Transcript of The Art Of Aging: The Heart Of The Matter New

Women have been understudied, underrepresented in clinical trials, and too often misdiagnosed for decades. That's why I'm so encouraged by the work being done at Northwell Health's Katz Institute for Women's Health. The Katz Institute brings together a network of more than 1,000 women's health experts across 26 specialties to provide coordinated, personalized care from heart health and menopause to nutrition, pelvic floor And more, they're helping ensure women have access to the support they need at every stage of life. You can learn more by going to northwell.edu/kcm. Hi everyone, I'm Katie Couric, and this is Next Question. Guess what, everyone? I'm turning 70 in January, and I'm on a mission to not just live longer, but to live better. And I don't know about you, but I am having a really hard time determining which articles, videos, supplements, products, and practices are science-based and which are just baloney. So we now present The Art of Aging, 12 conversations with people who have actual expertise in taking care of different parts of your body, including your heart, your gut, your skin, your sex life. We're not talking about the biohacking we hear from bros in the manosphere. We're talking about evidence-based science, separating fact from fiction, that will help us hopefully live longer, healthier lives.

And so for this first episode, we're starting at the heart of the matter. Heart disease is the number one killer of women in America. And yet for decades, the research, the warning signs, the treatment protocols were nearly all designed around men. Women were left out of the equation, and the cost has been devastating. My first guest, Dr. Stacy Rosen, one of the country's foremost cardiologists and a tireless advocate for women's cardiovascular health. She is also the executive director of the Katz Institute for Women's Health at Northwell Health and immediate past president of the American Heart Association. She has spent her career making sure women's hearts get the attention they deserve. We had a lot to talk about, so I hope you find our conversation as interesting and important as I did. And a huge thank you to our presenting sponsor, Northwell Health's Katz Institute for Women's Health, for making this episode possible. Dr. Rosen, first of all, thank you so much for being here, and it's great to see you again. I thought we'd start by talking about women's heart health in general. I was I was disheartened when I learned that only 38% of participants in clinical cardiovascular trials are female, despite it being the number one killer of women.

Why is that the case?

Oh, it's so discouraging and disheartening. And that data of 38% actually includes certain conditions that are much more prevalent in women, so it almost skews it. So things like heart attacks, heart failure, rhythm problems, participating is even lower. It's the history of heart disease. We thought this was a man's illness. We studied men. We treated men. We even thought women didn't get the disease, so we minimized their symptoms. So it was sort of this combination of bad— missed opportunities that basically perpetuated each other.

And it reflects sexism in medicine in general, not just when it comes to heart disease, right?

Absolutely. Tremendous amount of bias. If a woman's symptoms or presentation doesn't fit in a box, then it's called atypical. It's referred to stress. It's in your head, dear. I don't love the term gaslighting, but there's a whole lot of data about that we don't take women as seriously with medical conditions.

How has that affected diagnostics and treatments for more than half the population?

Right, right. I've been— my practice is totally focused on women, and I've been called a niche practitioner And I'm like, 51% of the population, we really can't call that niche. So imagine if you don't think a population gets the disease. We haven't done the studies to see how she would do with diagnostic testing, with treatment options, with prevention strategies. And then maybe she puts her whole family before herself. So she comes late, she minimizes her symptoms.

So it's the whole Is that starting to change?

It has to. You know, first of all, it's bad science. So, right, everybody's looking to do science better. So you can't call 51% of the population a niche. We know that sex matters. Every cell in your body is a female cell or a male cell, and that has to be different. So I see it as a golden opportunity. There are more women in medicine. It shouldn't take that. And in science. And I think even the tech world, the finance world are seeing this as an amazing opportunity to improve health outcomes, to develop new science, and to implement better.

How did the mythology that this was really just a man's disease— how did that happen and how was it perpetrated?

Yeah, I had the privilege of giving what's called the presidential address at the American Heart Association last fall at their scientific session, and I spoke just about that. And it started by the fact that there was historical bias. We didn't include women in the '40s, '50s, and '60s. We didn't think they could give consent appropriately. We thought that women's health was just entirely related to reproductive health, and so we excluded them. Men do present on average with heart disease 10 years earlier than women. So we certainly didn't want to include older women. So we missed that opportunity. Women sometimes do present in a different way with symptoms of heart failure or heart attacks than men. So none of them— women didn't fit into the male stereotype, the male model of the way heart disease was beginning to be investigated in the '50s, '60s, and '70s.

And culturally, I think, you know, we see dramatic, you know, images of a man clutching his chest. A Hollywood heart attack. Right, a Hollywood heart attack. What is a Hollywood heart attack?

It doesn't happen very often. So it would be— the cartoon would be a man in a suit with a briefcase and a cigarette and a pastrami sandwich and clutching his chest like this. And that would be the way we imagined heart disease. I graduated from medical school the year that more women started dying of heart disease than men. But for the early years of my training, we were taught it was a man's disease. And when a woman came with back pain or belching or just a little jaw discomfort, it was unimaginable to us that this could be heart disease because we didn't see it. We didn't learn about it and we dismissed it.

How are the symptoms of a heart attack different in women than men?

So the majority of people who present with a heart attack will have chest pain. It may not be the elephant sitting on my chest that we relay and define as the Hollywood heart attack, but most will have chest pain. Women, though, as opposed to men, will have other symptoms at the same time. So it may be a little discomfort. Women don't like to use the word pain, but mostly breathlessness, or maybe my back just hurts, or my head feels a little foggy, and it's less likely to be only chest pain. And so what we historically call that confluence of symptoms, we call that atypical, which is also pretty funny because it's 51% of the population. How could that be atypical? So if you—

are they more subtle, the symptoms?

They may be more subtle. So you start with the woman not thinking she can get heart disease because we worry about breast health and reproductive health in our families. Physicians often miss the subtle clues, so we don't rush them to get an electrocardiogram or put them in that part of the emergency room. And so each of these things kind of pile on to unfortunately still continue to have women with bad outcomes.

Isn't there something about your arms, like pain going down your arm? 'Cause my mom used to have a little diagram of that on her mirror.

Interesting. So yes, sometimes the classic chest pain will start in the left side of your chest. It will be described as a heaviness, and it can radiate to the neck, the jaw, and the left arm.

In women?

In both men and women, but nobody's heart attack symptoms are like anyone else's. So my goal is that we should educate scientists and doctors understand why women may present differently, but more importantly, let women know that even if they're not having— didn't really feel like an elephant on my chest, doctor, it went to my right arm, not my left arm— doesn't matter. If you're having symptoms that feel unusual or concerning to you, get them checked out.

A lot of women are reticent to go to the ER. You know, they're embarrassed. They don't Want to overreact? And is there a point where you think, I'm in serious trouble, I better get medical attention?

Far before you think about being embarrassed, because our running joke with my population, with my friends, is the worst thing could be to miss a heart attack. If this was the bad Chinese food you ate last night, or if it is a little bit of Or it could be muscle pain from something else. That's fine, because the flip side of that is sitting home with a heart attack and not going in is potentially catastrophic.

So better safe than sorry.

Absolutely.

Are there things you should do? Let's say you want to call 911, which I think is preferable than driving to the hospital, right?

Do not drive to a hospital. Do not wait, see if it passes by taking Tums. The moment you think you might be having a heart attack is the time to call 911. Don't underestimate and minimize your symptoms. Oh, I'm sure it's nothing. I took a Tums. Tell them you think you're having a heart attack because then they will get you there faster. They will do a first evaluation by the first nurse or doctor to see you quickly, quickly, because time is truly essential at that point.

Is there anything you're supposed to do while you're waiting for the ambulance? I remember Rosie O'Donnell a few years back. Didn't she take an aspirin or a baby aspirin? What, what is the protocol?

Absolutely. If you think you're having a heart attack, the best thing to start is to let the emergency technicians know. And if you have baby aspirin in the house, take 4 of them and chew them and tell the emergency medical people who come to your home that you've just taken 4 baby aspirin.

What about regular aspirin?

Regular aspirin is the equivalent of a couple of baby aspirin. So 1 full aspirin. Absolutely. More people at home will have baby aspirin because that's the prevention strategy.

But I think about, should I carry baby aspirin in my purse?

You know, it's funny because I have suffered from migraines and every handbag, every wallet has my migraine medicine. So the truth is, it's probably not a bad idea.

And for a full aspirin, an adult-sized aspirin, are you supposed to put it under your tongue?

You can chew it or you can swallow it, but ideally the baby aspirin are easier to chew.

Okay, but for an adult-sized chew or swallow?

Either one is fine.

Okay, let's talk about family history. How important are genetics when it comes to heart health? My— both my grandfathers died of heart attacks in their 50s, and my mom had angioplasty. She had heart disease as well.

How concerning should it be if you do have So how you decide to do lifelong prevention is based on everything about you. So the first thing is your family history. And I think it's really important to know it because, you know, knowing the age— you told a perfect story because sometimes I hear my grandfathers both had, and when we dive a little deeper, they had their first event at 87 and 92. So it's premature heart disease. So it's having your first event at 87, 92. first heart attack or stroke as a young person, 40s, 50s, 60s for women. That gives you sort of a check in the how aggressive are we going to be in your lifetime of prevention. So it becomes— and it's not— we can't modify it, but it's important to know. It's important to tell your daughters that that history exists because, you know, you want that to be something that continues over generation. And for those who have really significant family histories, we may start earlier on preventive strategies. So we may start earlier on testing if necessary to sort of avoid, not dissimilar to what we do with cancer screening, right?

If you've got a family history, then we start things younger for the children and the grandchildren. So we like to think of the genetics of heart disease the same way. It raises your awareness.

Let's talk about the phases of a woman's life, starting with those under the age of 40. When should women under 40 start getting their cholesterol checked?

That's a great question. Depending on their other risk factors, if there's no diabetes, no hypertension, no tobacco, no family history, every 3 to 5 years. And if they have other risks or reasons to check it more frequently, that's fine. It's a simple blood test. We wanna ask young women about their periods. If your first menstrual period was before 12 or your first menstrual period was over the age of 16, you are at a slightly higher risk for heart disease, whether your periods are irregular or miserable, all of that matters. In fact, the American College of OB-GYN consider a menstrual history as a vital sign. Nobody asks young women that. Certainly nobody asks older women that. So it starts, did you have trouble conceiving? Did you nurse after children? Did you have pregnancy losses? So everything that goes on in your OB-GYN office has to come to your internist or cardiologist's And then depending on your family history, you have cholesterol checked at regular times throughout your life.

There are other risk factors for young women, like something called PMOS. How does that increase your risk of heart disease?

So it is pretty common, 6 to 10% of young women, and it presents itself with potential for high blood pressure, for lipid abnormalities, for blood sugar abnormalities, and it's because of the way their metabolism works. The metabolic milieu is not entirely healthy. And these women are at higher risk for cardiovascular conditions as they age. We used to just tell young women it was a challenging period, or you're not menstruating correctly, maybe you'll have some—

Fertility issues, right?

Fertility issues, hair suit. But we didn't put the whole story together on this being a metabolic syndrome that can impact on heart health over a lifetime.

Let's keep going through phases of life, because I know pregnancy can actually increase your risk of heart disease. And cardiovascular disease is now the leading cause of death in pregnant women and those who are postpartum. I had no idea. What is it about pregnancy that increases your risk so much?

Yeah, it's a stress test, basically. It is truly a stress test. So fewer than 50% of women who become pregnant are at optimal heart health. So you imagine, because these are younger women, how much opportunity we have. So when you become pregnant, your blood volume goes up, the hormones are different, your heart rate and blood pressure changes. So all of that is truly a stress test on the heart. 10% to 20% of women will have some form of high blood pressure during pregnancy, and that identifies them at higher risk in the future. About 5% to 10% will have gestational diabetes, blood sugar abnormalities, and even if that goes away after childbirth, you are still at higher risk. So all of these are risk factors, and we call them APOs, adverse pregnancy outcomes, and say that what happens during pregnancy needs to be part of your history, even if everything resolves after delivery.

Do you think enough OB-GYNs are aware of sort of the heart risks that happen during pregnancy?

Not historically, but what's interesting about the women's health movement in general is we all have to work together. So we know that our younger— our daughters may have just an OB-GYN or gynecologist as their doctors. And if we want to start this prevention strategy younger, they need to be the partners for the internists and the cardiologists. So there's a lot of work going on with the American Heart Association, the American College of OB-GYN. How we train doctors and residents has to be different because you have to know this going in.

And to look at bodies more holistically.

Absolutely. I know that, you know, what is the definition of high blood pressure in pregnancy? What medications are important when the risk factors for bad things happening in women's pregnancy journey happen? All of that is critical.

For Black women, it's even more serious because they are more likely to develop pregnancy-related heart problems. And 59% of Black women over 20 are living with some form of cardiovascular disease. That's an unbelievable statistic.

And that number for white women over 20 is about 40%. So think of the disparity between those 2 numbers, between white and Black women in the U.S.

What's going on there?

You know, it's— it is a combination of healthcare bias. Lack of access. You know, we talk about social drivers of health and they matter. You know, your ability to stay healthy as an individual is only 20% what goes on in the doctor's office or a hospital. And the rest of it is how we eat, how we live.

Food deserts.

Education, food, housing insecurity, violence, trauma, pollution. It goes on and on. And we can't separate the value placed on these social determinants from a holistic approach to health.

Let's talk about women in their 30s and 40s, really when perimenopause starts and sort of the precursor to menopause. Perimenopausal women are twice as likely to have poor heart health.

Yeah.

Why?

It's a combination of that is a time period in a woman's life that she is less likely to be seeking care, 'cause then you're raising a family, your career is on fire, maybe the parents are aging, hormonal things begin to change. Blood pressure may go up, weight may go up, cholesterol panels may look less optimal. As few as 30% of women in the first year after having a baby will have their own checkup. How ridiculous is that? So then you get into this whole habit of not taking care of yourself.

So interesting. Then menopause.

Boom.

Which brings on even more hormonal changes, right? How significant is that timeframe for heart disease in women?

Yeah, it's enormous. And it starts with perimenopause. So, you know, we lose estrogen, We know that the average age of menopause means 1 year without a period is about 50, 51 in the US. But things start to change for a decade or more before that. And those are the time periods that we really want to start not ignoring things, whether we're not sleeping as well or challenges with our weight or little blips of increase in blood pressure. You want to start taking care of those things in your 30s, 40s, and early 50s.

There are 2 heart conditions unique to women, microvascular disease and spontaneous coronary artery dissection.

Right.

I'd never heard of these.

I know, and that's part of the challenge. So when we go back to, you know, how we misunderstood this to be a man's disease. So we thought heart attacks in the '70s, '80s, '90s were— you picture a heart artery as a tube, and that if there was a clog in it and blood couldn't go past, that was how a heart attack happened. So then we started seeing women who would have abnormal stress tests. They would have chest pain and abnormal EKGs. We would do an angiogram, a cardiac catheterization, and we had no blockage. And we told them they had no heart disease. We told them to take an antacid, maybe a Valium. We didn't think that maybe women could get heart attacks differently. So microvascular disease can cause all the damage of heart attacks without obstruction, without a blockage. Maybe the blood vessel can spasm. Maybe it reacts differently to stress or other catecholamines, those fight-or-flight things. So microvascular disease is a different way that individuals, maybe 60 to 70% women, can get heart attacks. There's something called MINOCA, which is myocardial infarction, heart attack, without obstructive coronary disease. So we don't have a blockage, but the artery behaves in an abnormal way.

And it's not just women. So are there tests for that? Yeah, great question. Once we finally realized that this was not in a woman's head, but this was a different form of what we call ischemic heart disease, we started developing tests. Some of them are invasive with catheters, others are special cardiac imaging studies, but you have to think of it. So you have to not say to a woman, this is in your head, this is your stomach, this is your stress. You have to say, this is a different form of heart disease. Or it can be maybe you're having a different kind of heart attack, a different type of angina, different than a blockage would cause. It's a whole new area of study.

Yeah, which must be fascinating.

It is.

And finally incredibly helpful to these women.

And really important, yep.

How rare are those conditions?

You know, it's interesting. We don't know for sure because we've sent too many women over the decades away without a diagnosis. And when we started to realize that this has to be something real because these women kept coming back to the hospital, and when we looked at their lifespans, they were shortened. So this wasn't nothing. This wasn't in their head. This was something that we had to study better.

Let's talk about postmenopausal women. Menopause is in my rearview mirror.

Me too.

And I know that this is something So, menopause is a serious risk factor for heart attacks. Why in postmenopausal women are heart attacks more likely?

So when we're menstruating in the beginning decades of our lives, we make estrogen. And estrogen is a hormone that is protective against the things that cause heart disease. It keeps our cholesterol a little better. It keeps our inflammatory markers a little better, our blood pressure a little lower. And then the lack of estrogen accelerates all of these things that we were really protected from for decades. So our weight goes up from inflammatory markers going up, our blood pressure goes up, our good cholesterol drops and our bad cholesterol goes up. We're more likely to have prediabetes or blood sugar abnormalities. So all of those risk factors almost accelerate in that time period. And I think that's a really important point.

So what about HRT? You know, I know there has been a complete reexamination of hormone replacement therapy for women in perimenopause and menopause, but if estrogen is so important and so protective of women's hearts, why shouldn't they be taking HRT even if they start after menopause?

No, it's a great question. I mean, and it's another— the history of all of these So, we did— the NIH did one of the largest trials ever.

I covered it. Bernadine Healy, the WHI, stopped prematurely.

Right, right. And then one day, we studied a certain group of women, a huge group. We studied a certain hormone replacement therapy. So, you know, it seemed like the perfect answer. As you said, this is all— this is so much related to lack of estrogen. Let's replace estrogen. It was a perfect hypothesis.

Right.

And then one day, And then we found more breast cancer, more clots in legs, more strokes. And instead of saying, hmm, let's question—

Let's recalibrate. Right.

Let's look at women at different ages, different— we shut it down. It was horrible. And then the whole concept of hormone replacement got women panicked, got doctors unwilling to even discuss it. But it didn't make sense to scientists. So then there's this revitalization of asking those questions, just as you did, studying different agents, different patient populations, different forms of HRT. For some reason, for some people, it may just be a vaginal insert or a patch or a pill. There are so many different ways that hormones can be replaced. And we actually call it menopause therapy now, menopause hormone treatments now, because But what about for older women? It is not recommended for primary prevention, so no one starts it for heart and brain health. For women who have symptoms— sleep disorders, sexual dysfunction, hot flashes, any of those symptoms— a conversation with your doctor has to happen. What your risks and benefits are, what the potential long-term risks and benefits are. And then every woman makes a decision what to do, how long to try it, what type of replacement to try.

Maybe this is a dumb question, but why, why not preventative for, for heart disease in older women?

Because we've never shown that it works. And there is some data coming on now That makes us still re-ask the question, but there's not no risk to putting on an agent that may not have any benefit for the future.

So what are the risks or what are the potential negative side effects? Is it the increased risk of breast cancer still?

Only for a certain population, the increased risk of blood clots and stroke for only a certain population, but again, till it's It's shown to be a benefit. The hypothesis that we had it when we were younger and we lost it now is not really a good enough reason.

I think about the population, those decades lost though, because of the WHI study stopped prematurely, and how much progress potentially could have been made.

Yes.

In terms of like a safer estrogen replacement for older women, you know, and I I got estrogen-positive breast cancer, so I had to stop taking estrogen, and I can't tell you how much I miss it.

It's terrible, of course. I, I, I, I, and that's why, and when you asked, you know, how do we train people and how, so few medical students get training in menopause hormone treatment. Most, or too few OB-GYNs or internists wanna have that conversation because it takes time. These lengthy risk-benefit conversations are important, and everybody knows what happened decades ago. And it sounds like, I don't even want to talk about it. My doctor won't even discuss, you know, menopause hormone treatment.

But hopefully that's changing.

It is. Menopause centers are being opened. And, you know, our OB-GYNs are better trained in it. Our internists, our cardiologists are training in menopause medicine so that we can be part of the conversation.

One of the risk factors in postmenopausal women you mentioned is One of the things that you mentioned is obesity.

Yeah.

You know, gaining weight from inflammation or other factors. And I'm curious about GLP-1s. A lot of women are between 50 and 64, according to RAND American Life Panel. They are the highest users of GLP-1s. And I'm curious if that seems to have any positive impact Tell us about their preventative qualities for heart disease and heart attacks.

Yeah, so GLP-1s are, you know, truly revolutionized healthcare and cardiovascular medicine. They are medications that were first studied in diabetics, and then we saw weight changes, but then we started to look at patients with heart disease and kidney dysfunction and diabetes and the impact on lowering blood pressure, lowering bad cholesterol, lowering blood sugar, has been incredible. And for almost every disease state that we've looked at, it's been an important player in the pharmacopeia of medications we use. The guidelines recommend a certain group of— whether it's obesity, diabetics, kidney disease, forms of heart attacks or heart failure, and there are great indications. For weight loss solely? For some people, it's an important part of their decisions about how to optimize their health, for sure.

But does weight loss lower your risk of heart disease automatically, or does it depend?

What it does is it lowers the likelihood of you having high blood pressure. A couple of pounds weight loss is the equivalent of a single antihypertensive medication. We know that you're more likely to have We know that you're more likely to have bad cholesterol from inflammatory markers if your weight is up. So they all kind of go together, honestly. To us, it's not solely about the appearance or discomfort of the way our weight changes in menopause. It's all of the markers that then optimize heart and brain health. So, Dr.

Women have been understudied, underrepresented in clinical trials, and too often misdiagnosed for decades. That's why I'm so encouraged by the work being done at Northwell Health's Katz Institute for Women's Health. The Katz Institute brings together a network of more than 1,000 women's health experts across 26 specialties to provide coordinated, With their comprehensive, integrated, personalized care, from heart health and menopause to nutrition, pelvic floor health, and more, they're helping ensure women have access to the support they need at every stage of life. You can learn more by going to northwell.edu/kcm. Let's talk about some across-the-board recommendations when it comes to things like diet, exercise, and sleep. What are sort of the recommendations you would give any adult woman?

So it starts with having a clinician who you trust, whether it's your gynecologist or internist. For young women, it could be their, their pediatrician or adolescent doctor. But you really want one physician who's in charge of all of you because that person can keep track of any specialists whom you need to see. So the data all comes together. you shouldn't be responsible for navigating that. Secondly, start young and know that so much of what you can do to prevent heart disease, and I think about it rather than preventing disease, to optimize heart health, and the things that we do to optimize heart health also optimize brain health, such an important priority for all of us as we age. So the American Heart Association makes it easy. There are things called Life's Essential 8s. So there are 4 lifestyle behavioral habits: quit tobacco, vaping, secondhand smoke, all of it, eat better, and we could go into all of the conflicting advice on eating better, moving more, and getting healthy sleep. And interestingly, the sleep recommendation is the newest of our Life's Essential Recommendations.

Why is sleep— why has that become so important?

Because we used to think that sleep was a waste of time. Hard-charging people used to joke that I don't need sleep. You need sleep, and there's decades now of science that shows that poor sleep is either a sign or a risk factor for cardiovascular health. Those who don't sleep are more likely to have blood sugar abnormalities, increased inflammatory markers, prediabetes, hypertension is affected, and on and on. So we know that seven to 9 hours.

You talked about nutrition. Do you recommend the Mediterranean diet?

I do. You know, I think because I think it's pretty simple. I start with the fact that there's no perfect way to eat. The more whole foods that you eat, things that don't come in a box, fresh fruits and vegetables, smart fats, you know, the avocados and healthy oils, lots of water, fruits and vegetables, and then minimal of the less healthy foods. Less good things, red meat, certainly anything that's packaged. The Mediterranean diet, I think, is simple for those with hypertension, something called the DASH diet, all about the same, a lot of healthy fruits and vegetables, healthy grains, healthy fats, lots of water.

What do you tell your patients about alcohol?

Yeah, that has been a complicated story. So we've been around long enough that we thought a glass of red wine or something a day might have been healthy.

Rest of all, right?

Right, we knew exactly The skin of the red grapes, but we've discovered not so. So the recommendations have been evolving, and what I tell people is there's nothing preventative about having a glass of wine or any alcohol. So you never start thinking it's healthy for you. I think the less you have, the better with regard to heart health, brain health, and cancer risk, honestly, as well as other stomach things. So I tell people everything in moderation, but don't think that it's in any way a preventive strategy.

Do you drink?

I do a couple of glasses of wine a week. Um, it's more social than anything else. I haven't gone to zero, but I know that it is not a preventive strategy.

What about hard liquor?

I'm fine with it, honestly, because the alcohol content— you will have to drink less, a smaller volume, to have the same alcohol. So, yes, I am actually a Scotch drinker. Not a lot, but once every once in a while. Wow! Look at you! There you go, right? It's a long story. And— but then it would be just, you know, a dollop of it, almost nothing compared to a small glass of wine.

But I can drink a skinny margarita? Yes.

Again, I think everything— you know, the only nevers are tobacco, as far as choices. I think every once in a while, to have steak, To, you know, we're making these food choices for sustainability, right? So if not doing something makes you so miserable that one day you go and have 4 glasses of wine or a 48-ounce porterhouse, there's nothing good about that, right? So we want to do this in a way that it's sustainable, that it doesn't make you miserable, and that it's something that you can do and continue to do.

I asked you about nutrition. I asked you about sleep. I didn't really ask you about exercise or stress.

Yeah.

My internist, not to bring it back to me, but it's sort of just a way to set the table for all women, said I should be doing exercise that makes me sweat 3 times a week for at least 30 minutes. Now, I play pickleball and I move around a lot, I'm not doing that, but I feel like I don't do enough cardiovascular exercise. So, can you just give us some guidelines for that, and if it's age-appropriate for all of us?

Yeah. No, it's marvelous. And I start with any movement counts. You know, in other words, because women also, we have this tendency, if we're not gonna do it perfectly, we're not gonna do it at all.

Right.

So, I can't join a gym. I can't run a marathon. Anything you do matters, and I really like to lower the bar for those who struggle with enjoying you know physical activity and exercise. So anything you do matters. Walk the steps, walk the supermarket aisles; everything counts. But the recommendations are 150 minutes a week of moderate exercise, and I you could still carry on a conversation when you're walking, even if you're huffing and puffing. If you So if you were playing pickleball and you were having a conversation with, you know, with your teammate, that's moderate. Or it's 75 minutes a week of high-intensity exercise is recommended. That's the stuff when you really can't carry on a conversation.

Yeah, and that's the stuff that I'm not doing.

It's okay. Then you do more of the other stuff. And maybe you do, you know, the 30-second burst of an exercise so that maybe for 30 seconds you're doing more.

And there's all kinds of ways to get those But in terms of strenuous, you say it's 75 minutes a week. A week.

And when you divide that by 7 days, you know, it's 10 minutes on a treadmill, or it's 25 minutes on a treadmill at the moderate. Maybe on a treadmill for 30 minutes, every 10, you pick up for 30 seconds, and you walk a little faster. You push. You hold weights. You put your arms, you know, in the air. Anything to get you really—

your heart rate up. And it's really when you can't talk and carry on a conversation.

That is strenuous exercise.

That's strenuous exercise.

So then you don't need watches to tell you about heart rates, and because that is another way to monitor how much, you know, exertion you're doing. But I just tell people, if you can't talk, that that's strenuous exercise.

What about stress? My Oura Ring says I have very high stress, but I don't feel like it.

I know.

And I've always been one of those people who thrives in stressful situations. But my Oura Ring says it's not good.

We all say it's not good. It's interesting. We used to think of stress as being in your head. Oh, we think it's not good. It's— but the truth is there's science. Because when you are stressed, it's not just that you're thinking something that's not productive, but it's— the bad hormones get released, the heart rate goes up, that fight-or-flight mechanism.

Cortisol, right?

Cortisol and all kinds of—

Which is the stress hormone.

Absolutely. And that's, you know, great if you're being chased by a tiger, but you can't have it regularly. But we all live in a stressful world. So to sort of tell someone, don't be stressed, is kind of crazy, 'cause for most of us, it's effective, it's rational. But then there's the small things you could do to manage stress differently. The Heart Association recommends yoga and mindfulness. And there's scientific validation that these things are effective for people with heart disease. You know, maybe it's learning to notice your breath when you're sitting at a red light in a car, or small little things.

Less road rage?

Yes, exactly. Whatever it takes. And everybody's got their— you know, yeah, anger management is definitely part of stress management. But there are a lot of things to do that can't, you know, Too many friends and patients would be, well, look at the world we're living in, or it's stressful. I have a busy job. I have a lot of responsibilities. None of that goes away. It's just how you modify your approach to it. And it's not an on-off button. I think of it as like a thermostat. You're picturing yourself turning down the road rage 2 degrees or a little more patient or a little more accepting.

Talk therapy is good for reducing stress too.

Big fan. Big fan. Our Women's Heart Program has to psychologists as part of our diagnostic and treatment option. I think it's looking at these conditions of optimizing heart and brain health much more holistically than just a cardiologist.

Women, again, often put themselves last. They take care of everyone else before they take care of themselves. But as you mentioned, chronic stress can increase the risk of heart disease. and increased rates of other risk factors like obesity. So in the United States, women make up almost 60% of unpaid caregivers, and you say that can really take a toll on their bodies. So what would you say to women who are doing the heavy lifting of caregiving, especially those in the so-called sandwich generation, taking care of their kids and their aging parents? What can you encourage them to do in terms of taking care of their own health Putting their oxygen mask on first, if you will.

Exactly. One of our integrative medicine professionals says that the grass is greener where you water it, and that's the oxygen mask. And, you know, I remind women, you know, simply put, you can't do all of the jobs you have if you're not well. You are entitled to all of the things that you advocate for everyone else. So figure out a way to make it easier for you. I do all of my testing during my birthday month. I will never forget. That's my mammogram, my eyes, and my specialists. So whatever it is, put yourself on your to-do list, as they say, and try to get those things done. And then start getting comfortable with asking for help. You know, you can't necessarily be best at doing 4 people's jobs. So, yes, maybe your sister isn't as good at helping your mom with something, but that's okay. Maybe your children aren't cleaning their rooms well enough, but maybe that's okay. And it's really managing the totality of your responsibilities and appreciating what that stress does to you.

And stop being a martyr.

Yeah, there's nothing healthy about it. There's nothing— It's it's it's just not good for you, and and you know I sometimes joke with patients and friends. You would never tolerate that behavior in a girlfriend. So I always talk about telling people to you know be open with your family, your friends. You know no that's not good. You know dad could go you know with somebody else to the doctor's appointment, and no you can't cancel that blood test for the fourth time in a month. You know think of it as like the team approach to healthcare that you and your friends, family. Watch out for each other when that— those tendencies, you know, take over.

Let's talk about cholesterol, because I know our thinking on cholesterol always seems to be evolving. We have the bad cholesterol, LDL, right? And the good cholesterol, HDL. I used to think, oh, my HDL is pretty high, so that's protective. But guess what? But that's not true anymore. It's really about your LDL level, isn't it?

We all used to think that, Katie, so don't— we all thought there were ratios and good and bad. It's all about your LDL.

So tell me about the difference between good and bad cholesterol, if you can, in layman's terms.

Absolutely. So these are all products that are created by your liver, little, you know, chemicals that go around our bloodstream, and some of them have the jobs of of cleaning up bad stuff in our blood, basically, and they're scavengers almost.

That's the good cholesterol.

That's the good stuff. The bad stuff, the LDL, as well as small particles of LDL, something called lipoprotein little a, which is getting a lot of press now, and ApoB, apolipoprotein B.

Should you get tested for both of those things?

Yes, you should. So dyslipidemia guidelines came out really just recently, and they're marvelous. ApoB is the worst part of the LDL particle, and that should be tested just to see whether or not your LDL particles are even better than just bad. And lipoprotein is a once-in-a-lifetime test. It is predominantly genetically focused. 20% of people will have elevated lipoprotein, and there are no There are no presently— there are no available medications to specifically treat lipoprotein, but it means that we have to be aggressive about all the other things: blood sugar, weight, blood pressure, your bad LDL.

Should everyone with high cholesterol be on a statin in your view, and what is the definition of high?

Yeah, that's also a great question. So each of us is individual, so there is a risk calculator called the Prevent Calculator, which is also relatively new, some amazing research from the American Heart Association. And you could find it online, and the Prevent Calculator asks you for your age, some other numbers, your cholesterol, your blood pressure, some kidney function numbers, and it will spit out a risk factor, a risk assessment for you, 3%, 5%, 10%. So the new guidelines talk about each of us doing the Prevent calculator, finding out what our number is, and then based on the number deciding, am I good or do I need to do more testing? Do I need to be on a cholesterol-lowering agent? We want everyone's LDL to be less than 100, and that's very different than what we— where we were in, in the old days.

Mine is 148.

We could do something about that.

So obviously, I've been talking to my doctor about going on a statin. But if you're over 100, is that when you should consider a statin?

Yes.

They're wonder drugs, by the way, aren't they?

I've been on one for several years, and I'm happy to tell my patients that because for some reason, there's such reluctance, and I'm not really sure I understand it. I tell people now that imagine that you think about retirement. but you don't want to start saving till you're 62. It's ridiculous. We'd never do that. So you want to start young with these things. So even if your LDL is mildly elevated or your coronary artery calcium score is mildly elevated, you want to protect your future arteries. It's literally like saving for your future. And the medications are inexpensive, minimal side effects. Yes, there is a small percentage of people who really can't take it, but that's very small. And we have other options. There are other agents that can impact with less cost, less side effects. 140, I don't really like 140.

148.

I really don't like 148.

Well, we'll discuss. Earlier this year, I know the American College of Cardiology and the American Heart Association said high cholesterol should be treated sooner. Your point about not waiting too long? Even starting in your 30s, and that, that could significantly reduce your lifetime risk of a heart attack or stroke.

Yeah, it is one of the most important equal signs that we have. The same with high blood pressure. The college and the Heart Association came out with new blood pressure guidelines, and we are much more aggressive in driving pressures lower, starting with medications along with lifestyle changes. And interestingly, the high blood pressure story is related to science that shows that it decreases the risk of dementia. What could be more important to all of us than that? So cholesterol, blood pressure, really critical to start young.

I want to ask you about other tests because it's not just cholesterol, right? I mean, there are other things that you can do that will indicate if you're at risk of heart disease and a heart attack. Is cholesterol the first key, or can you have good cholesterol or good cholesterol levels and still be at risk of heart disease?

Absolutely, particularly if you have other risk factors. So that can be somebody with terrible diabetes or terrible high blood pressure and not have a normal cholesterol— and still have a normal cholesterol. I liken it to a a tobacco user who never gets emphysema and then someone who never smoked getting emphysema because all of these are pieces of the puzzle. So checking your blood sugar is really important. Checking your blood pressure, even home monitoring, is very important. I would say hypertension is probably the most, after tobacco use, the most treatable and prevalent risk factor for Heart attack, heart failure, stroke, and dementia. And it's a simple blood pressure.

What about other tests? For example, I had a coronary calcium test in 2023 and a CT angiogram in 2024. Who should be getting those tests and at what age should they be getting them?

That's a great question. So when we go back to that Prevent calculator that we discussed, the Prevent calculator gives you a number on your risk for 10 years, 30 years, lifetime, there are certain categories of risk in whom a coronary artery calcium score is recommended. And what it is, is a very simple test, very little radiation, no intravenous, a modest price, so if it's not covered by insurance, you can pay for it. And it shows whether there's even the very beginning of plaque. And that may be a very early sensitive way to kind of double down on your risk factor profiles. Maybe you are reluctant to start a statin, but this may say, ah, these are my future arteries I'm protecting.

But who knows? I mean, how do you know if you should even be getting that test?

Well, it starts— I think it starts with that Prevent calculator.

But let's say, you know, if people maybe— I'm going to urge people to do the Prevent calculator, But are there certain signs? Are there— is it a family history, for example?

I think a coronary calcium score for anyone who has any concerns or risk factors is an important test to consider doing.

At what age?

You know, it depends. If you have very little, probably not before 40, honestly. If you do, if you had pregnancy-related issues, then you should do it younger, you know, in your 30s. If you have a family history or diabetes, even if it's mild, because it just gives you a baseline against which to decide how aggressive you're going to be with managing your risks.

So there's the coronary calcium test. What about a CT angiogram?

So CT angiogram is pretty neat. It does require an IV, you get contrast or dye, and it actually gives us, without putting catheters in your heart, a beautiful picture of what your coronary arteries look like. It is a little bit more expensive. It has a little bit more radiation. But for anyone who maybe is having some symptoms that feel a little unusual, and a stress test is good, but it's not really seeing the arteries, this may be a test to consider.

What about a nuclear stress test, which my brother-in-law George Beller helped develop? Dr. George Beller.

Absolutely. I still use it. It's in my armamentarium of tests. And it depends what question you're asking. So if your question is, how prognostic is my mild chest pain, or I found a small blockage or a small amount of plaque on the CT angiogram, do I have a stent, do I take medication? So doing a stress test with nuclear material is a beautiful pairing because it gives you the physiology, how the function of the heart is. And we got the anatomy, what the picture looks like from your CAT scan. So together, those tests for certain patients is the perfect combination to decide what to do next.

I imagine my doctor ordered these tests because my mom had heart disease.

Absolutely.

And my cholesterol is high.

Absolutely. And that is the right thing to do. And then each test doesn't necessarily make you go down, oh, then you have to get another test and another test. But each piece of information allows you to speak to your doctor about maybe my LDL of 148 isn't terrific. You know, that, that becomes additional information to make your risk-benefit decision on the next steps.

These tests sound pretty complicated. When should you get a cardiologist?

That's a great question. So I think honestly, anyone with concerns go see a cardiologist. Some of my favorite patient visits are people I see every 3 to 5 years, 'cause it's just a check-in for the future. If you have symptoms that are concerning and you feel that your internist or your primary care physician is not being concerned enough and evaluating them, absolutely. I think everyone should have a cardiologist because I think honestly that the— our approach to early detection, lifestyle management, early treatment options is just a little bit more aggressive, I'll say, in a good way.

I think now more than ever, we're learning that so much of your body is connected to other things. All these different incredible systems of ours can impact your heart health, even your mouth health.

Absolutely.

Bacteria in your mouth Can you explain that?

So we've looked at periodontal, like dental health, and there are issues with infection, the bacteria in all of our mouths. There are inflammatory markers that can be increased that are bad for blood vessels everywhere from mouth diseases.

Absolutely.

The idea that every part of our body is connected and that healthcare or medicine was always divided by organ systems, right? I'm a kidney doctor, I'm a heart doctor. But the truth is the connectivity from blood vessels, from hormones, from inflammatory markers is all throughout our body. And we have to get out of that silo of organ focus. Our view of women's health is a collaborative view of a woman in the center, and we figure out what her healthcare needs are.

How can we get women to take this more seriously? Every time I hear this statistic that it is the number one killer of women, I think, why aren't we talking about this more? Why aren't we educating women? Why aren't they advocating for themselves?

There's still the leftover— and one of the worst, I can add a disheartening statistic, only 44% of American women know that heart disease is their biggest health risk. And when we divide that to Black women and Hispanic women, And if you look at Hispanic women, the numbers are even lower. So the number one risk, women don't know about it. I think that there's still the bias thinking this is a man's disease. I think we think of women's health as being reproductive and breast health, so we don't sort of put it in play. I don't think we're training clinicians to really appreciate that this is a woman's biggest risk, not to minimize symptoms, to be as aggressive with diagnosis, treatment, prevention with women. But at the end, It all comes down to women being their best advocate and not accepting minimization of symptoms, not accepting, no, you don't really need a calcium score, you don't have anything. We have to be louder about it. We have to advocate. We have to investigate. We don't invest in it. We don't invest in the science. We don't invest in the education.

What would you tell women who are not being taken seriously?

Find a doctor who'll take you seriously. You know, everybody asks who's the best, who's the this. The relationship that you have with your doctor is so critical, that primary care, again, cardiologist, internist, gynecologist, because that becomes the person who understands you and will know that maybe you need to have another test because something in your head tells you it's not right, that you're worried about something, a family history, a symptom that's unusual. And I think that's so important. Find a doctor who you can really partner with to make these decisions together.

What are you excited about? You are at the forefront of women's heart health, dealing with patients every day as head of the Katz Institute at Northwell. So many exciting things are happening in health and medicine right now. What are you jazzed about?

I'm excited about the expansion of science because we don't do science now just in the historic way, test tubes and large research trials. We are studying behavior. Why do people not make the right choice if they're the same? We're looking at how we implement. There's this horrible gap we talk about in science about it taking upwards of 17 years between a discovery and getting it out to where people live. And we're studying how do we do science differently with large language models, with AI techniques.

I was going to ask you about AI and the impact it's having in your field.

It's extraordinary. We are all so excited and curious about what the opportunities are for us to do better diagnostics, better treatment, even the way our trials are done. You know, we'd study tens of thousands of people over 20 years. It's very expensive. That's a very long delay in getting the answer to these critical questions. So the way we do science is changing. And despite all of my frustrations about you know, being referred to as being in a niche specialty, a niche specialty, and women are the atypical form. I think we've made a lot of improvement. Women aren't tolerating that kind of minimization, that kind of lack of funding and advocacy. And I think scientists, not just women scientists, all of us are not missing these great opportunities to update our understanding of how to treat women better. It's not okay any longer to do that.

I think another area you really need to focus on is public awareness.

Absolutely. Absolutely. The Go Red for Women movement has been around for over 20 years. The Heart Truth from the National Institutes of Health. But it's clear that we are missing the mark in really making this something. I think the interdisciplinary clinicians— so if the obstetricians and gynecologists and if the pediatricians are asking the moms, sort of we bring in the whole, you know, house of healthcare to really focus on these opportunities, I know that we'll get better at it.

It's really about collaboration, isn't it?

Absolutely.

And then, of course, just having people talk about it. And in a fragmented media environment, it's hard to get these messages across. But, you know, there's still more opportunities with so many platforms popping up.

Yeah. And we have to do better. And I think it's bringing in the younger women. It's bringing in the older women who no longer want to tolerate feeling old. You know, we're still— our life expectancy is longer, and it's not okay to not include any cohort at any stage of life in all of the science and the advocacy.

And since you brought it back to longevity, and since this whole series is on longevity, clearly you have to start doing things early. to live longer and live better. But, you know, as somebody who's about to turn 70, and that's why I'm really focusing on this, is there anything people in my age group really need to focus on?

Yeah, all of it. It's deciding what's important to you. It goes back to those lifestyle. And if you can't do 150 minutes a week, do whatever you can. It is getting regular checkups. It's asking the questions. It's staying active physically and mentally. It's reading books. It's challenges. And it's never too late. My mother just started on a statin. She is 87 years old. We looked at her numbers. They all of a sudden jumped up. She is totally healthy.

The idea that you hit a certain age and we shouldn't be going all in in focusing on healthy longevity You really have to think of the total body and the whole sort of system and how these organs interact with each other and how, like, every aspect of your body is connected, right?

Yeah, absolutely. And historically, medicine training, medicine research was organ-based. I know that sounds silly, but we were cardiologists or kidney doctors or bone doctors, and we became so expert in one area, that other things, other organs outside of our field of expertise, we drove patients to other specialists. So if you had diabetes, you might have an endocrinologist and a kidney doctor and a heart doctor. And— but you were the same person every day with a single body of connected systems. Medical training is different. We're evolving to look at individuals in a more holistic way. And that's really critical because Because no part of you is unattached to any other part of you. And it shouldn't be incumbent on the patient to navigate a complicated system. We should do better.

Do you think that that will have an impact on longevity? Because I think it's such a sad statistic that women live longer, but they don't live well.

Right, because they have more chronic conditions. And part of that challenge is women have more doctors because of the increased number of conditions they have. They take more medications than men. And each of those facts allows us to have more complications or more lost opportunities to prevent and enhance longevity. So yes, whether it's, you know, some of the AI work that's being done now, even the singular medical chart that allows each of us to see data from each other is really going to move us to a much more holistic approach. And longevity is all about healthy aging and minimizing chronic So it had— we have to be able to do this better for sure.

Dr. Stacy Rosen, thank you so, so much. This has been such an enlightening conversation for me, so I hope it will help everyone watching and listening as well.

Thank you for having me here. We're so grateful to have the opportunity to get the word out of these important ways to stay healthier.

Once again, thank you to our presenting sponsor, Northwell Health's Katz Institute for Integrative Medicine. Next Question is a production of Katie Couric Media and Acast. The executive producers are me, Katie Couric, and Courtney Litz. Our producers are Adriana Fazio and Julia Lewis, and our production coordinator is Alyssa Horowitz. Julian Weller composed our theme music. For more information about today's episode or to sign up for my newsletter, Wake Up Call, visit katiecouric.com/newsletter. Visit us at KatieCouric.com and follow me on Substack and all the other social media platforms. Women have been understudied, underrepresented in clinical trials, and too often misdiagnosed for decades. That's why I'm so encouraged by the work being done at Northwell Health's Katz Institute for Women's Health. The Katz Institute brings together Northwell Health has brought together a network of more than 1,000 women's health experts across 26 specialties to provide coordinated, personalized care. From heart health and menopause to nutrition, pelvic floor health, and more, they're helping ensure women have access to the support they need at every stage of life. You can learn more by going to northwell.edu/kcm.