All of Us Are Overlooking Critical Facts About Our Heart Health. Dr. Suzanne Steinbaum Walks Us Through What We Can Do, Starting Today

When you think about the typical patient with heart disease, what image comes to mind? If you’re like most people, it’s likely an older man clutching his chest in pain, having a heart attack.

It’s understandable. For decades, we’ve collectively thought of heart disease as a man’s disease. Yet heart disease kills more woman than all forms of cancers combined. In fact, among women 20 and older, nearly 45 percent are living with some form of heart disease, according to the American Heart Association—and many don’t know it.

“Women need to know the truth, and the truth is that heart disease is our No. 1 killer,” says preventive cardiologist Suzanne Steinbaum, DO.

That’s a stark reality. But here’s the good news: There is a lot you can do to protect your heart, prevent heart disease, and even reverse heart health conditions that have already been diagnosed. Here, Dr. Steinbaum gives us the information and tools we need to close the gap in awareness and take steps in the right direction.

A Conversation with Dr. Suzanne Steinbaum

Heart disease is the leading killer of women. Why do many of us—men and women alike—still not realize this?

To answer that question, we have to look at history to give us the context. In my view, there are three issues.

First, no sex-specific research was done on women’s hearts before 1993, which is when the Office of Women’s Health was founded. In 1984, more women started dying of heart disease than men—and we didn’t know why. For years, we thought heart disease was a man’s issue. Sadly, we still don’t have all the answers. We’re making progress, but it takes 15 to 20 years for research to hit clinical practice. What that means is that research on women’s cardiovascular disease hasn’t yet fully changed the practice of how heart disease prevention is delivered. This means women have to know the facts and advocate for themselves.

Second, cardiologists are seeing women when they’re sick—not for preventive visits. Medical school training taught me that heart disease was a “man’s disease.” Thankfully, I think some of the younger doctors are much more aware of the specific risks women face when it comes to cardiovascular disease, but the past still lingers.

Third, even though most women understand that heart disease is the No. 1 health threat, they don’t believe it’s a threat to them. In one survey of 1,000 women, researchers asked: Do you know that heart disease is your No. 1 health threat? And while 98 percent of the respondents said “yes,” only 13 percent said they believed heart disease was a personal problem. Too many of us don’t believe heart disease can happen to us.

Every day in my office I hear things from my patients like, “Nobody in my family had heart disease, so I’m fine,” or “My father had heart disease, but I’m thinner and I work out, so I’m in the clear.” Not enough of us realize we’re at risk of heart disease. This has to change.

You often say that our hearts are the metronomes of our lives. Tell me more about this…

Your heart is an expression of everything that happens to you from the time you were born or maybe before then, depending on what you believe and who you speak to. Your heart health isn’t only about your genetics; it’s about anything that has triggered inflammation. It’s about all of your life stressors—and as women, I believe we carry these stressors very deeply.

This is why I think it’s crucial to look at the big picture, as well as risk factors such as high blood pressure, high cholesterol, diabetes, smoking, a sedentary lifestyle, poor diet, overweight or obesity, and lack of sleep. It’s also important to understand specific risk factors for women. For example, diabetes and high blood pressure (hypertension) have a greater effect on women’s hearts than they do on men’s hearts. Adverse outcomes of pregnancy, inflammatory diseases like rheumatoid arthritis and ulcerative colitis, depression, social isolation, PTSD—all of these factors play into your risk of heart disease. It’s important to know this and talk about this with your clinicians.

A lot of women have no idea that if they had any pregnancy complications—things like preeclampsia, gestational diabetes, or other issues—they’re at greater risk of heart disease later on, even if their condition resolved immediately after giving birth. Can you explain this?

Pregnancy is the first metabolic stress test of your life.

When you’re pregnant, your heart function increases to support your growing fetus. The endothelium—which is the lining of the arteries of your heart—helps those arteries dilate and relax in order to efficiently pump blood throughout your body.

During pregnancy, this dilation and relaxation really gets worked. And if your arteries don’t dilate and relax as they should, your blood pressure can go up—a condition called gestational hypertension or preeclampsia. You can also face adverse outcomes, such as early delivery or a low birth weight baby. In fact, any pregnancy complication is a reason for you to believe that you might be at risk for heart disease, because it means that during your heart’s first big stress test—pregnancy—there was a problem with your endothelium, and that means you are at risk for future heart disease.

There is an increase of heart disease and stroke for women with preeclampsia about five to 15 years after pregnancy. If you had preeclampsia, you are also 11 times more likely to have hypertension later in life and four times more likely to have diabetes—both key risk factors for heart disease. When we look at women with gestational diabetes, 70 percent of them go on to develop diabetes five years after pregnancy.

So, what do you do if you had pregnancy complications? Know that you’re at increased risk of heart disease, find a doctor who understands you’re at increased risk, and get a heart disease prevention plan in place. This is the preventive model that I’ve focused my entire career on, because the more we know and the sooner we know it, the greater our ability to change outcomes.

Understanding how to prevent heart disease requires understanding the heart’s endothelium. How do you explain the endothelium to your patients?

If you keep your endothelium healthy, you never get heart disease.

Think of a healthy endothelium like a pipe cleaner and an unhealthy endothelium as a popsicle stick. When you put force on a popsicle stick, it breaks. When you put force on a pipe cleaner, it’s pliable—it bends and changes shape based on what it needs to do.

When the endothelium is stiff, the sheer force of the blood pumping through your heart can cause micro tears in the lining of the artery. I often compare it to the lining of a pocketbook. When there are tears in the lining of a pocketbook, you lose your keys, gum, lipstick between the lining and the outside of the pocketbook. That’s how the endothelium works. When those microtears happen, cholesterol, inflammatory cells, fibrin, smooth muscle cells and proteinases build up in those tears and begin to form plaque.

If your endothelium never develops this stiffness—if it stays pliable like a pipe cleaner—your arteries can dilate and relax as they should as the force of your blood flows through your heart. You never develop those micro tears, and there’s never the buildup of plaque that can cause heart attack and stroke.

And here’s what’s interesting: If you are somebody who has hypertension, known plaque buildup, or even if you’ve already been diagnosed with heart disease, you can take steps to get your endothelium healthy again, which can stop the progression of heart disease.

Can you walk me through those steps? What can all of us do to keep our endothelium healthy?

It always comes back to the risk factors you’ve heard before, plus a few extras.

First, it’s important to keep your cholesterol and blood pressure low, as well as keep your blood sugar in check. The best way to do that is to exercise and eat a healthy diet. I realize you might be bored of hearing that advice. But you know what? These tactics work.

It’s also crucial to manage your stress and prioritize sleep, because the inflammation that results from poor sleep and high stress makes everything worse. And I’m not even going to talk about the importance of not smoking—this includes vaping— because if you haven’t gotten that message, I don’t know what to say.

Then, it’s important to think about your family history. We determine if you face a genetic predisposition to high blood pressure and if you do, we treat it. Knowing certain markers in your blood can tell us things like if you need to be on a low-fat diet, because you cannot process fat. If that’s the case, your paleo or keto diet is going to hurt your heart. We can check another marker that lets us know how you process sugars, which can help guide me when it comes to diet recommendations. For example, if you can’t process sugars, I’m going to tell you that you need to stop drinking alcohol—and that the red wine that’s OK on a Mediterranean diet isn’t OK for you.

The type of exercise you’re doing is also very important. For optimal heart health, you want to aim for a moderate intensity heart rate zone for 30 minutes, five days a week, including strength training. This “Zone 2” cardio training demands that your heart’s arteries fill and then relax. If all you’re doing is high-intensity interval training, where your heart is beating really fast, your arteries won’t fill and relax in a way that’ll keep them optimally pliable.

Finally, we need to talk about menopause when it comes to women’s hearts. We know that estrogen is a vasodilator, which helps keep the endothelium healthy. As estrogen decreases after menopause, we lose its protective effect on the heart. If you’re within 10 years of menopause, have a conversation with your gynecologist about hormone therapy, which we now know is safe, especially if administered in a transdermal form.

It sounds like all of us need to be thinking about our heart health now, before we have issues. Where do we start when it comes to finding a clinician like you who focuses on prevention?

Know that it may take some time to find a clinician who’ll partner with you on this. There is some point in our lives, at least for most of us, where we’re sitting at a fork in the road. Maybe we’re there because we got sick or had a surgery and couldn’t exercise for a couple months; perhaps we had kids and just couldn’t get back to focusing on ourselves for two or three years longer than we expected. We broke a bone, or we hit menopause, and everything felt like it went wrong.

When this happens, having a clinician who can help guide you on your healthcare journey—someone who’s going to be there for you when you’re at that fork in the road—makes all the difference.

Suzanne Steinbaum, DO, is a cardiologist specializing in preventative care, author of Dr. Suzanne Steinbaum's Heart Book: Every Woman's Guide to a Heart-Healthy Life, and founder/CEO of Adesso by Heart-Tech Health, a med-tech innovation for women’s cardiovascular prevention, health, and wellness.