We are two cardiologists and two primary care internists. Ask Us Anything about heart disease in women, including SCAD.

What is SCAD?

SCAD is Spontaneous Coronary Artery Dissection. It happens in men and women, but is more often associated with pregnancy so obviously is associated with women. The artery dissects or tears open instead of being the traditional atherosclerotic blockage that causes the heart attack. The dissected artery limits blood flow to the downstream artery and the heart muscle is starved for blood, oxygen, and nutrients. The end result is the same damage to the heart as an atherosclerotic blockage causing the heart attack, and the heart muscle a can die and turn to scar. BUT usually, the artery heals and the person has good overall heart function. The importance is to recognize it early so the person gets proper care and treatment. It can occur in late pregnancy or postpartum. And occurs in both men and women with extreme exercise. It is NOT associated with traditional cardiovascular risk factors and generally occurs in people under 50 yrs old. - Gina Lundberg, MD

Do women with a history of preeclampsia need to be more concerned about heart disease?

Yes, unfortunately. There is mounting evidence that preeclampsia places a woman at risk for cardiovascular disease (CVD) for the rest of her life and is in fact a risk factor for cardiovascular disease. Preeclampsia is a pregnancy complication that is associated with long term risk for high blood pressure, atherosclerosis, SCAD, heart attack and even stroke. The new 2018 AHA Guidelines for the Management of Blood Cholesterol list preeclampsia and gestational diabetes as well as menopause for age 40 as risk-enhancing factors for CVD and recommend using statins and cholesterol lowering medications when lipids are unfavorable to prevent CVD events. Women who have had preeclampsia should see an Internist or a Preventive Cardiologist for further risk reduction evaluation and long term follow up. These women need careful attention to lifestyle, weight, blood pressure, blood sugar and blood cholesterol levels. Preeclampsia increases a woman's risk of heart failure 4 fold and coronary artery disease 2 fold. But the good news is that with awareness and lifelong monitoring, these risks can be reduced and managed. -Gina Lundberg MD

Hello, what do you think of intermittent fasting as a means of ensuring long term well being? I know it’s a little out of left field, but I’m curious to get your opinion :)

There’s some good scientific evidence that intermittent fasting - when combined with HEALTHY diet and exercise can help with weight loss- especially with people that are at risk for diabetes.- Dr. Neha Pathak

is there anything other than exercise and healthy eating that you should do to prevent heart disease?

The major risk factors for heart disease include high blood pressure, high cholesterol, tobacco use (both smoking and smokeless tobacco), diabetes and family history.

Of all of these, the 2 biggest risk factors are smoking and diabetes. Simply put, don’t smoke. If you currently smoke or dip, stop. This is difficult (I know firsthand), but discuss this with your physician - there are many options to help quit.

Diet and exercise, as well as weight control, are extremely important for avoidance of diabetes, high blood pressure, and high cholesterol.

Also, regular follow up with your physician is important to screen for these diseases.

If you already have diabetes, high blood pressure, or high cholesterol, then active treatment in partnership with you physician is important to lower your risk for the development of cardiovascular disease. - Dr. Michael Rutledge

I would add that the good news is that 80% of all cardiovascular disease could be avoided or improved if we would just follow a heart healthy diet, have routine moderate exercise and “know your numbers”. Keeping blood pressure (under 120/80 mmHg), blood glucose (under 99 mg/dL) and blood cholesterol (LDL under 100 mg/DL, HDL over 40 in men and 50 in women, and Triglycerides under 150) in the optimal zone is key to heart attack and stroke prevention. -Gina Lundberg MD

I feel like the symptoms for women are ones that women can feel randomly at any time (upper back discomfort, jaw discomfort, nausea), how would you recommend hypochondriacs differentiate between real and fake symptoms?

It is definitely true that women may present with more atypical symptoms in relation to cardiovascular disease. The typical symptoms include substernal chest pain/pressure that extends to the jaw, left shoulder and arm, occurring with exertion and relieved by rest. Women may have more atypical symptoms that include pain in the back, both shoulders and arms, nausea, vomiting, shortness of breath, or upper abdominal pain.

Generally speaking, these symptoms will occur together. Should these symptoms occur, it is recommended that you be seen by your physician or proceed to an urgent care or emergency clinic for evaluation. - Dr. Michael Rutledge

You said vaping (e cigs) are an issue as well on the heart. Is it equivalent to that of traditional cigarettes as far as damage? What exactly does the nicotine do if that is the culprit?

Here’s what we know so far (and we will probably learn a lot more as time goes on with more people vaping): Vaping (e-cigs) may expose people to fewer toxic chemicals that traditional cigarettes- but there are still toxins, metals and other contaminants in those products - aside from the nicotine.

Nicotine from any substance can tighten blood vessels and make your heart beat faster. Over time this can damage your heart, lungs, and blood vessels. We don’t know all the risks yet- but we know enough to recommend that people stay away from all forms of nicotine (traditional cigarettes, vaping, chewing tobacco) Thanks so much for your question- I hope that helps! - Dr. Neha Pathak

What would you say the most effective ways to prevent heart disease are in order?

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1. Don’t smoke or use smokeless tobacco. This includes vaping - nicotine is an active contributor to cardiovascular and cerebrovascular disease.
2. If you currently smoke or use smokeless tobacco, it’s time to quit. I cannot stress this enough.
3. Diet, exercise, and maintaining a healthy weight. Three of the other major risk factors for coronary artery disease are high blood pressure, high cholesterol and diabetes. The risks of all of these are decreased by diet, maintaining a healthy weight, and daily cardiovascular exercise (you are supposed to get your heart rate up and sweat).
4. If you have high blood pressure, then maintenance of a blood pressure at least less than 140/90 (ideally less than 120/80) is very important. This should be done via exercise and medical therapy in partnership with your doctor.
5. If you have high cholesterol, then treatment with diet, exercise, and medical therapy in partnership with you physician is important. Know your numbers and work with your doctor to achieve and maintain your goal numbers.
6. If you are diabetic, tight blood sugar control is extremely important. Controlled diabetic diet, and medical therapy directed by your primary care physician or endocrinologist are needed to achieve fasting blood sugar and hemoglobin A1C goals. Achieving these goal will lower your risk.
7. Alcohol consumption. We have all heard the “glass of red wine a day” help lower risk for cardiovascular disease. This is true! However, when you start drinking more than 1 alcoholic beverage, the effects become deleterious and increase your overall risk. Low to moderate alcohol consumption is recommended.

- Dr. Michael Rutledge

My grandpa is 78 years old and lives on soup beans, Budweiser(not Bud Light), and canned food. He could run circles around most people half his age.

Based on his diet, he seems like a prime candidate for at least some kind of heart related issue, but knock on wood, has been absolutely fine. Does it just come down to good genes? Are there any kind of gentle tricks we can teach this old dog to ensure he’s with us for even longer?

Genetics do play an important role in the development of cardiovascular disease, but family history is only one risk factor.

Alcohol consumption is not related to the development of coronary artery disease, but is an important contributor to heart failure (inability of the heart to pump appropriately). However, the amount of alcohol to cause this is highly variable and dependent on the person.

We generally recommend no more than 1 alcoholic drink per day, less is preferred.

Additionally, adequate blood pressure control and cholesterol control in partnership with your physician are important.

Daily cardiovascular exercise is also recommended. - Dr. Michael Rutledge

Hello I am 21f and last year while get a routine checkup my doctor noticed my heartbeat was a lot faster than it should have been. I got sent to a cardiologist and got a shit ton of blood tests done and apparently I now have high cholesterol and sinus tachycardia. Besides eating healthy and exercising regularly (which I do), any other tips to slow down my hummingbird heart?

We do not give personal medical advice via social media.  You need to talk to your doctor about what’s best for you. 

But in general, an elevated resting heart rate which is called sinus tachycardia, is not uncommon. It can be associated with underlying disorders such as over active thyroid, anemia, dehydration, and overstimulation of the sympathetic nervous system. Usually a person wears a monitor to record the heart beats for 24 hours to quantitate the total number of heartbeats as well as any irregular heartbeats. The average resting heart rate under 100 is normal. 

Stay well hydrated, avoid stimulants, have moderate routine exercise, and continue to follow up with your doctor. There are medications that can help lower the resting heart rate when your physician feels that the benefits outweigh the risk of long-term medications. - Gina Lundberg M.D.

For those of us unable to exercise (and who must keep our heart rates down) for medical reasons, is there anything we can do at all to help our chances down the road?

I’m assuming you have a cardiologist or other physician whose treating you for the medical condition that prevents you from exercising. Ask them about cardiac rehabilitation. There may be exercises you can do that don’t pump up your heart rate, but allow you to improve your flexibility and muscle strength. Also, cardiac rehab includes counseling to improve your diet, reduce stress and make other heart friendly lifestyle changes. Hopefully multiple small changes will add up to help you a lot down the road. - Dr. Arefa Cassoobhoy

Hi Doctor Neha, I am from India, it's an irrelevant question, I would love to know your journey as a physician?

Thanks so much for the question. I grew up in New Jersey and went to an inner city public school. I tried out a couple of different ideas in college - I really thought I was going to be a teacher. Then I found that I really enjoyed the personal connection with people in the office during some volunteer work. I’ve been a primary care doctor for over 10 years and continue to love building relationships with my patients. Recently, I’ve branched out and am working at WebMD as a medical editor. There are so many amazing opportunities in medicine. Good luck on your journey!! - Dr. Neha Pathak

If RBBB (right bundle branch block) isn't that serious at all, why is there a name for it? Shouldn't it be normal? What consequences or symptoms do women with a RBBB need to be on the lookout for? Thanks!

The heart has an electrical system. This system starts at the upper right hand side of the heart called the SA node. This is the heart’s pacemaker. The SA node propagates its electrical signal to the AV node, and in doing so causes the atria (heart's top 2 chambers) to contract, filling the bottom 2 chambers (ventricles). From the AV node, the electrical signal is conducted throughout the ventricles via the left bundle branch and the right bundle branch. This causes the ventricles to contract, pumping blood to the rest of the body.

When there is a right bundle branch block, there there is a slowing of conduction through the right ventricle, whereas the left bundle conduction remains normal. This means the right ventricle contracts at a slightly later time than the left ventricle.

By itself, a right bundle branch block is of no consequence. It is a finding on the EKG, but we don’t evaluate or treat it further.

The importance of a right bundle branch block is found when there are other conduction system abnormalities that are much more complex. - Dr. Michael Rutledge

Sometimes RBBB is associated with lung problems such as obstructive sleep apnea, COPD, or asthma. Since these lung problems can put a strain on the heart, an evaluation for these things is warranted. Also, sometimes RBBB pattern on EKG is really another problem such as Wolf-Parkinson-White Syndrome or even Brugada. So it is always wise to see a cardiologist to confirm that RBBB is benign. Up to 50% of RBBB is eventually associated with a heart or lung condition. - Gina Lundberg, MD

I am a 59 yr old female , my BP is typically anywhere between 130-140/ 80-90. My cholesterol is 249 . I had an echo which revealed mild mitral regurgitate and trace tricuspid and pulmonic regurgitate and trace effusion. My father died in his sleep of ASHD . How high or low is my sudden death especially in a 100 degree hot yoga class?

This is a very specific question, and one that cannot be adequately answered in this forum. My best recommendation is that you seek a personal consultation with a preventative cardiologist. - Dr. Michael Rutledge

It’s great that you are paying attention to your numbers and know your family history. You should continue to work closely with your doctor to make sure you are addressing all of your risk factors for heart disease. As for any type of exercise, including hot yoga, you should pay attention to what your body is telling you. Look out for any symptoms, including dizziness and weakness, and discuss all exercise plans with your doctor. - Dr. Neha Pathak

Are there any symptoms or warning signs of heart health related problems that women should particularly watch out for? What I mean is, I've heard that sometimes the things we hear are problem signs for health conditions can be skewed toward what is common for men, which might not always be the same as women.

This is a great question- and you are right- women sometimes present differently than men when they are having a heart attack. Besides the chest pain and pressure, women might more commonly have:

-pain in the neck, back, jaw

-indigestion, heartburn

-nausea

-severe fatigue

-severe shortness of breath

When a group of these things are happening together- it’s really important to seek medical attention right away. - Dr. Neha Pathak

Does fish oil-induced great HDL, LDL and triglycerides numbers mean anything? How long after we stop taking fish oil before our numbers goes back to how it would have been without supplements?

Omega 3 Fatty acids are what is beneficial in Fish oils but are also found in nuts such as almonds and walnuts and in olive oil. Omega 3 Fatty acids lower high triglycerides (TG) and can boost HDL, the healthy lipid. Daily intake of omega 3 fatty acids is needed to keep levels high. Eating a diet rich in omega 3 fatty acids such as the Mediterranean Diet is recommended for a heart healthy lifestyle and long term benefits. Omega 3s are antioxidants and help other things such as joints and arthritis. Studies show that a diet rich in omega 3s is better than taking supplements. Omega 3s do NOT prevent heart attacks or strokes. But they do improve TG and HDL levels. And may have other benefits as an antioxidant.

A new study released at AHA November 2018 showed that a prescription brand of EPA only fish oils prevented cardiovascular events in diabetics. But another study showed that for primary prevention, the usual over the counter fish oil capsules did NOT prevent CVD events. Thus, for primary prevention, dietary intake of omega 3s is still a good idea but over the counter fish oils may have no significant long term cardiovascular benefits. - Gina Lundberg MD

How often do you find undiagnosed TOF in adults? (my 5month old just had her's repaired 2 weeks ago) If you have, what was unique about them that they tolerated the disease for so long?

Tetralogy of Fallot is a congenital heart disease (developed during fetal gestation and present from birth) that is a conglomerate of pulmonary valve stenosis, enlarged and over-riding aorta, ventricular septal defect (“hole in the heart”), and thickening of the right ventricle.

Untreated, children with tetralogy of fallot do not survive into adulthood.

Surgically treated patients can do quite well with consistent care. However, surgical repair does not return the heart to normal physiology. These patients should be followed into adulthood with a congenital heart specialist whose practice focuses on this population of patients. - Dr. Michael Rutledge

I hope that your baby and family are doing well after the surgery. TOF is not diagnosed for the first time in adults because it requires surgery in childhood. It is very important to continue to follow up with your baby's doctors and to find a specialist that continues to care for your child as they grow. - Dr. Neha Pathak

How bad is moderately-high salt consumption really? Just visited my cardiologist a few days ago- he says that with my low blood pressure, I can "eat all the salt" I want, is this true?

Well, that may be true for you specifically based on your age, your risk factors and your family history and based on your current blood pressure.

The problem with that advice is that you will age and you will get higher blood pressure as you age. You may be able to enjoy “all the salt you want” now but most adults over 50 yrs of age have cardiovascular risks with high blood pressure being very common. A new AHA statistic shows over HALF of all U.S. adults have risks for cardiovascular disease including high blood pressure. So generally adding salt is not recommended. So enjoy while you can and each year ask your provider if that advice still holds true. -Gina Lundberg MD

It sounds like your cardiologist is not worried about salt impacting your blood pressure. That’s great! My caution is high salt foods often tend not to be healthy like potato chips, pizza or margaritas with a salt rim. Keep that in mind when making food choices, and you should be fine. I’m glad you’ve got a doctor who you can see regularly to guide you over the years. - Dr. Arefa Cassoobhoy

What specifically about women makes the symptoms different? I in particular am biologically male (XY) but I have for a very long time had extremely low testosterone levels (around 88-175) from secondary hypogonadism that I have chosen not to treat (well tried treating but increased my anxiety).

Is the basis for the difference genetic or hormonal?

What do you think of Rosie O'Donnell's (who had a widowmaker she survived) mnemonic HEPPP (hot, exhausted, pain, pale, puke). It's very memorable like FAST for stroke (face, arms, speech, time).

And do you think HEPPP is a good MI mnemonic for men and women? Or are those extra ones (the hot exhausted etc) more primarily symptoms women have?

These are great questions and we don’t exactly know the answers. Women and men both suffer from heart disease- it’s the most common cause of death in both American men AND women. But we don’t quite know why the symptoms can be different. In a lot of cases, women DO have the same symptoms of crushing chest pain, but some studies show they tolerate for longer before seeking help. In some cases, however, women tend to have “silent heart attacks” where they don’t have symptoms. Or if they do, they are different- in the ways you described. I like your HEPPP mnemonic- I haven’t heard it before- but it’s useful. It can be helpful for men and women to know these other symptoms as well- especially if you have diabetes. - Dr. Neha Pathak

I’m curious about the link between high cholesterol and heart disease. I’ve been in a healthy weight-range my entire adult life. I exercise, practice yoga and eat well. In my early 20s I donated blood for the first time, and the blood bank reached out to me about my high cholesterol... around 270 (not fasting). My doctor recommended I exercise and diet, which seemed odd considering I was running half-marathons and watching what I ate. I decided to try a different route and went on a strict vegan diet, and, within one month, I was at 160 (fasting). I kept this up for four years, but I’ve re-integrated some meats and limited dairy into my diet. My numbers are now hovering around the 200 mark... I’ve also learned every woman on my mother’s side of the family has high cholesterol, but we have no instance of any heart disease. My Grandmother recently passed away at 97 years of age, and all of her 5 siblings lived into their 90s. Is it correct to assume most heart disease is accompanied by high cholesterol, but not all with high cholesterol have heart disease? Thank you!

Your story shows how important it is not to just “treat numbers” but to understand a person’s background and other risk factors. Although we sometimes group together “cholesterol,” we realize that cholesterol is made up of many different components-> HDL (good cholesterol) and LDL (bad cholesterol) just to name 2. Beyond the balance between good and bad cholesterol, heart disease risk factors include many other things like exercise, smoking, diet, family history. Thank you so much for sharing!- Dr. Neha Pathak

is it true that losing a lot of weight quickly (possibly from methods that are not healthy) and then gaining it back is harder on your heart than not losing the initial weight in the first place?

went through about 2 years of homelessness and at one point, starved and dropped about 80lbs in less than 5 months. after i was stable again in a home/with food, i'm heavier than ever with even worse health. heart issues run in my family, so i'm trying to eat/exercise purely for heart health. any advice for someone like me?

It sounds like you are focusing on a healthy lifestyle which is so important- not only for heart health- but also for prevention of other diseases as well. This is a great step! Your body definitely lets you know when you are not feeling well, that’s why it’s so important to pay attention. It is tremendously important to focus on healthy - whole-foods (preferably plant-based), exercise (include cardio, flexibility/balance, and weights), manage stress (after years of homelessness people can still carry the strain and trauma for years), avoid smoking, and maintain a healthy weight. Follow up with a regular doctor as well! I hope that helps you on your journey. - Dr. Neha Pathak

What is the best medication to give to control the BP, especially the pregnant women with SCAD, considering the teratogenic effects of the antihypertensive medications?

SCAD is best managed with just medical care. We try very hard to avoid going to the heart catheterization and we try to avoid stents. The arteries naturally heal and patients do best without interventions. But sometimes an intervention is necessary to improve blood flow to the heart and stop the heart attack. 

Lowering blood pressure with beta blockers helps prevent further dissection and calcium channel blockers can help reduce angina and vasospasm which cause pain. Beta blockers and blood thinners are standard care. If the patient has high cholesterol, we treat that as well. 

Most SCAD occurs at labor and delivery or early postpartum so generally the child has been delivered or is being delivered when this occurs. There is minimal risk to the newborn. The patient may be unable to breast-feed given the long-term medications but the child should not be affected by the medications. - Gina Lundberg MD 

how pronounced does ebstein's anomaly have to be to make it not advisable to get pregnant? (e.g. 50% of women with ebstein's shouldn't get pregnant)

I’ve taken care of a woman who lived to be 78 with Ebstein’s and had five successful pregnancies. At the end of her life, she did suffer from heart and lung problems associated with Ebstein’s but she was very happy that she had lived a full life and had her children. Ebstein’s is when the tricuspid valve is lower down in the right ventricle and so part of the right ventricle is actually considered part of the right atrium. The right atrium in these patients can be massively enlarged and the right ventricle is very small. In milder forms, patients live long lives and can have successful pregnancies. Each case needs to be looked at individually and is best assessed by an adult congenital heart disease (ACHD) specialist. - Gina Lundberg MD

Are Type 1 and Type 2 diabetics affected in the same way or are there differences between the two when it comes to the risk of heart disease?

This is a great question. Type 1 and type 2 diabetes both increase someone’s risk for heart disease, but newer research shows that this might be through different pathways.

In type 2 diabetes - not only does having high sugar levels directly damage blood vessels -> leading to clogged arteries over time- but people with type 2 diabetes also have a higher likelihood of having high cholesterol, high blood pressure, obesity and other conditions that also add to heart disease risks.

In type 1 diabetes - high sugar levels that are not controlled can also cause direct damage to blood vessels, but there seems to be an autoimmune component (a component where the body makes antibodies that attack the damaged heart proteins, as well). This has been found after years of not controlling blood sugar levels.

That’s why it’s so important for anyone living with diabetes to control their sugars with medications and a healthy lifestyle. - Dr. Neha Pathak

Can you tell us about the connection between endometriosis and heart disease?

This is emerging information that is not confirmed yet. Like so many other things in a woman’s life, early menarche, early menopause, pregnancy complications associated with gestational diabetes or gestational hypertension, and migraine headaches, these things indicate increased risk for a woman for cardiovascular disease later in life. It is looking like endometriosis may also be an indicator of increased risk for cardiovascular disease in women. At this point, we would advise women with endometriosis to maintain normal weight, exercise routinely, and keep cholesterol, blood pressure, and blood sugar all in the normal range. - Gina Lundberg MD 

Is there any association of SCAD with Kawasaki disease/coronary artery ectasia/aneurysm or auto-inflammatory conditions?

SCAD is not associated with any of those things. SCAD is associated with a thickening in the artery walls of the muscle layer known as Fibromuscular dysplasia (FMD). Many of the SCAD patients have FMD in the carotid arteries, renal arteries, and other arteries. All women and men with SCAD should be checked from head to toe for evidence of FMD. Not all patients with FMD will have SCAD obviously but there is an overlap. There is now a gene associated with SCAD that has just recently been identified. - Gina Lundberg MD 

What's safe as far as coffee consumption?

I LOVE the taste of coffee and have the equivalent to 4 espressos in the morning that I sip on while I start my day. Either around noon or at 5PM (never both) I have the same amount. I drink it black, no sugar or milk.

My BP is normally 100/74, my doctors say I'm in good health, with the only high blood pressure I have is when I get migraines - it goes to 140/90 - but once the migraines go away, the BP is normal again. I don't typically drink coffee during that time because I can't leave a dark room.

With a total of 8 espressos per day, you’re getting a high daily dose of caffeine! In a healthy person with no other issues, your coffee intake isn’t thought to be a heart disease risk factor which is what this Reddit AMA is about. But all that caffeine could be playing a role with your migraines. High levels of caffeine can trigger headaches like migraine, and headaches are the most common symptom of caffeine withdrawal. Double whammy! Slowly cutting down on you espresso intake may improve your migraine headaches. Good luck! - Dr. Arefa Cassoobhoy

My 11 y/o daughter was recently diagnosed with restrictive HCM w/ polymorphic VT, had a ICD placed in October 2018 ad is about to be listed as level 2 with a possible move to 1b once we reclocate closer to the transplant facility.

One of my biggest fears is that she receives a transplant (which I know will greatly improve here QOL) and a few months or years later a breakthrough occurs that could reverse the issue (specifically read up quite a bit on what myokardia is doing with medicine). My concern is she will need another transplant in 10 years give or take and her life expectancy natrually is reduced as through the current lens of medicine most receipients will develop coronary heart disease.

What is your advise for someone like me who is very concerned about this?

Secondly in your opinion how close are we to using stem cells to generate organs (in hopes of eleiminting the rejection factor)?

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I’m not involved with pediatric cardiac transplant so I can’t speak to your technical questions, but I can share with you my thoughts on staying up to date on the latest medical advances. It sounds like you’re already doing so much to support your daughter -- considering moving closer to a transplant center, and researching the benefits and risks of the various treatment options available for your daughter. I would talk to the transplant team about your questions. And if you don’t understand or feel reassured with what they say, let them know so you can speak further. Consider getting second and third opinions at other transplant centers. Ask for help connecting with other families who are ahead of you in this process to hear their experience. I hope it all works out for the best. - Dr. Arefa Cassoobhoy