 So, before we get started, we should define what is heart disease. So, there are many forms of heart disease, and that includes, you know, the avial dysfunction that includes issues with the heart muscle or the myocardial itself and also includes issues with conduction disease, but the most common cause of heart disease is coronary artery disease. And when we talk about coronary artery disease, we're referring to plaque buildup in the arteries of the heart itself. And so with CAD or coronary artery disease, it's a disease process that develops over time. It takes many years for it to improve. And eventually, what happens is that your heart or the muscle, your heart doesn't get enough nutrient rich flow as a result. And so when we refer to atherosclerosis, we're essentially referring to plaque buildup. And so, as I mentioned before, once you have, once you develop enough plaque, the plaque can obstruct the inner part of the artery of the heart and that restricts blood flow. And ultimately, that can cause the part of the heart that's blocked off to die or to have abnormal rhythm. And so, and this is usually considered coronary or heart artery problem, but it's not only confined to the heart. You know, atherosclerosis is a process that developed throughout the body and all the arteries. So when you pick up stroke, it can involve the arteries supplying to the brain. And when you think of having peripheral vascular disease or circulation issues, it can involve the arteries supplying blood to the legs. And so how do these coronary artery plaques form? And so essentially what happens is that you have the inner lining of the blood vessel, the inner part of it, and once it's damaged, the body attempts to repair this inner lining by essentially causing platelets and other vascular sub-factors to come in and essentially form a scar or a stab over that area to seal it essentially. And what that does is that invites excess plaque or excess cholesterol in the bloodstream, in particular LDL particles or the small cholesterol particles, which then attach to this scarred area. And then this then further recruits other elements in the bloodstream, as far as monophages or white blood cells and inflammatory heart cells, which then layer on top of each other until you ultimately develop this fibro-fatty plaque. And so over time, this plaque buildup approves and gets to become larger and larger. And once the outer portion of that plaque becomes very thin and vulnerable, it can be exposed. And that's the issue, because when it becomes exposed, the body then attacks it, seeing it as a vulnerable site that needs to be repaired, and then ultimately you get an acute blockage. And that can lead to many issues down the line. And so this is a schematic here that essentially outlines what I just described. So you start off with the fatty streak and the inner lining of the artery. In this case, it would be the artery to heart. Over time, those LDL particles or the cholesterol particles buildup, they then recruit other inflammatory cells that are present in the bloodstream to then continue to build up this fibro-fatty plaque. And then ultimately, when you have a very thin wall that's covering this plaque, if that becomes vulnerable or that has an opening, the body sees it as a disruption that needs to be clogged. And so you get this acute platelet buildup. And then that's what leads to heart attacks. And so this is the process that occurs over time, and to cause many acute processes as far as heart attacks, strokes, and limb ischemia, or if you could split both of them. And so why do cholesterol plaques form to begin with? And ultimately, it's a balance between inflammatory markers in the body, as well as your tendency for clot. And this is balanced against your body's ability to naturally thin the blood and also to cause basal dilation or increase of blood flow to an area. And so this balance is disrupted whenever you have any type of processes that increase risk or the amount of inflammation or blood clotting when it's in the body. And these different circumstances include having high glucose or high insulin levels in the blood, because that does increase your inflammatory markers in the body and also makes you more pro-thumbotic or increases your susceptibility to developing clots. And high blood pressure causes high shear stress that tips the balance towards inflammation and blood clotting tendency, smoking as you can imagine. You have toxic substances, which increase inflammation throughout the body and then tips the scales towards developing information. Obesity, which is associated with high cholesterol, high blood pressure, etc. That can also tip the scales and for direction for patients' care and their disease processes. Inactivity, where you have increased basal dilatory properties in the body, which also tips the scale, and we can imagine the seat deprivation. You are essentially having increased stress hormones in the body that also tips the scales in that direction as well. And of course, infection and air pollution that occurs along with the whole thought process of inflammation. So why is this important? So this is important because over time that imbalance that you have in your bloodstream can cause plaque support. And we talked about the mechanism or the way plaque progresses throughout your time in the heart or the arteries throughout the body. And ultimately, it can lead to a heart attack in the case of the arteries supplying the heart and then for the arteries supplying the brain, it can lead to a stroke. And it is this plaque filled up that ultimately leads to heart attacks and death. And so, as you can see here, this is a graph on the y-axis we have death and the x-axis we have a year and you can see that cardiovascular mortality is on the rise for both men and women. So this is something that we need to bring more awareness to as a result. And for women in particular, it is the leading cause of death in the US and worldwide. And so 35% of all deaths in women worldwide are caused by cardiovascular. Okay. 275 women, 275 million women were diagnosed with cardiovascular disease in 2019 and 8.9 million of which died in cardiovascular disease in 2019. When it comes to cardiovascular disease in women, it is understudied, it is under-recognized, it is under-diagnosed, and it is under-treated. And while we know that heart disease is a leading cause of death for both men and women, a gender gap does exist when it comes to diagnosis and treatment. So, for instance, women are more likely than men to die within the first year after a heart attack. And this is due to a multitude of factors, one of which is delayed diagnosis. So, if you have healthcare providers who are less likely to do upfront testing because women may present differently to men when it comes to cardiovascular presentations, that's one way that diagnosis can be delayed, but the other is women themselves. If they aren't aware of the different ways that heart disease can present within women, or just not having, not accepting the fact that they potentially could have a heart problem, even though they haven't had any other issues in the past. And so that can culminate to a delayed diagnosis and ultimately presenting later in your stage of cardiovascular disease than you otherwise would have been had there been a more aggressive intervention. And also for women who are diagnosed with cardiovascular disease, there tend to be less aggressive invasive interventions that are offered. And this is something that we're seeing with more and more research with women who do develop heart attacks. Invasive interventions are not being offered to the same way as men. And they are being prescribed less medications. So, when it comes to aspirin and cholesterol medications and women who are admitted to the hospital for a heart attack, they're not being prescribed it at the same rate as men who have similar cardiac presentations. And also women who after suffering a heart attack are less likely to be referred to cardiac rehab. So as you can see, there are multiple reasons as to why there's a gender gap that does exist in women compared to men. And this has been all explained why women ultimately are more likely to die within the first year after a heart attack compared to men. And despite the increase in awareness over the past several decades, only about a half of women recognize that heart disease is their number one killer. And as we know, heart disease is the leading cause for death for women in the United States. It's killed over 300,000 women in the year 2019 alone, about one in every five deaths in women. And so what attributes to this gap is simply misinformation from commonly held myths. So myth number one, women just don't get heart disease. And we know that not to be true based off the data that I just presented to you before. Because heart disease is the leading killer for women in the United States and throughout the world as well. Myth number two, women are more at risk for breast-reader and ovarian cancer than they are from heart and cardiovascular disease. You also know that to be false as well. So worldwide cardiovascular disease is the single most common cause of death among women. And it's nearly twice as many women in the US die of heart attack, stroke, and other cardiovascular diseases as from all forms of cancer combined. So when you combine breast, uterine, ovarian, and all other, and GI, and women, the rate of death from cardiovascular disease is more than double. Okay. Now myth number three, women are not at risk for a heart attack until after menopause. We know that to be false. In fact, heart disease is the third most common cause of death among women aged 25 to 44. Okay. Myth number four, current research on heart disease applies equally to men and women. We know that to be false based off of recent data that was collected. We know that women only represent 25% of all study participants based off large landmark or randomized people. And myth number five, men and women receive the same treatment for heart disease. And we know that to be false as well. So women are less likely to have an electrocardiogram done within 10 minutes of presenting with potential heart attack symptoms. And they're less likely to be cared for by cardiologists during their admission to the hospital or through their presentation to the emergency. And although we know that women have the standard risk factors that men have, hypertension, high cholesterol, obesity, smoking and unhealthy diet. There are also other sex specific risk factors that make women or increase women's risk for heart disease when compared to men. And this includes premature menopause. We know typically estrogen itself will be cardiovascular when it comes to developing cardiac disease. And so if you undergo premature menopause, you're not having, you're having less years of added protective benefit compared to women who don't have premature menopause. Gestational diabetes associated with cardiovascular disease after pregnancy and also high blood pressure. Okay, hypertensive disorders of pregnancy. So when it comes to the clamps, the clamps here are just gestational hypertension. All of those particular risk factors can increase your risk of developing cardiovascular disease as a subsequent date later on. PCOS or body system are very simple. That particular disease process increases your risk of developing heart disease, diabetes, high blood pressure, high cholesterol. And those particular risk factors, as you all know, are one of the leading causes of cardiovascular or actual death. And throughout the audience at the body when it comes to developing cardiovascular exactly in the future. And then also systemic inflammatory and autoimmune disorders. So when it comes to rheumatoid arthritis, when it comes to lupus, when it comes to APLS. These particular disorders are more frequently developed for women compared to men. It's about a two to one ratio. And a member from what I mentioned before, that is that balance between the blood stream of inflammatory and pro thrombotic factors balanced against the blood thinning factors in the blood. And so if you're tipping the scales towards increased inflammation, you're going to put yourself at a higher risk of developing accelerated atherosclerosis. And in addition, there are other under recognized risk factors that are all that often fall under the stress related category. So women, as you know, are more prone to experiencing abuse and intimate partner violence, psychosocial factors. And when it comes to health literature, not having that same access to educational opportunities throughout the world compared to men. And all of these factors which increase stress hormones throughout the body, which ultimately influence that hormone that the inflammatory balance throughout the body does increase your risk as well, compared to men. The other thing I actually now listed here is breast cancer. So if you have women who have a higher risk of breast cancer, not only the cancer itself with this information, but the treatment for the cancer, all can increase the risk. And so these are all the specific risk factors that make women just as likely to find more like men to develop cardiovascular disease and that's undirected. So when we talk about coronary artery disease or CAD, we break it down to two main categories. Stable CAD or unstable. And when we were discussing stable CAD, what we're referring to is plaque that's pretty stable, that's causing a blockage, and it's leading to symptoms, but it's reproducible in the sense that you can do the same activity and cause it to occur and know that you stop that activity that would go away worse than patients that they have any type of emotional distress that can provoke their symptoms to develop. But then once you remove yourself from that particular situation, then the symptoms go away. And that's considered stable CAD. It's when you really can't determine or anticipate when your symptoms will develop. It just happens out of the blue. It can happen at rest, it can happen when you're sleeping, it can happen when you're sitting there and watching TV. And it's something where the symptoms last for more than 15 minutes. It's not a brief injury because that's something that you can turn on and turn off. And that's important to know because when you fall under the unstable category, it goes under the umbrella of acute coronary syndrome. And when we were talking about acute coronary syndrome, we're essentially referring to a heart attack. Okay. And so it's important for you to recognize what a heart attack is and what are the common symptoms when it comes to women compared to men. Now, first and foremost, the predominant symptom presentation for a heart attack for women is chest pain. Okay. Women are, in addition to developing chest pain, they are more likely to develop additional symptoms, but the most common cause for the most common presentation for heart attack women is chest pain. Okay. And the accompanying risk, the accompanying symptoms that women tend to develop more are compared to men would be associated with shortness of breath, pain in the upper back, pain in one of both arms, having nausea or lightheadedness. To kill this reclammy skin is the symptom that both men and women do experience. And also unusual fatigue, something where it happens all of a sudden out of the blue, I'm provoked feeling extremely fatigue. That could also be another sign of a heart attack. And so to reiterate what I mentioned before, the most common cause, or the most common presentation of a heart attack women will be chest pain, but it's going to be discovered that it's going to be associated with other symptoms as well. It's an upper body back pain between the scapula, pain to the neck, pain to the jaw, nausea, shortness of breath, having a lot of colds, but those are all signs and symptoms of potential heart attack that's developing. And so minutes matter when this is happening. You know, time is my party. My party. And so you want to be able to we talked about the warning signs you want to be able to recognize them because if you're developing the symptoms happening all over the blue. You want to call 911. Okay. Faster you act in more timely intervention to be able to receive. And so you don't want to drive to yourself to the hospital you just want to call 911 because it is not safe to be able to drive and potentially have worsening of symptoms or having abnormal resumes or passing out or all the above. Don't be embarrassed. So uncertainty is normal. It's better to be safe than be sorry. And so if you go to the emergency room and do the full work up if they don't find anything that is a better scenario than delaying your treatment showing up. 1520 30 and then an hour, two hours later, having a delay in your care and then ultimately having more my party of being at a vulnerable at risk or potentially parking. Otherwise, would it be able to be avoided had to come and go. Okay. And so what we're essentially concerned about in this particular scenario would be an acute heart attack. And so we were talking about the different factor of that. So here was a schematic shown the an acute blockage. So you're essentially not getting any blood flow to the heart. You're going to develop symptoms that are hinting at that. So you want to prevent prolonged increase in blood flow to the heart. And so when you arrive to the hospital, they will complete standard set of testing. Depending on your presentation. So if you were to check your blood pressure. And then based off of what they find based off your presentation and their exam, we'll determine what the next steps are. So, based off of what they find based off your presentation and their exam, we'll determine what the next steps are. So it's either for the testing or they might decide to do further evaluation when it comes out of functional or anatomic evaluation. So when it comes to functional evaluation, if there's, if you're primary doctor or cardiology consultant decides if you would be best for the evaluate with the stress test, then they'll do it in patients with nuclear stress test. And then the others, they want more of an anatomic elimination, then they would either do a CAT scan of the chest or or evasive anti-aggression, which really depends on how you present and what you expect yourself. And while all the aforementioned tests are meant to identify a blockage within the heart. There are many women who develop other forms of coronary artery disease that doesn't necessarily cause blockage in the heart. And you can develop cardiac symptoms in the absence of that. So the two main forms that are more common women compared to men are what's called coronary artery spasm and microvascular coronary artery. And so if you look at the schematic up top, this is the blood vessel of the heart. And so if there was a blockage, you would see the artery spasm here, you do the angiogram, find it and fix it if it's amendable to a fixed extent. However, you can have what's called coronary artery spasm where the artery itself or the inside lining of the heart is wide open. There's no blockage. However, if the artery spasm closes down on its own, it can obstruct blood flow. And so if you could think of anything that spasms, then you're temporarily causing these blood flow to the heart, even though there physically is no blockage. And another form of cardiac or not a disease that can cause cardiac discomfort without any evidence of any blockage in the heart is what's called coronary and microvascular coronary microvascular spasm. And so you can have wide open arteries inside the blockage. However, remember your arteries break down to smaller arteries and arterials. And so here are these small arteries that you can't really visualize based off of current testing methods. Those small arteries can be dysfunctional to the point where they're not providing blood flow to the heart. So if you're having blockages in these tiny arteries, there's no definitive treatment that you can have. You can't have a stent for the scale because it's just too small. But it can lead to the same discomfort that you would have if you would have a major blockage in the main artery of the heart. And so that's in these particular disease sets can present in the women who have coronary catheterization and they don't find anything. It's why it's important to really hone in on presentation and realize that women are compared to men are more likely to develop coronary artery spasms on microvascular disease and to do further testing if there is a clinical suspicion. And the special testing that you would do for microvascular disease and particularly what's called a pet nuclear stress test. And that's a stress test that looks that not only as a nuclear stress test looks at relatively growth of differences in flow of the artery of the heart, but it measures the absolute blood flow throughout the heart at rest and with stress. And so actually for heart rate we have had a pet nuclear stress test that's not the only one in the region as far as practice would be concerned. And it's very helpful because we have patients with major catheterizations, we don't find any major blockages. They're having angina or chest pain like symptoms that suggests it's cardiac in nature. And that stress is very helpful because it can rule in or rule out potential for microvascular disease. Now there are other special tests that are performed as well as the stress cardiac MRI which are done up large academic institutions, which is another option to evaluate for microvascular disease. And when it comes to that coronary basal spasm that I mentioned before, you can do what's called a provocative endocrine. Now this is a test that has not done routinely it's done at certain centers that have a lot of experience. But that's one potential way to diagnose microvascular spasm or macrovascular spasm essentially. And so we've identified the different ways that women can present with heart disease and how it's diagnosed, but now it's transition to strategies to mitigate or even prevent it in the first place. And so this diagram shows life simple seven. And so these are seven simple strategies to mitigate or to prevent heart disease from developing in the first place. And you can see here, normalizing your blood sugar, free diabetics and undergoing diabetics. Eating healthy, as you'd expect, maintaining a healthy weight, being active, stopping smoking if you do smoke. And just so everyone's aware, even a few cigarettes a day, more than double your risk of developing cardiovascular disease in the future compared to those who don't smoke at all. So it's never too late. Normalizing your blood pressure. So that's blood pressure, like I mentioned before, alters that the balance when it comes to the pro pregnant factors and the time for markers in the blood. And that can accelerate or increase your risk of developing cardiovascular disease in the future and blowing blood pressure by 12 milliliters of mercury at 12 points for 10 years can save one life out of 11 patients. So definitely see the emphasize flowing cholesterol and as you'd expect to go, you know, I showed you the schematic for how black blood cells in the first place with cholesterol in an essential role. These are the life simple seven ways that you can, from a lifestyle perspective really reduce your risk of developing heart disease in the future. So as far as risk factors from that life simple seven control yourself, maintaining a healthy diet is one. Increase your risk of diabetes, high blood pressure, another potential way you can. Is another risk factor that you can control yourself as well with the caveat being that there. Yes, there are metabolic disorders that do increase or cause diabetes or obesity and high blood pressure develop. But by and large, a lot of it can be mitigated or reversed with lifestyle modification. A lot of exercise, something that can respect you can control and then start to smoke. So we are all connected in a larger control by lifestyle modification something that we have in our hands in October and it does one. As far as risk factors that are beyond your control. So as you get older, plus you're off to a level of 10 to increase platforms will ultimately start to form. And this depending on how many other comorbidities you have that you're confident. But it doesn't necessarily mean that you are destined to develop for you are just an additional risk factor that you can't necessarily control. So, as I mentioned before, with the estrogen, it's more of a cardio protective hormone. And so before menopause, we tend to have a lot of cholesterol and also lower risk as a result of that to develop heart disease. But after menopause, that was start to level out. And then family history, you can't hide from that. So having history of heart disease that develops at a young age, having high cholesterol, having history of high blood pressure. Those are things that you can run away from, but you can mitigate it to the best of your ability. And we talked about the cholesterol as one of the simple seven categories that we can control or try to control. And so I would want to touch base on different types of cholesterol. So you have total cholesterol, which is the sum of all the cholesterol of the mind. And when it's elevated, it raises your list of developing cholesterol. Okay, HDL, it's the high density of the protein is one of the components of cholesterol. And it's like the idea of HDL is that it maps up on this cholesterol level. It may lower risk, but we're finding new evidence that this might necessarily not be the case if you have a high HDL level. So this shouldn't be reassuring. We need to make sure that the other components of this control are LDL or bad cholesterol or low density cholesterol. That's the one that's involved in the pathogenesis of fat for a month. And the higher the level, generally, the higher the risk of developing a subsequent cardiovascular disease. And the LDL, the other very low density of the protein falls in the same classes as LDL and the higher the level, the higher the risk. And as far as specific putoffs, so for total cholesterol, we want to be less than 200 for HDL. For women, we want to be more than 55. For men, more than 45. The bad cholesterol, LDL, we want that level to be less than 100. And these are the targets when it comes to cholesterol. So now going back to the simple seven, what are the strategies to be helpful? And so with healthy food techniques, including choosing lean meats and poultry. So removing the level of fat when you can, grilling, baking and broiling meats poultry as opposed to frying. And you want to select non-fat or low-fat dairy products. So choosing skin, choosing low-fat or 1% low-fat or non-fat yogurt and cheese. And living dairy products is the best of your ability. And then when you're making salads, try not to dress it up with too much dressing because then you start negating the benefits that you are striving to achieve. And then try to use spices instead of butter and salt. Now as far as cholesterol in particular, you want to limit total cholesterol intake as well as saturated fats. So with saturated fats at room temperature, it becomes solid form. And that's what contributes to fat production throughout the body. When it comes to all the unsaturated fats, it is liquid form at room temperature. And so it is less likely to develop or contribute to fat production. So that's why you want to be able to limit the saturated fat intake. And so for total cholesterol itself, about 300 milligrams a day, I always get asked how many eggs I eat. And generally around six eggs a week is considered okay. Try not to do more than that. And then with fats, you want it to be about 10% of saturated fats, especially for calories. And a high percentage of saturated fats are going to be coming in on the fats in dairy products. That's why we always recommend limiting red meats and dairy products for our patients. I'm sure as everyone has heard in the past, trans fats are the fats. And these are the fats that come with the food that tastes really good. So when it comes to cookie, crackers, snack cake, et cetera, they're full of trans fats. And these are just hydrogenated or partially hydrogenated fats. And they're bad for you because they increase the bad cholesterol at the end. They lower the good cholesterol, the HDL, and they increase regular stress. And you want to be able to look at what the label is pretty closely because if it mentions that there's food containing less than 0.5 grams of trans fat for serving, they can label it as trans fat free. So just because it says trans fat free doesn't necessarily mean it's completely free of fat. So, and, you know, for one or two meals here there might not be an issue, but if you're continually eating a lot of food that has traces of trans fat, it does add up. And then I mentioned before the difference between saturated and unsaturated fats. It's basically one is more solid form. And then temperature in the other is liquid form. And so the healthy fats will be the unsaturated fats because they're more liquid form. And so they're within that liquid form of the unsaturated, the saturated and non unsaturated. And so for polyunsaturated they're great because they help lower the LDL or the bad cholesterol. And in the sample foods that contain that would be sunflower, safflower, soybean, sesame oils, nuts and seeds and fish give you lots of amounts of polyunsaturated fat. As far as mono-unsaturated fats, it does lower the total and bad cholesterol may increase your HDL. And so that's why you have a lot of infomercials really promoting olive oil. So it actually works in olive oil to large amounts of mono-unsaturated fats. And that's what I thought it would do as well. And for any patients who are on the SIPA, the SIPA contains highly concentrated form of EPA or omega-3 fatty acids. And these are forms of polyunsaturated fat stuff are very beneficial when it comes to decreasing your triglycerides and lowering the information in your body. And you know there's been a trial that was informed within the past six to seven years that has shown benefit in patients who have cardiovascular disease or cardiovascular risk and who are on the SIPA and have been taking the SIPA. And so this is why we always recommend a SIPA and increase in SIPA intake when it comes to the Mediterranean diet that's been recommended. This includes fish in your diet 20 times a week and fish is great because it's low in saturated fats and it's a good source of polyunsaturated fats. And from that simple seven diagram that I showed before, categories are reducing carbohydrates. And not only just carbohydrates, but simple carbohydrates. So anything that causes a spike or a rush in glucose in your body which causes a rise in insulin. Because those two products tip the balance towards inflammation in your body. So having excess sugar in the body simply gets towards that. And so you can think of any sugars, sweets, fruit juice, even dried fruits or anything like that as well. And then when it comes to alcohol, called in moderation, and that's because excess amounts of alcohol can increase your triglyceride levels, and it's simply high in sugars. So as we discussed before, increasing simple sugars will essentially gets towards the spat and will raise the glucose levels and even some levels in your body. So one way to combat this is fiber. So lots of non-stargene whole vegetables and whole fruits are great because they have lots of soluble fiber and the benefits of soluble fiber in lowering the total and specifically the LDL in the back cholesterol in the body. And then soluble fiber is great because it adds both to the gut. So you're not absorbing as much of what you eat. And one thing to keep in mind is that any time you see the word instant, it's going to be a process full grain. So you're not going to get as many benefits of which by the way would from something that's full in nature. So if you get whole oats, beans, lentils, peas, these are great sources of soluble fiber. And then exercise, real exercise. So start off 10 to 15 minutes a day and you want to gradually increase the limit to 60 minutes a day, five days a week. You can do it in intervals. What I will say about exercise is that something is better than nothing. There have been studies comparing patients who are completely sedentary to those who do just a little bit of exercise. And there are significant benefits from those who even do a small amount of exercise. So shouldn't be thought of as an all or nothing phenomenon where you're not doing half mile runs and 40 minutes exercise intervals each and every day. Then you shouldn't be doing anything at all. If something is better than nothing. Okay. And also do not forget a weight bearing exercise because this is just as important as doing the robots. It's great for bone strength as well as as well as stretching and flexibility. Then weight loss. So we know that excess weight causes high cholesterol and high triglycerides, also high blood pressure when you're interested in diabetes. And it's hip to scale towards a pro-inflammatory state. Okay. The same thing. It's not an all or nothing phenomenon. Just using five or 10 pounds can be significant to cardiovascular benefits. So something is better than nothing. And I wouldn't take it as an all or nothing phenomenon. And just doing a little bit of your state. Five minutes of exercise that you otherwise wouldn't do. If it's taking out instead of having if you can make a lot of diet coke or coke. And instead of having two, you have one that can have significant impact on your health. Baby steps are a better than no steps at all. And so we've touched upon the lifestyle modifications that can be implemented. But sometimes that's not enough. And some patients will need to take a cholesterol and medications even with them maximizing or achieving their lifestyle intervention. And so who should take cholesterol drugs? People who've already had a heart attack or stroke. But once you've already developed an event at that point in the cast after that, you need to be on a cholesterol medication to reduce the risk of further issues going forward. And that also plus the aspect. So I already did that in questions and patients. The study that recently came out, or I used to be from the news saying that you don't see an aspirin. Well, that isn't a part of patients who already have developed an event. They're in a completely separate category. They're the time target. Yes, one of the patients never developed. Okay. Those who are LVL or load incident. That was a matter of significantly elevated. So if your cholesterol is that high, you have to be on a cholesterol. If you're diabetic over the age of 40, and the LVL is above 70, where you do derive a benefit. And then in general, there are risk profile scores that are out there based off of your risk factors. And if you have an elevated 10 year cardiovascular list, you would also benefit from a cholesterol medication as well. And so the commonly prescribed medications are statins and PCSK mine. So stands are the drugs that are most commonly be prescribed PCSK mine inhibitors. They're an injectable form that helps remove that bad cholesterol, the LVL easier. And that's something that's usually prescribed by cardiovascular specialists. Even on the side of medication, you're still not at your goal. That's something that will be prescribed or it will be prescribed as an alternative if you have side effects. And then these other forms of cholesterol medication that reduce cholesterol that provided here, but the two most common forms of these kinds of PCSK mine inhibitors. And as with any medication that's prescribed, so discussion between you and your doctor when it comes to social side effects and rainbow side effects to your health benefits for your particular situation. That's just discussions between you and your patient. And so as a take on cardiovascular mortality is on the rise for both men and women. But in particular, particularly for women, I think there is not as much emphasis on how prevalent it is the number one killer in women. And as I mentioned before, when you combine all cardiovascular disease stroke, heart attack and cardiovascular disease, it is more than double number. And when it compared to all cancer women in front, so breastfeeding and GI etc. So it's something that we definitely get the word out on, and it is under recognized as under diagnosed and just under treated. And so because of that women are being diagnosed in later stages than the ordinary would have had a high index of suspicion. It's important to know what the signs of heart disease are in women in particular and acting on that area. And then focusing on the simple seven, you can do your part to mitigate the risk or help prevent any of these practices from the current. And so why me why now, as I mentioned before, even in younger women, less than the age of 44, heart disease is the third common cause of death. And so it starts early on. And so you want to start the simple seven early on to help mitigate that. And the risk does increase after menopause because estrogen. So you always want to keep this in the back of your mind and be proactive in order to catch something is catching the early on. And it begins today, one step at a time. You don't have to make the article from zero to 60 is just taking a day by day and do what you can to ultimately look something being a life bar. You don't want it to be something temporary. Okay. So I can smoking being active and adding to function or all the things that don't get emphasized as much pressure. And these are the resources. How far are the both for health, health, education, so if you go to hmh4u.org, you would find all the resources. Thank you so much, Dr. This was great. We do have a couple of questions that came in during the presentation. So I'll start off with what cars is the heart arteries plaque buildup? Is it specific foods that you eat? It's a combination of things. It's a combination of your genetic makeup. And also the circumstances. So what causes plaque to develop is inflammation. Plus cholesterol elevation in your body and how your body processes that cholesterol. And that final with the different inflammatory part of markers, which can be raised for multiple reasons for having an autoimmune disorder, smoking, having high blood pressure, having diabetes, or just having high circulating hormone levels, just as a genetic cars. All those factors combined when can ultimately lead to plaque to start to develop and also not only for to develop but for to progress and build. So it's not any one particular thing, but it's a combination of markers that increase inflammation and also cholesterol and how your body processes that all together. Thank you. The next question is, I have uncontrolled diabetes for years. What are my chances of having a heart attack or stroke. It depends on what type of diabetes, whether that's type one or type two, and when when it developed and how many years you've had for years, but five and 20. So being a diabetic, it's doesn't necessarily mean that you are ultimately going to develop cardiovascular disease, it just increases your risk, and it's never too late. So if you haven't seen a cardiologist and had a diabetes stroke for years, you definitely want to see one to be screened. Okay, so you want to make sure that the circulation of your legs that we perform to the heart are optimized as possible and also that your cholesterol is where you used to be. So to answer your question, there are a lot of things that contribute to that it depends on your other comorbidities that also depends on lifestyle factors if you smoke, how high your cholesterol is high blood pressure is all those things can increase it but it doesn't necessarily mean you're ultimately going to develop it but it does increase your risk which is hard to say without having the full clinical picture. Thank you. What are good oils to cook in is canola oil good. Canola oil, when it comes to the medium chain fatty acid oils, there's mixed information mixed data as far as it's actually being beneficial versus being neutral to potentially harmful. And we know that extra virginal oil for sure is something that is beneficial vegetable or something to be avoided canola oil remains to be seen as their mixed information and mixed data that's been published on that. Okay. Are there any recent studies or data that shows the effects of COVID on the heart. COVID when COVID first came out there was a concern for my rights. And so there is a small increased risk of developing my product as a result. But COVID can be associated with abnormal rhythms during an acute COVID phase. So you're working obviously with increased information so you're at a higher risk of developing heart attacks and strokes. But the data keeps changing and so it's not as high as we thought as a first came out but the risk is still there for sure. Thank you. And then I have three more questions that are all combined into one. What is the calcium scoring test? And who should have this test? Great question, sir. Calcium score, it's a cascane in the chest that does not use contrast. It takes about 30 seconds to do it. And you're essentially looking for a calcified plaque product in the heart. And so if you have calcified plaque product, it depends on how much, but the absolute number is, but also when you percentile. It's mass based off of your gender and your faith. And that helps this further the stratified patients who otherwise are on the fence of determining whether or not they will need to be on cholesterol medication. So for the guidelines, if you have a risk factor score around 7.5% where that's on the borderline is potentially suggesting that you need to be on cholesterol medication. And having a coronary calcium score in that case will serve as a high barrier on your age and also your absolute score and your percentile based off your background. And so that's when the coronary calcium score will be helpful. And as far as who is beneficial for it's, it's individualized. I think part of the guidelines we know as for patients who are at borderline risk, you're not sure whether or not they benefit from a cholesterol medication. But it also depends on your particular clinical scenario. So, you know, for instance, if you have a patient who doesn't want to be on a cholesterol medication at all, even though we know that they're high risk, or would potentially benefit from having that knowledge, having that coronary calcium score is a yes. You happen to have a score of 140 and you're in the 80% of your age and gender and you would benefit from it. And having that knowledge is powerful. It's something that helps reinforce potential benefit. Thank you. And actually this is also about calcium scoring. And I'm going to read them both at the same time. So how is it performed. Do you give a pill to adjust the heart rate during the test, and are there risks to the test. So yeah, the coronary calcium score is different from the coronary CTA. The coronary CTA is CAT scan of the chest where you do get contrast through an IV. And your heart rate has to be at a certain number so that it's slow enough to be able to get very quick to answer the question. When it comes to the coronary calcium score test alone, where you're not using contrast, it's simply a CAT scan of the chest. And it's only looking at a small portion of the chest wall and basically confined to the heart itself because you only want to see if there is calcium on the back of the heart. It's a low amount of radiation. So low risk because you're only exposing yourself to radiation within the heart region itself. And there's no contrast that's being administered because you're not doing the coronary CTA. You're essentially just doing a simple CAT scan, only focus on the heart and only looking for a classified plasma. You're not looking at the heart rate itself. When it comes to contrast, so very quick low risk and there's no need for medication to store the heart rate.