 Hello, everyone. My name is Brianna Costello. I'm an interventional cardiologist here at the Texas Heart Medical Group in Houston, Texas. And I'm so excited to be here at the inaugural Global Cardiovascular Forum, celebrating 60 years of excellence at Texas Heart Institute. I'd like to thank Dr. Rogers, the president and CEO of Texas Heart Institute, as well as Baylor St. Luke's and Baylor for all collaborating with us here. This is awesome, and I'm excited to talk about one thing that I'm very passionate about, and that's heart disease in women. So here, heart diseases in women, what we know and what we need to do. Just for a fun starter, there is a picture of a heart and some anatomy version heart. Male heart, female heart. Well, this is meant to be a little comical. Male hearts generally are a little bit bigger than females, but the point is we both have a heart. They both have the same disease processes, albeit at different times. I want to dig in and talk about how women are affected by cardiovascular disease. So what we know, heart disease is the leading cause of death in American women. More women die than men of heart disease every single year. That is a shocking stat for some people. Nearly 43 women are currently living with or at risk for some sort of CV disease, and more than 8 million women are currently living with heart disease and know it. 292,188 women die annually from heart disease. That's four times more than breast cancer and more than all cancers combined, and this stat is even a little older, so this is probably upwards in the 300s. Women, we know this from study after study that women are less likely to receive treatment according to cardiovascular disease prevention guidelines as well as treatment guidelines. In the interventional world, this is another thing that I'm very interested in, and women, unfortunately, have are treated less aggressively or inadequately many times, and we need to start addressing these things. So CBD, cardiovascular disease, is a woman's disease. One in 31 deaths in women are due to breast cancer. One in three deaths are due to heart disease. One death per minute among women due to cardiovascular disease, and only about 20% of women know that heart disease is the number one killer, which is one of our passions here, even at the Texas Heart Institute, in the women's heart center, is to kind of promote women's knowledge and make them aware of this disease. So just a brief overview. What are the types of cardiovascular disease, of course? We all know coronary artery disease, there's cardiomyopathy, there's hypertension, cholesterol issues, heart failure, arrhythmias, valve disease, peripheral artery disease, and congenital heart disease. But, you know, these diseases affect both men and women, and we really, unfortunately, in the South are pretty plagued by heart disease, in particular coronary artery disease and PAD. So here, rates of death by state, you can see the dark is not as bad. So cardiovascular disease deaths here in the South were much higher than perhaps in the West and the North and the Midwest. Stroke death, of course, kind of parallels this and is much higher in the South. So let's just break it down by sex. So cause of death by sex, as you can see, cardiovascular disease for men and women is the leading cause of death. 30.9 and 30.3 of men and women, respectively, died because of heart disease. So obviously, this is something that we're all very passionate about. So mortality trends, you know, back in about 2010, you can see we kind of hit a low. So we hit a nadir in our cardiovascular disease mortality trends, which was exciting. And you can hypothesize or you could surmise that all this was back in, you know, the late 90s, early 2000s, there was smoking, rates dropped, statins were pretty widely used, we're making a lot of advances in, you know, medicine and lifestyle. But as you can see in about 2010, this starts to tick upwards. Again, certainly the obesity epidemic, diabetes epidemic, has kind of caught up with us, I think, and we're back on the uptick. Fortunately, women's mortality from heart disease is actually staying lower than men. So that's a big improvement. As you can see, women's mortality from heart disease was significantly higher than men for a long time because women were treated differently. Nonetheless, we're back on the rise, but it was good to see an improvement there in the empowering, you know, movement to get women motivated to take other heart. So what's the breakdown in cardiovascular disease deaths? Like why is it happening for women? So you can see the majority of it is coronary heart disease. So heart disease of the arteries in the heart. So, you know, heart attacks, atherosclerosis, et cetera. Followed shortly thereafter, 49% of coronary disease and 16% from stroke. So stroke is another big focus for us here, especially for men and women. So what risk factors, the whole point of this is what can we do to prevent heart disease and prevent, you know, coronary disease, heart failure, et cetera. So what we have to know is what are the risk factors for that? And of course, men and women, both, hypertension is a huge one. As you can see by about the age of 55 to 64, nearly half of patients will have hypertension. A lot of people are shocked to see that. And then of course, as you see, as the ages move on up, by the age of more than 75, females have an 80% chance. So I say, if you've made it to about 80 and you don't have high blood pressure, you are a lucky human. So again, knowing these risk factors, knowing to screen your screen patients appropriately and at the right age is super important. African-Americans, both men and women, are in particular a very important group to focus blood for blood pressure. African-Americans have higher blood pressure at earlier ages. And certainly women, this is a huge portion of the population that perhaps, you know, focusing at an earlier age in their late, mid-30s, late-30s, 40s, we really have to be on top of screening for hypertension. You can see there at the age 40 to 49 group, at least 30% of African-American women will have hypertension. And the problem with this is it often goes unnoticed, undiagnosed, untreated. As you can see among hypertensive African-Americans, 88% are aware of hypertension, 68% are medicated, and 51% have their blood pressure controlled. We're doing a very poor job of controlling blood pressure, which is quite frankly the easiest thing for us as cardiologists to modify for our patients and make a huge impact. So what about the incidence of myocardial infarcts or heart attacks classified by age, gender, and ethnicity? Unfortunately, as with hypertension, African-American men and women both have the highest risk of heart attacks or, you know, coronary events. And of course this likely parallels with the fact that blood pressure is earlier onset, less well controlled, but we certainly have to focus on this sooner than later for all patients, but in particular African-Americans with hypertension. Stroke risk, comparing men and women, of course, or the prevalence of stroke, certainly as we get older that risk goes up, but you can see women's risk of stroke in the age 40 to 59 is even a bit higher than men's. So perhaps we're missing some screening earlier on for some women. Stroke death, of course, for all males versus females in different ethnicities, you can see here, the stroke risk for African-Americans is grossly higher than for any other group. So we really have to focus, and we know that stroke is intimately related to hypertension, so I harp on that one more time, especially for women and men, of course, but we really have to be screening for blood pressure earlier. So let's just recap the risk factors so we can get into some more meat and potatoes of what we are going to do for women. So what are some non-modifiable risk factors for cardiovascular disease? Well, certainly your age, you can't turn back time. Family history, of course, you can't decide what genes you were born with, so if you're an unfortunate person that has a family history of really high cholesterol or early onset hypertension, you can't change it, but you certainly can address it as we'll talk later. One thing that I really love to talk with all of my female patients, and they kind of look at me cross-eyed when they come into the office and I ask them about their pregnancies, preeclampsia or eclampsia history. This is a huge screening question or screening discussion that I think we miss a lot because patients who've had preeclampsia or eclampsia are certainly at higher risk for cardiovascular events later in life, and that meaning two to three times the risk of having a cardiovascular disease event. They are definitely at risk for a much higher risk of hypertension, so they need to know that. Of course, establishing that is hard when you have a new mom and maybe in their late 20s, early 30s, the last thing they want to hear is they're at high risk, but we really need to be talking about that a little bit more. So what are we going to modify or what can we do in the office, in the cardiology office, in the primary care office? Of course, cholesterol modification is one of our main focuses. Obesity, of course, we're counseling patients on weight loss and that's difficult for many people, but we should really be striving to exercise cardiovascular exercise weekly. Diabetes, hypertension, of course, and smoking. So what are some disparities in cardiovascular disease that we see due to perhaps these risk factors being different? So African-American women have a 48.3% established CVD in the population. They have the highest CVD mortality rate. Interestingly, Hispanic women, 32.5% have an established cardiovascular disease, but interestingly, the lowest cardiovascular disease mortality. It's unclear exactly why this is, but nonetheless, we need to focus and try to modify risk factors in both groups aggressively. In Hispanic women, very high degree of diabetes, starting at an early age, high blood pressure, of course, and cholesterol, which just kind of goes with metabolic syndrome that is seen in the Hispanic population. So African-American women in heart disease, certainly, as I can't repeat enough, hypertension is huge for them, but also obesity. 53.9% are obese and 73.1% are overweight or obese in the population. Physical inactivity is certainly reported to be high among patients reporting. High blood pressure, of course, and diet with a relatively higher salt intake, sodium intake. 40% of African-American women over the age of 20 have high blood pressure. That's huge. So, I mean, that's a huge proportion of our population, of course, again, that we need to be very screening early. All right. So, Hispanic-American women in heart disease, they're also slightly higher risk for heart disease than Caucasians, and they're less aware of risk factors. Obesity, again, physical inactivity, hypertension, untreated diabetes, or poorly controlled diabetes is huge for this population. They have nearly two times higher rate of diabetes than Caucasian women. Among Mexican-American women, 30.7% have cardiovascular disease. Again, one-third of that population, it's huge. So, what do we do in the office, or what do we need to be doing in the office to kind of counsel patients regarding their risk of having cardiovascular disease ultimately throughout their lives? So, I think it's an easy discussion to start with about blood pressure, because that's something that patients can do at home, and we can often have them help us screen themselves intermittently at home if they haven't been diagnosed with hypertension yet. They're on their way there. So, I like to say, you know, a goal of blood pressure less than 120 over 80. That is normal. And that is what we know from data from the Sprint Trial and multiple other trials is going to make you live with strokes and heart attacks. Cholesterol, of course, if you're untreated and your cholesterol is less than 180, you're winning. And then, of course, no smoking history or diabetes is optimal. Non-optimal, I like to focus less on the total cholesterol and more about what their ASCBD risk is in the risk calculator that we use from the ACC. However, focusing on a trend towards less than 200 for untreated total cholesterol or maybe starting a discussion about treating it if it's higher than that is reasonable. Elevated risk, certainly, if your blood pressure is untreated and you have a diagnosis of hypertension, you are certainly at high risk. So, good old versus bad old. Many times it is a choice and this is just to, you know, really hammer down the fact that many of these things we can modify early in life, meaning in your 40s or your 50s, so that when you make it to 80 and many women with diabetes can live a healthy happy 80 instead of an inactive, you know, bedbound 80. So, it's not a disease that we're powerless over. Counseling for the patient every day don't smoke, manage your blood sugar and in saying this, someone needs to be screening patients for blood sugar. So, I screen every one of my patients for diabetes when they're a new patient in the office because guess what? Heart disease is related to diabetes and it actually changes some of the medication management that I do if you have diabetes. Know your numbers again, counseling patients on screening themselves for hypertension, cholesterol via diet versus medical therapy, family history, huge if you have a really early onset cardiovascular disease history you need to discuss this with your provider. I say 150 minutes of activity per week as the AHA recommends to decrease risk of heart attacks and strokes. So, that's 30 minutes of day, 5 days a week whatever you want to do, brisk walking, jogging Zumba. And lose weight. Losing weight is hard, it's really hard and there is certainly a large body of evidence that say most patients don't lose weight but, you know, talking about small changes in life to help modify weight or at least get some fat off is important for us every day. Smoking is no brainer, the risk of smoking the risk to your heart is just huge so the risk of smoking is 25% higher in women than men which is a shocking stat and the risk of stroke is 2-4 times that of non-smokers. So, if you have a patient, they don't want to have a stroke this is like number one check mark. So, of course as we've always been told since being young kids don't smoke. Diabetes among Americans it's been diagnosed in 18 million and this is certainly higher now because it's a little bit old data. Diabetes is undiagnosed in 7 million and pre-diabetes is present in 79 million. I almost think it's a little hard for me nowadays if I'm screening patients to find a normal A1C. Many patients are living in the pre-diabetes range and they don't know it or they haven't been counseled on it. I find it really is motivational for patients sometimes to say look you're pre-diabetic. We're not going to do anything but medication wise but we need to make some lifestyle changes. And of course, why we care so much about diabetes here, heart disease, kidney disease, peripheral vascular disease. Again, this is just harping on the fact that women certainly are suffering just as much or more than men from diabetes and we need to focus on this and start to modify, discuss and manage patients in the cardiology office and in the general office aggressively. So, knowing the numbers, again targeting to a normal blood pressure 20 over 80 or lower, we know is going to make patients live longer with less strokes and heart attacks, cholesterol. I think now as the guidelines are kind of suggesting if you have that intermediate risk patient who as we all know many patients are wary of statins, getting a calcium score to see if there is a presence or absence of atherosclerosis in the coronary arteries is super helpful. I'm pretty aggressive obviously in the established cardiovascular disease we're going to target that LDL quite low to less than 70 but even in the patients who are otherwise asymptomatic but have identifiable plaque on a calcium score driving to at least less than 100 and perhaps if there's a large burden of cardiovascular disease adding a baby aspirin for a calcium score maybe more than 400 per the guidelines in Europe. Weight and BMI of course patients need to know you're overweight, you are obese, sometimes they don't even realize that they need to shed pounds and we have to counsel them and why it's important. Again back to the diabetes I can't emphasize this enough prediabetes is so prevalent and it certainly will lead to diabetes as patients age if they aren't aware or making changes. 32% of Americans engage in no meaningful physical activity and of course women this is higher than men and we can all hypothesize why as speaking as a woman myself I think you know especially if you're working you work all day you come home and perhaps you're the one who's doing the childcare or you're the one making dinner or whatever it is not making time for yourself as a female to get active it's important for your health and we're taking care of the rest of our family but we have to take care of ourselves. So again 150 minutes or more a week is what we know is going to be helpful. Weight loss again it's hard it's not impossible but it is hard so just you know working on lifestyle changes instead of just focusing on a diet is very important for our patients. And then I like to say eat to live instead of live to eat. So yes you can enjoy what you love to eat but remember that whatever you put inside your body it's got to be your body has to handle that so if you're going to eat the fried food all the time or you're going to eat the french fries and carbs and pasta your body is going to respond in an unfavorable way so be smart about your food, Mediterranean diet certainly is what I discussed in the office with an emphasis on limitation well not limitation but being mindful of your portions of carbohydrates and starches. Alright thank you guys I hope this was fun I again appreciate everyone you know being here with me today I hope we all learned a little bit of something and women's heart disease continues to go down. Thank you.