong. And I don't think women waste their time in the emergency room or going to the doctor unless their symptoms are real. And what we have been doing as an injustice for women is discounting their symptoms, discounting their chest discomfort, their palpitations, their shortness of breath, and asking them frequently, are you anxious? Are you depressed? What's going on at home? We're all anxious. We're all tired. We're all probably have some level of depression with life, but that is not why we're wasting time in the emergency room.

59:43People come to an emergency room or come to the doctor because they really have something wrong. And if a man came in with the exact same symptoms, we know he would get evaluated. And his heart would be the thing that every doctor is thinking about first and foremost. And for women, it's almost you have to beg to get an EKG before somebody even thinks about your heart.

1:00:04Dr. Gabrielle Lyon:We're talking a lot about the difference between men and women? And what about heart attacks? Is there a difference between a woman, her symptoms of a heart attack versus a man? That's such a good question. I think that we have somehow misled women to think that they're so different than men, that sometimes when women are having symptoms of a heart attack, they don't think they're having a heart attack because they're somehow told it is different. We have contemporary research that has shown actually that 90 % of women and 90 % of men actually report chest pain or chest discomfort when they're having a heart attack.

1:00:41So in most people that's present, but the difference between men and women is this, women are more likely to have other accompanying symptoms. Chest pain may not be the most important symptom that they actually experience. They have it, but the question is whether us as physicians actually hear it because they may actually have more shortness of breath. They may have neck pain, jaw pain, back pain. They may have profound fatigue. I will tell you women are more descriptive in their symptoms at a time of a heart attack than men and we know this is true from a bunch of studies now. The Virgo study which was women under the age of 55 who had a heart attack.

1:01:22We have the high stakes data which was the ones that brought us the high sensitivity cardiac so that was all age men and women. And then we had this really interesting study called the Hermes study. And the Hermes study used cardiolinguistic technology. So a type of AI, it was really a computer that recorded every word that was said as a doctor and the patients talked. And it was men and women. And in that study, so interestingly, just like those other studies showed 90 % of men and 90 % of women did say the words chest pain or chest discomfort. It's again, though they did find that women had more accompanying symptoms.

1:02:02They were much more descriptive about what they experienced. So if someone's experiencing chest pain or chest pressure, and especially if they have cardiac risk factors, they should be evaluated for heart disease and they should be seen as quickly as possible. They should call 911. They should not delay. And if someone does not evaluate their heart before they leave that emergency room, they should ask, do you think I'm having a heart attack? Because at least then I think an emergency room team would ultimately say, okay, let's just make sure and get an EKG or get the blood work and not attribute those symptoms to stress or anxiety because we're all stressed.

1:02:43And especially when we're having chest discomfort, we're all anxious, but everybody, male or female, deserves to make sure the leading killer is not present.

1:02:53Dr. Gabrielle Lyon:Hopefully we're moving in the right direction. I mean, definitely with people like you who are advocating. And yet there are still areas where we're so far behind, particularly fitness. I mean, you walk how many how many miles do you walk or jog a day well I walk three miles to work in three miles home so I get always six miles but I actually run my dogs beforehand before I go to work and I do resistance training before I can go to work so I'm I try to practice what I preach maybe to a point of obsession but I really think it is so important that you know some of the work that I did do show that the more physically fit you are the longer you live independent of all your other cardiac risk factors so it's an independent predictor of both cardiovascular mortality dying from heart disease or dying from any cause so exercise is medicine i love that i definitely believe that to be true Have there been studies looking at the kind, for example, if someone is really busy and there's a lot of discussion on cardiovascular, zone two versus high intensity, which actually came out of McMaster University, and resistance training.

1:04:08Dr. Gabrielle Lyon:How do you place them in order of importance for men and women? Yeah, I think men and women both need a dose of both. they need aerobic activity and they need resistance training and it's funny because men tend to be more likely to do resistance training and women this is a generalization but women tend to do more aerobic activity and are less likely to do resistance training and everybody needs a bit of both our current guidelines all over the world are exactly the same for men and women. It's 150 minutes a day of moderate to intense aerobic activity and then we say that you need that much 150 minutes per week and then you need at least two 20-minute intervals of resistance training.

1:04:59So that's a generalization because we know activity is good for you but I do think that we are learning more about differences between men and women and some of the work that we published last year really showed that actually women for once we had good news for women that women got women got more depressed over here well they got more bang for their buck if they did the same amount of exercise as a man they actually reduced their cardio their risk of cardiovascular death more so than men and also reduce their risk of dying from any cause more so than men. And so, you know, men really needed to do more activity and that was true both for resistance training as well as aerobic activity.

1:05:47So maybe women get more out of exercise and maybe one day we'll have guidelines that say women need to get away with less. The most important thing though is that women do exercise and that that right now we know that men at every age there's more men do regular activity and women as we age we start doing less and what we need to do is try to build it in at the youngest ages because if it becomes habit I think one of my my recommendations is like schools should teach and equip our children for their future adulthood yes team sports are great but you're not always going to have a team. So those of you who played on a soccer team or football team, what do you do after you leave high school or leave you know where in college maybe you have intramural sports and you find teams to play with?

1:06:43We all need to have an ability to find activities that we love that bring us joy that we can do alone too. It's nice if you have other people you can play with but if you can do it yourself you're more likely to do it and you do it on your own schedule and that's what we need to equip everybody with a little bit of training and resistance training and aerobic activity and when I think of my school and I grew up in Canada I don't know if it's different in the United States but I remember even when I played on the soccer team the men's soccer team would go into the weight room and train partially there we never were invited into the weight room and most of our training was running around the track so that we could run after the ball so they just wanted us to get faster but nobody ever talked to us about strength training and I feel like this is something I acquired quite late in age where I suddenly started seeing the benefit of resistance training even for my own work research work and then I was like, I got to start learning how to do this.

1:07:48And at quite a later age, I started picking up weights. And not that it has to be weights. People can find many different types of resistance training. But that for me is a new thing that I do every day now because I love it. But I wish I had learned it before.

1:08:03Dr. Gabrielle Lyon:Is there a difference from a cardiovascular standpoint? And that's a really broad question from endurance training or cardiovascular training versus strength training. In my mind, when I think of zone two training, I'm thinking of continuous, moderate activity where your heart is pumping continuously versus strength training. It's a spike and then a relax. The long-term outcomes, do we know the difference in cardiovascular impact? No, we just know really right now from big population studies like the one we did is we know that in terms of cardiovascular mortality there's a reduction we don't know we don't have enough data to say what even enough about all the different types of things that constitute resistance training so there can be of course you can do things like heavy weights or even small weights but you know resistance training is also things like pilates or yoga and people can do those intensely or not so intensely.

1:09:09When we study from a survey the way that we did, we didn't get to ask, you know, more than that. And so we have small studies where people have done, you know, studies of 20 people doing weightlifting or 20 people doing different types of resistance training. But all we learn about that from that is like the hemodynamic changes, not so much what exactly is changing in the cardiovascular system and how, you know, is there one type of activity that's better than another or is even the duration, I would say we've kind of made up the duration.

1:09:47Dr. Gabrielle Lyon:Mom jokes coming in hot. Okay. My old pan was so toxic. Even my veggies wanted to detox after dinner. Okay. My mom jokes aren't that good, but seriously, nonstick cookware is still being used because it's convenient, but it comes at a cost. Non-stick contains harmful chemicals like Teflon and other PFAS, which is leached into food. Now, if I could go back in time, I would change out my toxic cookware to Our Place. And it's never too late to make better choices. We get rid of toxic people. You should do the same with your pots and pans. And we use Our Place, which is a toxin-free, high-performance cookware, and we use their appliances.

1:10:29Dr. Gabrielle Lyon:They are designed for safer, simpler use, and there is no hidden dangers of these forever chemicals. It's not worth it, and again, it's the one thing that I wish I had changed. Our Place four-piece cookware set is the best way to start if you want to overhaul your kitchen with a multifunctional space-saving pan and pots. You can get your set at fromourplace.com, one of the sponsors of the show. That's fromourplace.com slash Dr. Lyon or use the code Dr. Lyon for 10 % off. Also, they have a 300-day risk-free trial. Hopefully, we will begin to get better at the recommendations Again, it's very difficult to make generalized recommendations for entire populations.

1:11:27Dr. Gabrielle Lyon:Yeah. It's the best we can do, which leads me to this idea of the traditional fitness formula, 220 minus age. Oh, that's your heart rate formula. What did I say? Fitness formula. We even have a fitness formula, but yeah. Tell me, is this inadequate for women? Yeah, so if anybody who's listening is ever interested, you can actually find the paper that described 220 minus your age. And the 220 minus your age wasn't even a good formula for men. And it was, if you look at it, though, they used five studies of men who were preparing for the army. So they were at the VA, and we used to put these men on treadmill stress tests.

1:12:11And that's where we learned a lot about normal physiology. But these were young men, right? Going off to the army. Or Navy. Or Navy. Yeah, I don't know at the VA, who is it everybody? I'm too Canadian to actually fully know. But there were all these studies done at the VA. And so they learned a lot about men. But even that formula, they just said most people would fit in this formula. And the person who described that formula never thought that this formula was going to be the most used formula. It's the most used formula in medicine and it's the most used formula actually by lay people because we use it, many people use it when they exercise or if you're like me and you wear a smart watch and you follow your heart rate when you exercise, when it's telling you you're in the zone, if you use a Garmin or an apple and you're trying to achieve it, it's all based on that silly formula of 220 minus your age and for women at least we know that that formula isn't accurate.

1:13:10So I was really fortunate when I was just finishing my training, I fell into this study called the Women Take Heart Project and it was a study of just under 6 ,000 women in the Chicagoland area. We put them all on a treadmill, sort of like the veteran men, but they weren't veterans and they, they exercised for us using the same protocol that we had used in those older studies and we found from that again we created our own formula it's not sexy and it's not easy to remember but our formula is 206 minus 0.88 times your age which I know nobody will remember

1:13:47Dr. Gabrielle Lyon:are you kidding uh everybody listening is going to remember that this is I guarantee you this is the first time that team have you heard this Juliet Matt is Matt here producer we've never heard that and we've never heard it this is our third year on the show and again we only select the very best the best we've never heard that yeah well we we need to be using formulas that fit for women because it's important we know that of course there's not when you whenever you make up these equations there's some people that are above that number and some people below that number and it's really a mathematical regression equation that you've created out of a large population.

1:14:29So you don't get too worried when people are off, you know, when people are like, my heart rate is 10 beats higher than what it said by the formula. I always tell people like, how did you feel? How was the exercise? You know, that can tell us a lot. The talk test can simply tell us if you're in the right zone of training, depending on what you were trying to achieve. But it's a way to say for a population where your heart rate should be. And it is, this is part, One is such example of why we need to study women rather than just apply formulas based on men and say women are just small men. We are physiologically different and there is going to be differences in how we respond to exercise.

1:15:11It is.

1:15:13Dr. Gabrielle Lyon:I have to pause and think about this. I believe that to be true and I'm grateful to have you say that because right now with the tools that we have so much in exercise science from what I see I struggle to see really well designed studies that show this training is sex specific and I do believe eventually will see that but even through the lens of something so simple as this um you know equation even the analysis of that data of you know looking at endurance or heart rate activity is probably going to be have done through this lens of 220 minus your age and i understand i'm not saying that this makes or changes huge numbers again i don't know but the fact that it's wrong is a problem.

1:16:12Dr. Gabrielle Lyon:And to the other thing that you are saying, the other sentiment is that we're clearly different. We might not have the data yet to prove exactly how or how that translates. You know, I just think from a resistance training standpoint, a well-designed program is going to be a well-designed program. But there are probably things that we're not considering that we just don't know yet. Absolutely. And I think we aren't always, we shouldn't assume everyone knows everything about us. I mean, this is why my mom does. We told me, she's told me for many years. Yeah, no, we the research, you know, that's why we do research.

1:16:55And that's why science is so exciting. And why medicine is so exciting, because we don't know everything. And that's why we should ask questions about even the data that we use as physicians who was it based on where did this come from what ages of people were in there did they include people like me a woman me a south asian woman walks a lot but you know every on time everybody we should know this about it and i i think it's the burden a little bit is on obviously us as a medical community to say who does this data apply to because our patients don't always know these things and it you know we can debate them in the medical community but then whether it gets translated to our patients is a completely different uh question but I think that that's we there's a lot of things we don't know still and that's what makes medicine fun because every day there's discoveries there's new drugs there's new techniques new interventions new devices um and we're learning because you know not everyone even when we talk about working out everyone works out a little different everyone's resting heart rate starts out at a different place if you're somebody who exercises a lot probably your resting heart rate is a lot lower than somebody who doesn't exercise very often so even you have to take those caveats even when you make these formulas but you know when we make these smart devices and and you know what happens is that a lot of patients will come in because they're concerned about what their device is saying they feel fine but the device is telling them they should be tired or you're not working out in your zone or you are you know you should back down because your heart rate's too high or whatever the thing is and and these devices that we wear as smart as they are have not all been tested in fact very few of them have been tested for accuracy so I also like devices because they like we all like getting feedback right but no I don't know it's gonna say your sleep sucks and uh I yeah I know that well when we have these things though people should know that very few of them have actually been assessed for accuracy so they're marketing them to you but whether they're accurate or not is a complete different question so don't get too bothered by them if you're someone who loves the feedback.

1:19:22And if there is something concerning, bring it to your physician because they might decide you actually need a more accurate assessment of whatever problem has been identified.

1:19:32Dr. Gabrielle Lyon:I have to point something out. On this podcast, we bring innovators, true trailblazers. Do you know Abe Morgenthaler? No. So Abe Morgenthaler was a Harvard-trained urologist for 40 years they were castrating men because of this idea that testosterone caused prostate cancer somehow he figured out he questioned the status quo everyone called him crazy he went down to the basement of harvard he pulled out this paper that was with one person and he proved that it was wrong. Our last, one of our last podcast guests, Dr. Larry Lipschultz, another urologist, we joke, I have the number one men's health podcast.

1:20:21Dr. Gabrielle Lyon:I'm just kidding. But he was the guy who innovated the feel of male infertility. And now I have Martha Gulati on here. And for some reason, you thought to say, you know what? we're defining normal with thisst james women take heart cohort right this idea that um my metabolic equivalent is the same as my husband's which is everybody's using 220 minus their age you said you know i i don't think that that is right was there a reason did you have a feeling it's very unusual for individuals especially trained in the traditional medical systems to make such innovations in a moment? Well, the reason I asked the question actually started with fitness level, and I came up with that formula for women too, from the same cohort of women.

1:21:21I remember right at the time where I was finishing my cardiology fellowship, we all supervised stress tests. And I always knew women didn't go as long as men and their fitness level, because that's how you estimate someone's fitness level when you put them on a stress test. It was clear that there's a difference partially because of our muscle mass, partially because we were a little bit shorter than men. And when you put them on a treadmill, sometimes it's more, if you're shorter, you don't have the leg spread to go uphill as easily, or it's just much harder. So you end up stopping sooner. So I knew that there was a difference.

1:21:56And I, you know, was wondering why in the guidelines, there was just this one formula, and it was for men and women. And so I went and pulled that paper. Where did it come from? Those same veteran men. And I was like, You're not excited. I was like, okay, this is for men. What do we know about women? And so when I had the opportunity to take over the Women Take Heart study and realizing they had all had a stress test, that was the first thing. I'm like, I am going to find out if their formula actually works. And I found it did not. And we published in the New England Journal of Medicine, actually, the formula for women for their fitness level.

1:22:32and then we validated that formula in a group of symptomatic women showing that it by if you were under your age predicted fitness level you were more likely to die from cardiac causes so that formula now we use in our stress labs and say this is you know we have what percent of your age predicted fitness level then I asked the question actually about the heart rate second I was like okay what about that formula is that even accurate in women I think that I think because I had always been in tune that women aren't exactly small men, that I wanted to know what I'd been taught. Was it accurate? And I tell everybody that, you know, when I train medical students and residents and fellows, like question where the data came from.

1:23:19Go look sometimes, sometimes 20 years after we've been doing things and we think we're doing it right. And then we suddenly find out, you know what, we weren't doing it right, or we didn't know. and we assume when you assume something you know there's that expression but you should also where did the data come from did it come from good reliable data or is it something we can now study and make sure it's accurate and especially whenever something's identical for men and women I always teach my trainees ask are you sure make sure it's true because the more when you look for sex differences, you often find them.

1:23:56Dr. Gabrielle Lyon:Do you think that that translates to dosing, both, again, dosing and exercise, dosing and medication? Because right now, the majority of medical care is not, okay, so your dose of azetamide is 10, but actually you're a woman, so your dose is 7.5. That's such a good point. And I actually think that that's important questions also that we need to ask. You know, when we think about medications, and if you remember in medical school, we all learned, but you remember the pharmacology, they would tell us very clearly that medications, how they were metabolized, how they were absorbed, how they were excreted, was different if you were a man versus a woman, and even a pregnant woman.

1:24:43So all, we always knew that there was some sort of difference. And yet, when we study the drugs, they would put either all men in the study or clump it all together and not analyze if there was a difference between men and women. So think about a common drug that we use for blood pressure. A lot of people might know this or be on it. It's called hydrochlorothiazide. But the problem is, is that when we use that medication, we are more likely to see electrolyte abnormalities in women than men. Why is that?

1:25:13Dr. Gabrielle Lyon:Do you know why? Well, the distribution is greater for women at the same dose. And so it's excreted slower in women. And so it's not surprising that women would have more electrolyte disturbances, and as a result, have more arrhythmias when they're potentially on that medication. And we should be aware of it. It doesn't mean we can't use the medication, but we need to be aware of those sex differences. Similarly, beta blockers, we use a lot for hypertension and also for heart failure and coronary disease, but for women at the same dose blood pressure drops more, heart rate drops more. We should be aware of those things when we use drugs because then we might understand why women have more side effects than men.

1:25:58And some drugs we don't have any differences but you know we need to find out, we need to study and we need to include women and men in the studies, analyze it by sex so that we really understand is there a difference because a lot of drugs and this isn't just true of cardiac drugs this is true of drugs for every organ system that there potentially could be a difference in how they are metabolized how they are absorbed how they are excreted that might change how long they last in the body and their side effects and dosing we know even for some of the drugs that we commonly use in heart failure like ace inhibitors, women get full effects at lower doses compared with men.

1:26:42And that may be why at higher doses we don't need for women. But we've never written any of our guidelines to date have said different doses by sex. And so that's what we need to be looking at in the future. I won't say we're there yet. But I will say that, you know, we certainly need to be looking and we are working with our pharma colleagues, because we have been pushing them to be more inclusive when they are doing new drug trials, to get more women into trials, to make sure that it's representative of our diverse population so that we really know that the drugs work in the people that we care for.

1:27:25Dr. Gabrielle Lyon:Very, it's so informative and just really important work. You also mentioned something before we were recording that I had never heard about before. And this is really the environmental impact on cardiovascular health. We spoke a lot about soft plaque as this, would you say it's an inflammatory agent or process that is happening? It is. Okay. Soft plaque is driven by poor lifestyle correct so sedentary behavior being obese smoking um diabetes high cholesterol high blood pressure stress whether that it's emotional or physical stress can at least accelerate the process when you do have underlying disease process or inflammation in your body and it's safe to say that the soft plaque is the outcome.

1:28:28Dr. Gabrielle Lyon:All of these inputs, the soft plaque is the outcome, right? Soft plaque or rupturing of that plaque. And I'm going somewhere with this. Yeah. Those are known entities. We know that if you are overweight or you're smoking or you're eating a crappy diet, that you are increasing inflammation. But one of the things that we don't think about is the environmental influence. We think a lot about the environmental influence on our brain. Am I exposed to mold? Is this heavy metal in my bone? Very rarely, at least I don't think much about it. I think about it in the lungs. I don't think about the environmental impact specifically on cardiovascular tissue or the influence on soft black.

1:29:16Yeah, I think we need to be thinking more about the environment and its association with cardiovascular disease, particularly with plaque and plaque rupture. We know that if you are living in certain geographical areas where there is higher pollution, that there is more heart disease. We know that after forest fires, like the fires we experienced in Los Angeles, that again, there is more heart disease. than was preceding a forest fire, especially when it occurs in a big city. And there's some, there's studies that are going on right now to really examine that after the LA fires. So we know that environmental pollution is a big risk, and we need to be able to capture it.

1:30:05We know from big population studies, when we look at zip codes, and we see these differences, the EPA actually can gives out what daily exposures are based on your zip code. and so we you know one of the things I talked about earlier with you was how our new risk score does actually have your zip code and so if you plug in if if you're plugging in your prevent risk score and you plug in your zip code your zip code represents a lot of things one of which is the pollution that is in our environment and pollution you know we're learning a lot more about it I think I will still say we have a long way to go to fully understand the pollution effects but there is the environmental pollution that maybe sometimes you can see like on a smoggy day in Los Angeles we all know that it is there's more pollutants in the air and the reason that I think a lot of people notice those pollutants is because of breathing we know people with asthma will have more trouble outside that day and people can almost see that haze but you know sometimes the invisible stuff and we talked a lot about this during the LA fires actually was that things even when the sky cleared even when the index that you would get on your phone would say that today was okay but the part that it was not measuring is the plastics in the air because when things burnt when all these houses burnt down in the air was released all kinds of toxins including plastics that we're probably going to be contending with for a long time both in our water supply in our oceans to our you know wildlife and in the ground that people are rebuilding their houses on so we have a we have a lot more to do about understanding it there's just a paper actually this morning I didn't even get a chance to read it but I wasn't surprised by the headline was that sound pollution as well is harmful to the heart and we know that there's all kinds of different pollutions that we need to be assessing and worrying about.

1:32:07Our environment has dramatically changed as we're all experiencing climate change has affected the whole world and that climate change is making places hotter, making natural disasters more and again even at those times when we have heat waves we see higher risk of heart attacks. So there's a lot going on right now in our world that I don't think we fully understand but I do think that they're we're working very closely now with environmental scientists there's actually a great group here at Houston Methodist actually looking very specifically at the environmental effects and cardiovascular disease so they're doing some pretty exciting work right here in your backyard.

1:32:48Dr. Gabrielle Lyon:Well I might be paying them a visit so I'll get those names and And probably be wonderful to talk to them. You mentioned earlier that women are not small men. And when we think about cardiovascular health and disease, what is the difference between a woman's heart and a man's heart? Well, I mean, to begin with, they're smaller. So anatomically, you know, I tell everyone to make a fist. And usually that's kind of the representative sign of the size of your heart. So size matters, but of course, how we respond physiologically to insults differs if you're a woman compared to a man. And so, you know, when we talk about the disease processes that we see that are different between men and women, men are more likely to have those blockages in the coronary arteries that people hear about and seem to be familiar with, whereas women don't have those blockages, but have the small vessels react differently.

1:33:52And that's where the disease actually begins before they get blockages. That's that disease state that we had talked about called ANOCA, ischemia with no obstructive coronary arteries. And it's the small vessels that we can't see, but we can detect reduced blood flow to the heart by certain types of testing, like stress testing. Additionally, even the types of heart failure that we get are different. And there seems to be a difference in the response to stressors or the risk factors that make heart disease more likely. So if a woman has diabetes, for example, she is much more likely than a man with diabetes to develop heart disease.

1:34:32And we don't entirely know why. We know that there's more inflammation, but we don't understand exactly why is a woman's vasculature, why if you are a biological woman, you have a difference in response to being a diabetic than somebody who doesn't, somebody who's a, you know, a man. And that's not entirely clear. We see it even with smoking. So tobacco, you know, a woman smokes the same amount as a man, and she will actually have more vascular damage than a man. So there's something about being a biological woman that sometimes these risk factors actually cause more damage and may change the underlying pathophysiology of the disease.

1:35:17We know even though how women get treated though sometimes is different just simply because of our size. So when women get something called aortic stenosis almost at the same rate as men do. It's a where the aortic valve gets very calcified and it needs to be replaced. For a long while women were dying during surgery so they were less likely to be offered surgery but now we have a procedure called TAVR where it's a non-invasive way or a less invasive way I should say. It's not open heart surgery where we can replace that aortic valve but who did they design that aortic valve on men and so the size of it wasn't always fitting most women and that led to less women actually being eligible for a TAVR.

1:36:10I will tell you though the good news is in the last two years we've had some really big studies where they developed a smaller valve replacement that seemed to be the right size for more women and we showed that women actually have really excellent outcomes. It's the same though with all our devices. Sometimes we build the device based on a man and we don't even think about even the anatomical differences, the size differences between men and women. We're still figuring out though a lot of the other things that are different or how sex specific risk factors affect the heart and why they're making women at a higher risk for heart disease.

1:36:49And I don't think we fully have all the answers right now.

1:36:52Dr. Gabrielle Lyon:Dr. Martha Gulati, with you on our team. I'm sure that we will continue to improve. And I just have to say, I thank you from me personally, and I know the audience, but really for all women. Thank you. Thank you. It was such a pleasure to be here with you. Heart disease is not just a man's disease, and women are not just smaller men. Dr. Gulati's research proves that when we take sex-specific science seriously, we can catch heart disease earlier, treat it better, and prevent more lives from being lost. So if you've ever had unexplained fatigue, chest pain, shortness of breath, or we're told it's, quote, just anxiety, don't ignore it.

1:37:37Dr. Gabrielle Lyon:Know the tests to ask for, know your risk, and advocate for care that sees you fully. If this episode resonated, share it with a woman you love. Want more science-backed tools for strength, longevity, and prevention. Subscribe now and stay strong.