Heart to Heart: A Cardiology Blog

Anne Riley, MD, FACC, is a cardiologist at the CardioVascular Institute at BIDMC and BID–Needham. She practices predominantly in Needham and lives in Wellesley with her husband and four children. She is an instructor of Medicine at Harvard Medical School and president of the BID–Needham Medical Staff.

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New Post! Pregnancy and your Heart

Hello, ladies. First, a quick update on my 10K training for those of you who missed my earlier posts—I have signed up for my first 10K, scheduled end of June. I have sustained a slight injury. From running? Oh no, this is my first organization injury. I love organizing, and in a fit of organizing my kids’ books, I decided to carry a laundry basket full of them down to our basement. Unfortunately, I missed the last step of our basement stairs and pulled my left hip flexor. But never fear, a little ice, ibuprofen and rest, and I’ll be back at it next week, I’m sure of it! Either that, or I’ll be visiting my favorite orthopedic surgeon friend—she will know what to do.

This month, I’d like to address the topic of your heart and pregnancy. Most women will have healthy pregnancies without complications and no need to worry. I am not writing about this to raise panic about pregnancy (which frankly, is stressful enough in the healthiest of situations). But, some women have health issues even before becoming pregnant that require careful attention to prevent complications. Some others develop health issues during pregnancy that can put them at higher risk to develop heart disease later on in life. Historically, cardiology, as a field, has not paid much attention to this portion of the population (pregnant women). But we are finally coming around and have recognized that we have an important role to play in helping this amazing group of patients.

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What should you talk to your doctor about? Well, even before getting pregnant, you should talk to your internist or ob/gyn about any health issues you currently manage, particularly high blood pressure (HBP) and diabetes. These are both very common issues that become more frequent as people get older. And as women in general are having babies later in life than we used to, these problems tend to be more common for pregnant women. You want to make sure that these health issues (and any others you may have, like thyroid disease for example) are under EXCELLENT control even before getting pregnant. You want that little baby to be developing in the best environment possible from day one, and that means normal blood sugars and normal blood pressures to start (or as close as you can get!).

Some women have a history of congenital heart disease. That means they were born with an abnormality in their heart that has been present since their own birth. If that includes you, you should make sure that your cardiologist (or your internist, if you don’t have a cardiologist) knows about any plans you have to become pregnant and can talk to you about whether that is no big deal or poses some health risks to you or your baby AND how those risks can be managed by your healthcare team (meaning at minimum, your ob/gyn and a cardiologist).

A small percentage of women will develop a problem during pregnancy or sometimes right after pregnancy known as preeclampsia or pregnancy-induced hypertension. The American Heart Association considers these disorders major risk factors for the development of cardiovascular disease including stroke, heart failure and coronary artery disease. Your future risk of developing one of these problems seems to be higher if you have more severe preeclampsia, if you had to deliver your baby early, or if you had preeclampsia during multiple pregnancies. If you know someone who had preeclampsia or high blood pressure develop during their pregnancy, it might not be a bad idea for them to bring this up with their internist, ob/gyn or cardiologist, so they can talk about how it affects their risk of developing heart disease later in life.

The issue of heart disease in pregnant women is gaining much more attention in recent years, both by cardiologist and by obstetricians. At the beginning of May 2019, the American College of Obstetrics and Gynecology (ACOG) released a document stating that “cardiovascular disease is now the leading cause of death in pregnant women and women in the postpartum period.” They go on to lay out a description of the issue, how to best identify women with heart disease prior to pregnancy and during pregnancy, and how to care for these women with heart disease. It was co-authored by Janet Wei, MD, a liaison for the American College of Cardiology, whom I applaud for her work in this area. Both obstetricians and cardiologists have tuned in and are focused on the treatment and prevention of heart disease in pregnant women, and that shift is good for us all.

Reference:

  1. Pregnancy and Heart Disease. AOCG Practice Bulletin No. 212. American College of Obstetricians and Gynecologists. Obstetrics and Gynecology: 2019;133:e320-56.
Post 3: Cholesterol: Know Your Numbers, Know Your Risk

Cholesterol: Know Your Numbers, Know Your Risk

Hello, team. First, a small update since the last post. I have signed up for my FIRST 10K! I’ve never run a 10K before (only 5Ks in the past, all as fundraisers for my kids elementary school). I’ve told my kids about it, which means I have to come through! What have you decided to do for yourself and your health? Who are you getting healthy for?

So far, we have discussed two major ways to reduce your risk of developing heart disease:

  1. Control your blood pressure
  2. Get regular exercise

Today, we’ll tackle another:

3 . Know your cholesterol numbers and what they mean for your overall risk.

I know, I know, as my kids would say “Mom, that’s BOR-ING.” Don’t close the browser window yet. High cholesterol is another major risk factor for heart disease. As the smart, strong woman I know you are, you should know what your cholesterol is, and what those numbers mean for your long term risk of heart attack and stroke.

The thing that trips up most people about cholesterol, is that everyone’s goals for cholesterol can be different. Yes, this makes it slightly more complicated, but let me walk you through it.

First, cholesterol is reported as 4 different numbers:

  1. Total cholesterol: this takes into account all three values of cholesterol/fat listed below.
  2. Triglycerides: another type of fat (not cholesterol). Having high triglycerides can increase your risk of heart attack and stroke.
  3. HDL: Good cholesterol. Having higher HDL seems to reduce your risk of heart attack and stroke.
  4. LDL: Bad cholesterol. Higher levels of LDL increase your risk of heart attack and stroke.

The goals for your individual cholesterol all depend on your PERSONAL risk of developing heart disease over time. That risk depends on a whole lot of factors—some of which you control (exercise, blood pressure, weight, smoking) and some which you don’t (family history, diabetes, your age).

The general rule of thumb is that you want the triglycerides and LDL to be low (and lower is better) and the HDL to be high. Most of the medications we use for cholesterol are focused on lowering the LDL, because in lots of scientific studies, lowering the LDL is how we can reduce people’s risk of heart attack and stroke.

Your doctor will take your cholesterol numbers and use them along with age, smoking history, current blood pressure, and other medical problems, to calculate your risk of heart disease and stroke over 10 years and potentially over your lifetime. Then, depending on how high that risk is, she will help you figure out what you should do with your cholesterol to lower that risk.

Let’s take the following woman and her cholesterol profile as an example of what your doctor could do to evaluate your risk of heart disease.

A 41-year-old female cardiologist (one guess as to who we are talking about) without diabetes, or high blood pressure wants to evaluate her risk of developing heart disease or stroke. She has never smoked.

Her cholesterol is: total cholesterol: 198, triglycerides: 106, HDL: 49, LDL: 128

Her blood pressure is 118/62 (this is normal).

Now because she has never been diagnosed with heart disease and has never had a stroke, she can use the ACC/AHA risk calculator, plug in her numbers and demographics and get a risk score.

Based on the ACC/AHA risk calculator (available online for anybody who wants to use it—link below), her 10year risk of developing heart disease or stroke is 0.6%. Woohoo! Interestingly, this is the first time I have ever done that calculation on myself!

Based on such a low risk, she should continue to exercise and eat a healthy diet to prevent her LDL cholesterol from going up further, but there is no reason for her to start on medication for cholesterol at this point in time.

Now, what if my risk had come out much higher because of a higher age and/or a history of high blood pressure, but with the same cholesterol numbers? Let’s say I had a 15% risk of heart attack or stroke over the next ten years. Then my doctor and I would have a discussion about what else we could do (like using medication) to bring my cholesterol down further in order to lower my overall risk.

So that is why (with some exceptions) no single cholesterol result is necessarily good or bad. Any one number could be “fine” or “high” depending on the total risk.

If I can calculate my 10-year risk of heart disease and stroke, so can you. So get into your primary care doctor’s office to review your risk and discuss what can and should be done to mitigate that risk. You deserve to take care of yourself. You deserve to put your health first. You deserve to know your risk. Find our your cholesterol numbers, and find out what they mean for you.

I’m getting mine checked again later this spring (PCP appointment made?—check).

Links to calculate your risk of developing heart disease or stroke. Both contain the same risk calculator, the information is just presented somewhat differently in each.

ACC: http://tools.acc.org/ASCVD-Ris...

AHA: https://ccccalculator.ccctrack...

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Post 2: Investing in Yourself

Investing in Yourself

One question I ask almost every patient is “So, what are you doing for exercise these days?”

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I generally get one of three responses. Sometimes, a patient will respond with, “Well, still walking/running 3-4 miles 4 days a week, doing yoga once a week and doing some weights and resistance training twice a week.”

If that sounds like you, I will say the same thing I say to those patients: Awesome work. Keep it up. See you at the next blog post. More often, I hear “Well, I was walking pretty regularly last spring, but then this summer my mother started having a lot of health problems, and I needed to go home to take care of her.” Or, “My daughter got married and it threw off my whole schedule, and I haven’t really gotten back on track yet.” Or, “I’ve had a really hard time with an ongoing divorce and I just can’t find the time to focus on myself.” The third response that is also pretty common is “Still not exercising. I know I should be, but I’m just lazy.” If any of these sound familiar, read on.

After reading piles of medical articles about the benefits of exercise and hearing my patients talk about what works and what doesn’t, I have come to a few conclusions:

  1. You need to invest in yourself.
  2. Anything to can do to move your body is better than nothing.
  3. Getting with the guidelines is doable.
  4. You were made to move.

There are times that life throws us curve balls and times when we cannot figure out how we can possibly fit one more thing (like exercise) into our lives. But if your “this is a crazy time” time of life seems to be stretching out for months and then years, it’s time to restructure, rethink, and reinvest in yourself. Exercise is one of the most powerful things you can do to reduce your risk of heart attack and stroke. It is (almost) entirely within your control. And if thinking about health risks in the abstract is not compelling, exercise gives immediate health benefits in terms of stress reduction, improved stamina during the day, and better sleep at night. Patients often ask me how I manage to have four kids and be a cardiologist. I tell them—I work out a lot. My current favorite way to break a sweat includes anything with a 90s hip-hop sound track and an instructor who yells tons of encouragement. My husband and I both work out a lot, alternating who gets up at 5 am to go to the gym, and who stays home to get the kids off to school.

When figuring out how to move that body of yours, do not let perfect be the enemy of good. In fact, do not let good be the enemy of ok. You do not need to be training for a marathon, or going to the intimidating spin class with strobe lights and loud disco music to be helping yourself and your body. You do need to spend some time finding activities that you enjoy and trying to do them consistently. Also, if you have not been moving your body much, start slow! Try 10 minutes a day of exercise, most days of the week and then add another 5 minutes to that each week until you reach 30 minutes at a time. The most important part is making this a regular part of your life. (for a resource on habit change, see below for a book that I have found helpful).

The American Heart Association recommends at least 150 minutes of “moderate” exercise each week. You can do that in 10–15 minute chunks, 30 minutes for 5 days a week, 75 minutes each weekend day, or whatever combination you come up with. Do what works FOR YOU. Exercise does not require a gym membership to the place with the eucalyptus scented towels and marble locker room (although that place does sound amazing). It requires a pair of comfortable shoes and stepping outside. Walking is a fantastic form of exercise, particularly for anybody just starting up a regular program. When the weather is bad, walking at the mall before the stores open up is also essentially free and has the added advantage of being weather protected.

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Guess what other activities count as moderate exercise? Gardening?—yup. Doubles tennis, water aerobics, ballroom dancing (as one of my patients loves to do)—all count. In addition, add two days of strength training per week and you can really pat yourself on the back. Women start to lose muscle mass around age 40, and weights and/or resistance training will help add back that lost muscle. Goodbye flabby arms, hello sculpted triceps! And bonus, all of these forms of exercise will help lower your risk of heart attack and stroke when done regularly.

Whether you want to call it evolution or God’s divine plan for womankind, the fact is, we were born to move. Modern day life has brought us further away from movement with our computers and our desk jobs and our sitting-in-car-line-at-school-pickup for 30 minutes. But the “I don’t have time/everyone else comes first/I’m not good at exercise” mentality is not helping you. So leave that nonsense behind. I promise you: your body WANTS to move. Most of us have the great privilege of being ABLE to move. We GET to jog. We GET to lift. We GET to make ourselves proud. So, hold your head up high, turn up that music, and go break a sweat.

Resources:

Rubin, Gretchen. Better Than Before: mastering the habits of our everyday lives. Random House Inc, 2015.

https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults

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Post 1: Blood Pressure: Put it on the list

Blood Pressure: Put it on the list

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In my time as a cardiologist (about seven years and counting), I have seen many women ignore their own health needs because they are too busy taking care of others around them. They have a sick parent, or a sick spouse, whose needs they put before their own. I have literally seen (in the most extreme), women ignore their own heart attacks, or their own worsening heart failure, because they are pushing and pushing to keep the other members of their family going. It is because of this observation that I decided to start writing this blog.

I know what it is like. You have a list. A really, really long list, full of things you have to do. Things for your kids, your spouse, your house, or your parents – or maybe for your spouse’s parents, your dog, your parents’ dog (who you are currently taking care of), just to name a few. But where are you on this list? If you are anywhere, you are most likely somewhere down towards the bottom. More than likely, you are not on your list at all. I get it. I have the same list, and I’m not on my list either. But I should be. And you should be on your own list, too. Here’s what to put on your list this week, and why it’s so important.

  1. Check your blood pressure.

I know, this sounds incredibly boring. But here’s the thing: knowing your blood pressure (BP), while boring, is incredibly important. It’s the first thing almost any physician wants to know about you. Why? Because it affects every single part of your body. Heart? Check. Kidneys? Check. Brain? Check. Lungs? Check. (I could go on…) The tricky thing about blood pressure is that you won’t know if it’s abnormal unless you get it checked. Let me say that again. You won’t know if it’s abnormal unless you get it checked. We don’t feel high blood pressure. In fact, unless your BP is severely high, you won’t have any symptoms at all for years and years. But all those organs I just mentioned? They will know. And over time, they won’t work as well because of it.

I am going to guess that most of you don’t know your BP. I’m guessing this because up until 4 weeks ago I didn’t even know mine. I hadn’t had it checked in about two years. To make matters worse, I actually happen to have a risk factor for developing high blood pressure (HBP). During my pregnancy with my twins, I developed pre-eclampsia, which basically means I developed high blood pressure at the end of my pregnancy, and had to deliver a little bit early as a result. Fortunately, after delivering, my BP went back to normal. This condition puts me at risk for developing HBP later in life. So what I’m saying is, I should know better.

The good news? Getting your BP checked is pretty easy these days. (Hint: you don’t even have to go to your doctor). Last week, I was in my local Wegmans and saw a blood pressure cuff set up along the wall by the pharmacy. Without exaggeration, it would take less than 90 seconds of your time. You can pop into a surprisingly convenient number of places that are likely part of your daily travels: the pharmacy, grocery store, fire station, senior center. More advice? Normal BP is less than 120 for the top number (systolic) AND less than 80 for the bottom number (diastolic). If either of those is high, then it is time to go in and see your doctor. I promise it won’t take that long. You deserve to know your BP numbers and understand what they mean. You deserve to be on your list. At the top.

If you want learn more about HBP, this is a great and very readable site published by the American College of Cardiology with more information on high blood pressure: https://www.heart.org/en/health-topics/high-blood-pressure.

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The CardioVascular Institute (CVI) at Beth Israel Deaconess Hospital–Needham is staffed by highly trained Harvard Medical Faculty Physicians, each with clinical privileges at both BID–Needham and Beth Israel Deaconess Medical Center in Boston. Each is here to provide you with care for all heart and vascular conditions.

To schedule an appointment at the CVI in Needham, please contact 781-453-7750.