Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand. blood pressure, weight, cholesterol, for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Warrick Bishop. Welcome to my podcast and videocast station. Today I've got with me Dr. Fiona Fu. She's a cardiologist. She's an interventional cardiologist. She has a specific interest in women's... heart health issues. She works at Sydney Cardiology and Macquarie University in Sydney. And I'm absolutely delighted to have you back as a guest, Fiona. Thank you. Thank you for having me. Look, I've been really looking forward to speaking with you about this. There's often questions about how men and women are different when it comes to cardiovascular risk. And I know this is an area where you'll... deeply passionate and involved with so I'm super excited to be speaking with you about this from the get-go when we talk about risk of cardiovascular disease and I'm guessing we're going to talk primarily about atherosclerotic cardiovascular disease so the build-up of cholesterol pluck calcium fibrosis inflammation we're going to talk about that primarily I'm guessing Lead us into that. My guess is that some of the risk factors that we apply for men are equally applicable to women, but then there's probably nuances and extra things we need to understand. So start us off there. What are the standard risk factors that you're concerned about when you see a woman come into your office? So I think even just going back before that, I think we need to identify that it is a big problem and it is an under-recognised problem. So we are talking about coronary heart disease today, mainly the risk factors for coronary atherosclerotic cardiovascular disease. And just to remind, I guess, the audience is that in Australia, this is actually the second leading cause of death in women. OK, you know, secondary to dementia. So it is a big problem. And heart disease in women causes more deaths than all of the cancers combined. Actually, sorry, to jump in there, Fiona, I'm so glad you mentioned that. I think often because of all the awareness around some other cause of death, for example, breast cancer, there's a mis... placed belief on where women's risk really lies but you're exactly right coronary artery disease is a much greater killer of women than all the other cancers actually so this is super duper important and and and i think it is that that yeah it is under recognized by both patients and as well as the medical profession itself so getting into the risk factors i guess yeah so I like to think of it as what we call the traditional risk factors. So risk factors that are known to like affect both men and women. And I'll talk a little bit about that because some of them, even though they are known to both men and women, they are actually more, they cause more problems in women. So I'll talk a little bit about that. Then I'm going to talk about what we call sex specific risk factors. So the biggest ones are adverse pregnancy outcomes, things like early menopause. PCOS, those kind of conditions that affect mainly women. And then we'll also talk about breast cancer treatment because, you know, that affects a lot of women, but it also has cardiac implications. And then the other ones are what we would kind of consider, I guess, non-traditional risk factors that, again, affect both men and women. uh also again affect women more so the biggest ones would be like mental health disorders so depression is a really big one um the immune diseases um which like rheumatoid arthritis and lupus that affect women more so that's that's that's what we're going to talk about today um and yeah like just give a bit of an overview of like what um all these kind of risk factors that women should be aware of and then what i guess what we can do about it So the traditional risk factors I think we can probably deal with very quickly, the cholesterol, blood pressure, family history, diabetes, the like. But some of these traditional risk factors, more of a problem in women, for example, is smoking more of a risk factor in women than men, for example, or any of the other risk factors, more of an issue in women than men. Yeah, so the studies have shown, for example, a woman with diabetes portends a greater risk of coronary heart disease than a man. Hypertension is particularly more prevalent as women get older and they tend to be undertreated. They don't get to targets as well. Again, smoking about, again, increased risk in women more than men for whatever reason. We know that both of them, it increases coronary heart disease, but it increases. even more in women, and obesity. So obesity, physical and activity, again, they tend to affect women more, but also, yeah, pretend a greater risk compared to men. Look, I really value this sort of opportunity to share this information because I think cardiovascular risk in women often, I shouldn't say flies under the radar, but it is often, it doesn't get... the spotlight that it probably deserves in actual fact. So I think it's a really good opportunity to raise this sort of issue broadly and let people know about it. Let's move on to those sex specific risk factors, Fiona. You mentioned already a couple of things like early menopause. What are these sex specific risk factors that you tend to speak with your patients about? Yeah, so pretty much every female I will take, I will start early, like so with a pregnancy history. So I think it's always, I always ask about pregnancy and menopause, the age of menopause. So if we look at, I guess, let's start with... uh i guess earlier so i with pregnancy disorders because that's something you know this this affects younger women um reproductive age uh and we don't think that you know they're going to be at risk of heart disease but we but there's a lot of evidence that shows any uh pregnancy disorder um Certain pregnancy disorders increase your future risk of cardiovascular disease. So the biggest ones are hypertensive disorders of pregnancy. So having high blood pressure or what we call gestational hypertension, having something called preeclampsia and then something called eclampsia. Okay. So all of them increase your risk of future high blood pressure, but also cardiovascular disease. So not only coronary artery disease, but actually stroke as well. Okay. So that's. any high blood pressure during pregnancy and then the more severe high blood pressure disorders such as preeclampsia, eclampsia. The next biggest one is gestational diabetes. I'm not saying next biggest, but another big one is gestational diabetes. So gestational diabetes increases your risk of future diabetes, but even if you don't have future diabetes, it still increases your risk of cardiovascular disease. So having gestational diabetes increases your risk of... cardiovascular disease, high blood pressure, diabetes, all those things just by having gestational diabetes. The other ones that are also important are small for gestational age baby and early births, preterm delivery. So I guess the take home from that. Because these are young women and probably won't have cardiovascular disease in the short to intermediate term following that. But I guess the take home from this, Fiona, is that women who go through and have a complicated pregnancy for these reasons that you've alluded to, they should maybe have a little... checkbox next to their name as they're aging to really be watched very closely in terms of the traditional risks and screening for cardiovascular disease. That would be the way you would see that? Yes, that's that. Yeah, exactly. That's the, that's what I want people to realize that, you know, I don't want to, we don't want to scare, you know, they've just said, you know, just a complication during pregnancy, but what we want to kind of, I guess, you know, just let them realize that they, they do have an increased future risk, but you can do something about it. And the main thing is regular follow-up with your GP, checking your sugar. checking your blood pressure, you know, and then also just instilling a very healthy lifestyle, you know, regular exercise, keeping a healthy weight, keeping a healthy diet. So I think it's not to kind of scare people, but just to kind of follow that up and know you can do, like you do have an increased risk, but you can do something about that. And look, I think while people are listening, one of the really, really. driving reasons for Fiona and I to be talking about this is that cardiovascular disease, if identified, shouldn't kill you. We can manage it incredibly well these days. We've got blood thinning agents. We've got cholesterol lowering agents. We've got blood pressure lowering medications. We can image the arteries. We can know exactly what's going on. It's when these things occur as a surprise that they can really be detrimental. They can take lives. But what we're talking about here, Fiona, is being ahead of that game, really being proactive by identifying people who might be at risk and keeping a really close eye on them. And I think that's really what my passion is about, and I know it's yours as well. Yeah, correct. I think it's that prevention in the timescale, yeah. Yeah. Look, so we've covered some of those very sex-specific... risk factors. Thank you for doing that. Let's talk about some of those other things that people may not be thinking about. Things like autoimmune diseases. Talk to that for me a little bit. And when I talk about autoimmune diseases, for those listening, we're talking about things like arthritis, rheumatoid arthritis, psoriatic arthritis, maybe polymyalgia rheumatica, maybe inflammatory conditions like Crohn's disease. or ulcerative colitis, things where there's inflammation in the body by what we call an autoimmune process. Share with us a little bit about that, Fiona. Yeah, so that's right. Yeah, you touched there, all those autoimmune and inflammatory conditions. We know part of the atherosclerotic process does involve inflammation. That is a big, big contributor to it. So the biggest ones from a female point of view, something called systemic lupus erythematosus, or SLE, so lupus, and rheumatoid arthritis, because that also tends to affect females a bit more. Psoriasis is also a big one, but as you know, it affects both men and women. But the other thing with psoriasis is also very common. So with SLE and rheumatoid arthritis, it affects women more, and they have significantly increased risk of cardiovascular disease, particularly ischemic heart disease and myocardial infarction. So SLE... does increase your risk of a heart attack and at an early age. So we're not talking like, you know, 60s, 70s. We're talking like, you know, before menopause almost sometimes. So their risk starts early because of that inflammation. And the other thing to note with that is that the more, I guess, the more severe the inflammation and the more complicated that autoimmune disease, that also increases the risk. Yeah. I was going to say my guess here is that these amplify as well traditional risk factors. So a patient who may have raised cholesterol, raised blood pressure, diabetes, and has an autoimmune condition, they're probably snowballing their risk. So again, the takeaway here is... Be aware of this. If systemic lupus erythematosus is a diagnosis that you have or someone you love has, then be aware this is a condition that may have knock-on effects. Be aware of that cardiovascular health journey. Speak to the GP about it and really, you know, have some ownership as well. Be engaged. I love to see patients engaged with their doctor, whether the GP or specialist, to make sure that they're also asking the questions that need to be asked. And that's part of the reason for producing these podcasts. I think, yeah, and I agree that that is part of it. And it's good to see that a lot of the rheumatologists and the immunologists are also on board with this and dermatologists, sorry, like I do with like psoriasis, for example. So, you know, they're recognizing that they also need to be looking at the whole patient, you know, apart from treating that autoimmune disease, they also need to be managing their risk factors. And actually it was a rheumatologist who told me, you know, when I was doing my physician training, who said, Rheumatoid arthritis patients don't die of rheumatoid arthritis. They die of heart disease. So I think it is important, yeah, if you have any of these autoimmune conditions, you do a heart health check. You keep all your risk factors under control. Yeah. Look, one of the other risk factors that you flagged previously was breast cancer and breast cancer therapy. How does that tie in with cardiovascular disease, Fiona? So interestingly, breast cancer and cardiovascular disease have shared risk factors as well. So there's a few shared risk factors that both of them share. So being overweight, not exercising, smoking, et cetera. But then the treatment for breast cancer. also has implications for the heart. Now, from an atherosclerotic cardiovascular disease point of view, it's like radiation treatment, particularly on the left, can have delayed coronary artery disease. The main issue is not as much atherosclerotic cardiovascular disease with breast cancer treatment. It's got to do with impaired heart function with a lot of the breast cancer treatment. And then again, having breast cancer. On top of that, also there's evidence that shows that it increases your risk of future cardiovascular disease as well. So breast cancer survivors, their main issue is cardiovascular disease. Yeah. And I think what you're alluding to there for those who are listening and just trying to follow that is that the therapies used for breast cancer treatment can lead to the heart. muscle being affected in such a way that it doesn't work as normal it tends to get a bit stiffer and that can have a consequence with shortness of breath and symptoms down the line would that be the way you'd yeah sorry yes that's correct yeah yeah it can be stiffer but yeah as well as uh not contract as well correct correct okay so very important as well and feeding in there In the interest of time, I do want to touch on the last aspect that we flagged at the beginning, and that's psychological health, well-being, the impact of depression, anxiety on cardiovascular disease. Let's touch on that. Let's do it briefly because I know it's a huge topic, but in the interest of time, I want to touch on it, but keep the podcast in a controllable space. So, yeah, so I think we all, so hopefully we all are aware that depression increases cardiovascular disease. And particularly in women, women do get affected, I guess, more with depression, but it's also a really significant, much more significant, almost risk factor, particularly in middle-aged women, like, sorry, depression is, than, you know, some of the other traditional risk factors. Depression increases your risk of cardiovascular disease. And if you have cardiovascular disease, you also have an increased risk of depression. So they kind of feed into it. And depression is one of them, but there's also anxiety, post-traumatic stress disorder, all of these things, all of these mental health disorders definitely increase your risk of cardiovascular disease. And again, it's identifying, yeah, there's multiple reasons why there's that link, but identifying identifying that, but again, treating your traditional, treating all your other risk factors is important. I think that's, and, you know, treating your mental health, but also treating your other risk factors is also important when you have that. And, you know, there's other things that unfortunately women do get. You've got the mental health and then, you know, the socioeconomic issues and environmental issues as well that tend to affect women more. you know, domestic violence, all those things. You know, it is definitely, there are definitely risk factors that are under-recognised but do affect women more. Look, Fiona, as we sort of come to the finish line of this particular podcast, what sort of advice would you offer for the people who, for particularly the women who are listening or even the doctors who may be caring for women? In the context of traditional risk factors, gender-specific risk factors that you've touched on, so the complications of pregnancy, the autoimmune group, women who have been treated for breast cancer, and women who may have the influences of depression or anxiety. What's your advice? How would you advise them to deal with that in the future? I think the biggest take-home message really is about having a heart health check, recognizing these risk factors. So recognizing these risk factors, having a heart health check, and then being proactive about prevention. So, you know, keeping all your cholesterol, blood pressure under control, your sugar levels, being active. having a healthy diet and lifestyle and obviously not smoking. So I think that's the main message, recognizing that it is a problem, but recognizing that you should check your heart and doing something about it. And I think for both... the audience, but also for doctors. There's a term called bikini medicine. I think it's quite good because, you know, unfortunately, a lot of us practice bikini medicine, which is essentially you see a female and you only think about their breasts and their reproductive organs, like what the bikini covers. So I think we, you know, instead of seeing a female and yes, they get their mammogram, they get their pap smear, you know, they talk about all these other things. They need to be talking about their heart health. Yeah, no, that's great advice. Look, that term, bikini medicine, is a really nice reminder and does let us know that we can have a blind spot to the entire person and their entire risk profile. What I might add, though, is my own interest in prevention is really centered around imaging the arteries, taking a picture, using a calcium score. I think it's an incredibly valuable tool. And I know there's plenty of GPs who move and patients who can't get to GPs for access or can't get away from work. And some GPs will refer onto specialists to get things like a calcium score. So for those listening and interested, I've actually put together a website. You can write this down or you can remember it, but it's www.virtualheartcheck.com. virtualheartcheck.com. And it means it's a virtual online platform where you can engage, put in some details just to make sure you're the right candidate for getting a calcium score and looking at the arteries. And then you can purchase a scan online without the need to see a GP or the need to see a specialist in any major centre in Australia. This is just a way to break down barriers and make access to some of this screening technology more widely available and easier for people to get to. And I think that's great. As I say, like a calcium score is so, you know, I order a lot of them as well, but, but it's so, I think it's so quick. It's like, yeah, I say it's such a quick test and it's so useful. Yeah. Yeah. Look, it's for me, it's the final common denominator. We can have all sorts of risk factors, whatever they may be traditional and non-traditional as we touched on today, but at the end of the day, it's what ends up in the arteries that defines. whether someone suffers from coronary artery disease or not. So looking under the bonnet, having a look at the arteries, in my opinion, is gold. Now, I'm pretty happy to wrap up there. Is there anything else you want to say just to round it off, Fiona? No, I think that was good, yeah. I think we've covered a heap of stuff. Look, I'm, again, super grateful that you found some time to do this. For those listening, Fiona is really, really busy. We were talking about that before we even started recording. Genuinely appreciate you finding the time to share and raise awareness for the people listening. For now, I'm going to wrap up. If there's queries or questions, drop us a note at info at drorichbishop.online. Again, I'm really grateful for people tuning in and listening. And for those listening, until next time, I hope you live as well as possible. For as long as possible, take care and bye for now. Hi. Ever wondered what your risk of heart attack is? You should. It's the single biggest killer in the western world. We're talking one death less than every 30 minutes in Australia. One death less than every 60 seconds in the United States. Nine million deaths globally per annum. Well how do you check your risk? Well you can go too. www.virtualheartcheck.com.au You'll find out about your risk and what can be done beyond that to be even more precise.
