Why Women Need to Be Paying Attention to Their Heart Health with Dr. Tara Narula

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Did you know that heart disease is one of the top killers of women in this country? That was a stat that surprised me. We hear a lot about the risks for diseases like breast cancer and we hear about hormonal imbalances for women. But we don't spend a lot of time talking about the importance of heart health. Today, my guest is Dr. Tara Narula. Tara is a cardiologist and a medical correspondent for CNN Health, and the author of a new book, The Healing Power of Resistance. We talk about the many unknown factors that make women at risk for heart disease and why you may need to go to the cardiologist earlier than you think. We also talk about the tools you can use to maximize your heart health. Let's get to my conversation with Dr. Tara Narula. So at what point in medical school do you kind of declare your specialty? You don't declare it in medical school, so it's really more in residency. So once you get to residency, then you kind of have to disqual. I guess in medical school, you have to decide sort of generally OBGYN, surgery, medicine. But then once you go into residency, that's when you then decide, like for me, I want to do cardiology versus infectious disease or pulmonology. And why? Why did you choose cardiology? Oh God, you know, I love the heart. First of all, I father's a cardiologist. So I kind of grew up seeing it. But it's such an awesome organ because it has the electrical system and the valves and the pump and the arteries. And at the end of the day, people can get better, which I really loved. Cancer's hard and neurology's hard because you can't always help people. But in cardiology, we have so many things we can do, whether it's treatments or prevention. And I get to see all ages. So I've just finished seeing patients today. And in my practice, I see, you know, 20 and 30 year olds and then I have 90, 90 year olds. So the full gamut. The full spectrum. Where are you? Where are you based? I'm in Manhattan. So I'm my offices in Midtown, right? My Bloomingdale's. Yeah. Dangerous. It's very dangerous. That means you're near right near the Tracey Anderson Studio, too, on 59th Street. Yeah, I'm on 59th between Lex and Park. Oh, that's great. I won't ask you about Tracey Anderson right now, but-- I know who she is, but I didn't know her studio was right here. Yeah, it's right there. In fact, you know, I'm told this part of the reason my heart has been staying, you know, relatively healthy. So I did want to want to ask you a little bit about that. I mean, so it turns out heart disease is a top killer of women in this country, which was a stat that I wasn't really familiar with until a couple of years ago. And it's interesting, like, when I sit around with my women friends, we talk about, you know, our hormonal health. We talk about, like, fears around cancer. We talk about, you know, joints and that kind of thing. But I don't-- and breast cancer, of course, concerns about that. But I don't-- we don't really talk about heart health, which is kind of interesting, because just when you correlate it with how often women have heart disease. That's right. Why do you think that is? Why is it not, kind of, a derogor topic, like, at a girl's gathering? I mean, you hit the nail in the head. And I just had a meeting today. I'm going to be speaking at an event that Northwell Cat's Institute for Women is putting on. And we're-- I'm going to be paired with an OBGYN. And part of our conversation was around why women think about their mammograms and their pap smears and everything else and not their cardiac health. When, in fact, it is, as you said, the leading cause of death for women. We always give the statistic that it kills more women. And then all forms of cancer combined, one out of every three women dies of cardiovascular disease. It's like one woman a minute. And it's just not on women's radar at all. And, you know, my vision and hope would be that women start to think about screening for heart disease in the same way that we think about visiting our GYN and having, you know, our breast checked and our ovaries and our uterus. And we have really great tools in cardiology, whether that be blood tests that can help pick up on risk to risk calculators that we can use to calcium scores, which are cat scans that can look for heart underneath, you know, that you couldn't see, and pick up on disease early. So we have these powerful screening tools. And also, you know, I work, I helped run our Women's Heart Program here at Lennox Hill Hospital. And there are female specific risk factors that a lot of women are not aware of. So in addition to the things like high blood pressure and high cholesterol and diabetes, if you had early periods, for example, you got periods before the age of 11, that's a risk factor for cardiovascular disease. Lupus, rheumatoid arthritis, psoriasis, the skin conditions, the erus factor, inflammatory bowel disease. And then all the things that happened during pregnancy. So if you had preeclampsia, gestational diabetes, an early delivery of a baby, a small sized baby, miscarriages, there's a whole host of things, those specific things that would increase your risk of cardiovascular disease that women just aren't told about. And they get discharged from delivery, never told, you had preeclampsia, for example, you're at increased risk of cardiovascular disease. And then we think about the arc of a woman's life and the later life periods and things like menopause, when we start to see risk go up for women. Cancer treatments for women. So women who've had breast cancer and have had radiation or chemotherapy, for example, to the left side of the breast radiation, that can increase risk of cardiovascular disease. So it's this incredible list of risk factors that women are unaware of and are hope as cardiologists who work in this field is to raise awareness number one of the risk factors, number two, of all those powerful screening tools. And number three, and this is really important in symptoms. So a lot of women don't pay attention to symptoms and they get blown off, either they blow them off or doctors unfortunately blow them off. So many times women will feel something here and they're told, you're just anxious, you're just stressed out. It's just acid reflux. So really increasing awareness. - It's a response to a woman complaining of anything. - It is, it is. I had a family member actually go to the hospital in upstate New York with chest pain and she was told that she was having a panic attack and anxiety and sent out of the emergency room. And she called me and she said the only reason that I'm calling you is 'cause I've heard you talk about how in women, they can have things like just shortness of breath as a sign or fatigue or feeling like your bra's a little too tight, you know? So it's so important that women advocate and really recognize these symptoms so important. It is killing our sisters, our friends, our co-workers, women that we love. - Has there been a material increase in heart disease and women over the last, I don't know how long? - Well, we've definitely seen risk factors go up, right? So we've seen a rise in obesity and high cholesterol and diets that are full of ultra processed foods and sugar, lack of exercise. So so many of the lifestyle things that we know influence cardiac risk, we've seen a rise in the last 20 or 30 years. And the important thing is that a lot of these things are things we can control and that they can be preventive. So we always say in cardiology that 80% of cardiovascular disease is preventable by risk factors so that we have so much power in our hands by sleeping and exercising and eating healthy and managing stress and mental health, you know, all of these things that we can do on a daily basis, small little changes that will add up over time to reduction and risk. - You talked before about screening. What age are we supposed to start going to the cardiologist? I mean, nobody even suggested it to me until I was in my 50s. - Yeah, so interestingly, groups like the American Heart Association, for example, talk about starting to know your numbers, for example, in your 20s. And starting to have checked your blood pressure, your cholesterol, knowing your body mass index, your high weight ratio, the blood sugar. So a lot of these numbers we can start looking at in our 20s. Another important thing is to know your family history. So a lot of people don't ask, they don't know. But if you have a strong family history of early cardiovascular disease and your parents or your siblings, in and of itself that can be something that would want warrant you being screened at an earlier age. age. But then a lot of these risk factors that I mentioned, you know, the pregnancy risk factors and the migraines, for example, are risk factor for women. Those come up in your 30s and 40s. And so, you know, I always say it's never too early to see a cardiologist. It's never too late, but it's never too early to start really kind of getting a handle on what your particular risk factor profile is and what is in your hands to take control of. You could become a routine thing, like to start getting these baseline markers of cholesterol and blood pressure and everything you're saying in your 20s. In your 20s, you should be knowing those important numbers. And, you know, there is a risk calculator that we use in cardiology. You can look it up. Anyone can look it up now. It's called Prevent. If you go online and type it in, you can put in your age, your gender, some of your numbers. And it will give you a 10-year risk score. What is your 10-year risk of having a heart attack or stroke, and it will give you a 30-year risk score? And this, you know, is for people who are anywhere, you know, starting in their 30s up to their 70s. So a lot of these things we can start doing earlier and earlier. And really the push in cardiology is to say that we are catching people too late. We need to be starting much, much earlier with our screening, with treating things like cholesterol, for example, they just released the new cholesterol guidelines on Friday that really lowered the age from really even thinking about cholesterol medicine to 30 from 40. So, you know, there's just this widening understanding that we need to start being more aggressive about risk factors and screening much, much earlier. When we look at even teenagers in autopsy who are 18, 19 years old, we see heart disease. We can see plaque in the arteries as early as the late teenage years. So that tells us actually we should even be targeting kids, right, much, much earlier, terms of how they're teaching them to live and eat an exercise and sleep and manage stress. So as far as heart disease goes, I mean, you were saying it's good to catch because it is treatable. How much of it is statins, rapathas, those classes of drugs, and how much of it is lifestyle, diet, exercise? Yeah, it's really both of them together. And I always tell my patients, you know, the medicine is really important, but equally important is all of those other things that you're doing that I'm not going to maybe write on a prescription pad. You need both. And they're both really powerful tools that we utilize. And I have a lot of patients who don't want to take drug therapy, you know, they hear a lot of bad news, bad about statins, for example. But they there is quite a lot about statins, negative, negative, I mean, it is. What is it? Oh, really, are you, are you pro statin? I mean, every cardiologist will tell you that they are one of the biggest tools we have in our toolbox to lower cardiovascular events like heart attack and stroke. On average, by about 20 to 30%, which is huge. Millions and millions of Americans take them without any sort of problems. There are a handful of people usually say anywhere from 10 to 15% in studies that will develop some side effects. But those side effects are usually reversible, you know, their muscle or joint aches or paintings. And typically we'll, we'll, you know, take someone off a statin and try them on a different one. We'll try a couple before we eliminate the class. And as you mentioned, we have new drugs like rapatha and Zedia and Dexlatol and lots of tools that we can use outside of statins. But statins really in the guidelines are the first line because they have the bulk of research over the last, you know, 20 years showing that they really reduce heart attack and stroke risk, not only by lowering the cholesterol, but also by stabilizing plaques. So if you have a plaque in your vessel, the statins will help it prevent it from rupturing, which is essentially what happens when you have a heart attack. That plaque becomes unstable. And they have anti-inflammatory benefits. So, you know, there's, it's definitely not everyone gets a statin, not everyone needs a statin. But for those people where it really is recommended, they really go a long way in terms of reducing risk. Right. And what about, you know, it was obviously I spend, this is such an interesting space like the intersection of functional medicine and traditional alopathic medicine. And I actually have a, a good friend who's a functional cardiologist, which I think is so interesting. So some people say, you know, try first with, you know, red rice yeast, that supplement and coq 10. Is there a place for that? Does it depend on the severity of the heart disease? So the new guidelines that just came out actually recommend against supplements. Interesting. Or cholesterol, for example. And I will say in my practice, I tend to avoid them mostly because they're not regulated by the FDA. And so you really don't know what you're getting. And there's a growing body of data showing, for example, liver injury in particular from supplements. So a lot of these supplements can damage the liver and people end up going to the emergency room in the hospital with liver elevations and problems from taking things that, you know, we just have no idea what's in them. The idea might be good, but you don't know like the supply chain necessarily of these, right? Yeah. I mean, there's no question that they're, I mean, I believe that Eastern Medicine, there is so much we can learn from outside of Western medicine. Yeah. But I think you have to be cautious, right? And especially with something that isn't looked at or examined or regulated. And that might interact with other things that you're taking for example. Well, yeah, absolutely. There's for sure a real risk there. I heard you talk about something which I thought was really interesting, the kind of, you know, I think in our culture, right, we're in this incredible time where people's data is available to them. They're health data, you know, you can be on a mattress that gives you data or a ring, you know, CGM on your arm, you know, all the things and and I really, I mean, I have an or a ring, of course, and I love data personally. So I find it really interesting. But I heard you say that, you know, you you think that on occasion that this popularization of the wearable technology can actually, that you've seen it cause anxiety and it can sort of be contraindicated for lack of a better word. And I think that was really interesting because, you know, and I suppose it depends on personality type. But for me, for example, data helps me make better choices, right? I'm like, oh, you know, or like I can say, I'm, is this glass of wine worth it? Like I'm going to wreck my HRV and I'm, you know, I'm just, I'm not going to do it, right? So I'm going to skip tonight or whatever. Or my sleep scores lower because I went to bed, you know, I watched TV for too long and bad. And so my latencies all fucked up, you know, like that kind of thing. Yeah. So for me, it, for me, it's like a kind of a, just a compass. But, but tell me about how you have seen or what worries you about people having so much access to their metrics. Yeah, it's such an interesting space because like you, I think there's so much power in information in the hands of the person, right? Gone are the days where you come into the doctor's office. I mean, or should be gone where they kind of talk at you and tell you, well, this, this, this, and this, right? We want to put patients, people in the driver's seat of their health care. And so much of what is helping us do that is are these wearable devices where you can come in and say, you know, here is what I found about my sleep. Here is what my Apple Watch told me about my heart rate. And there's so much useful information. I will say even, you know, the Apple Watch, for example, has picked up on irregular heart rhythms in some of my patients, like atrial fibrillation that they wouldn't have known they had. And that can cause a stroke. So I think tech and how we're using it is wonderful. But as you mentioned, I think there are a subset of people, not everyone is like you, I think I'm more like you, I would want the information. But for some people, it does cause anxiety, you know, they, first of all, everything in their world becomes around the numbers, right? And then they're sort of not paying attention to just enjoying their life because they're so focused on getting the numbers in line. And obviously life is so much more bigger than that. So it takes away from their enjoyment, but also they get worried when they see the slightest blip or change in some of their data points. And then I think the third thing is, you know, as good as these devices are, they're not perfect. And so there are times where people will come in and say, my device told me this and actually it's not accurate information. And then, you know, they've been worked up and anxious and upset for no reason. So I think it really is like everything in medicine and life, it's a personalized approach. And you have to kind of know you and what's going to work for you. But I think for the right person, it can be really great actually, really motivating. Do you feel that the sort of pressure to, you know, like in this longevity space and wellness, and do you feel like that pressure can be counterintuitive for people? Like do you think they have real stress responses to that? I do. I have like, I see several like young guys and finance, for example, who are very much, you know, into wanting to live to, you know, New York City, wanting to live to 100 and they come in with literally spreadsheets, spreadsheets on their laptop that they showed me of their data. And they will tell me it is, you know, in their quest to sort of be the healthiest and the longest, the monitoring of all this is making them stressed out, right? So there is this balance between being healthy and living healthy and wanting to live long, but also enjoying your life and not trying yourself crazy. It's sort of like being focused on outcomes like on grades, you know, like if you're taking a test, like, what is the grade? What is the grade in living your life in that space rather than like, I'm going to go sit outside and breathe some air and be in my body and live from that space. It's like when we get stuck in that achievement mode, which I guess can apply to any sector. I mean, it is stressful. It doesn't feel, it doesn't feel good for longevity. Yeah. And you're losing, as you said, like to use your example, I mean, you're not reading to read and, you know, enjoying what you're reading to just learn. You're so focused on the end goal. And it's that same thing. I want people to enjoy every single day. And sometimes that means that your numbers, you might drink a glass of wine or you might skip your exercise that day. You know, I mean, you have to be human. We have to allow people to be human. Just reading about, you know, the link between stress, not only on the heart, but on all the systems on inflammation, etc. Everything, every system in the body, like stress is obviously so bad for us, but we keep so hooked into it. It's like an addiction. It is. And that, I mean, that was so much about why I wanted to write, you know, the book that I wrote was because stress is this like pervasive health issue, public health issue, that affects all of us. And we talk about it being bad, but people don't really understand how bad it is that turning on of that pathway of those hormones, the epinephrine, the nor epinephrine, the cortisol, every single day, non-stop 30 times a day. I mean, that's damaging long term for every organ system, but in particular, the cardiovascular system. So yes, you know, even if in your quest to live longer and be healthier, you're getting stressed out, that stress response is damaging. You're working against your goals of longevity by creating more stress. And we have to kind of prioritize managing stress in this country. And we just, we just don't go to do a good job teaching people how bad it is, and we don't do a good job teaching them how to kind of control it and turn off the stress response. I think it would be really helpful if you don't mind for me. And I'm sure anybody listening to break down exactly what happens, right? Because we just like see a text or get a notification and to us it feels like, oh my god, like, and then you're like, oh, okay, no, it's fine. It's not a big deal, but there's a cascade of things that happen, right? Once you have that kind of like hit from that you're going to, that you're, we're anticipating as bad news or a problem or etc. So could you break down exactly what the body does in that instance in the cascade effect? Yeah, I mean, I think the interesting thing is that our stress response evolved to protect us. So when you look in the animal kingdom and we are animals, we have this stress response to help us survive. But we're meant to turn on the stress response briefly to evade a predator, for example, and then to turn it off. And as you said, you know, we get a text notification or something happens at work or with our child anything and we turn that on and we're doing it over and over again every single day and that's where it becomes damaging. And so what happens is when you sense that threat or whatever it is, you know, it starts in the brain. So everything starts in the brain, you're processing it in the brain. And from there, you're activating a pathway where you're releasing hormones that ultimately end up causing your adrenal glands to release things like epinephrine, the fight or flight hormone or epinephrine, adrenaline, otherwise known. And cortisol, kind of the mother of all inflammatory hormones, the stress hormone. And all of that causes things like chronic inflammation. It can cause elevation and your blood pressure elevation and your heart rate. Those things can damage the lining of the blood vessels. We talked about plaque in the blood vessels. That can take a plaque that's stable and make it unstable. So it can trigger a heart attack, a stroke. It can cause arrhythmias or abnormal heart rhythms. There's actually a phenomenon called a stress-induced heart attack. We see it predominantly in women, women who are older, 90% of the time in women. And it is essentially from this massive flood of these hormones that stuns the heart muscle. And causes essentially damage to the muscle, weakening of the heart muscle. And it is absolutely in the setting of stress. And it doesn't have to be negative stress. We see it sometimes from positive things that just make people excited or overwhelmed. But that really shows you. Like a win, world series win or something like or you win the lottery or something amazing happens. But we think about it with this stunning phenomenon of the heart. Most people will recover, but some people don't from this stress-induced heart attack. But it is one of the most classic ways for us to talk about the damage of stress. The field of stress research is relatively new. It's essentially over the last hundred years. And part of the problem is that the stress research has really been separated, the psychology research from the practice of clinical medicine. But we are starting to use, which I think is great imaging studies, to show literally what's happening in the body at the same time. So you can see with a pet and MRI scan how the brain is lighting up, as I mentioned, you can see inflammatory cells being released from your bone marrow. And you can see inflammation in the lining of your blood vessels. And suddenly this phenomenon that sounds, oh yeah, stress is bad. We actually see a picture of how bad it is and what is happening in the body. And so I think over the next 10, 15 years, as we develop this more and as we talk about this more, hopefully people will start to take stress more seriously and importantly learn how to dial it down, right? That's what I want to ask you about, because now listening to you talk about it, now I'm stressed out, thinking about how stressed out I am all the time. So how do we mitigate that? What are your tools in your life, for example, for reducing stress? Right. Well, the stress as we can't, I tell my patients, you can't take away the stressors. You can't take away what's going to happen. But what you can do is change how you respond to the stress. That is really the key. And in writing my book, the Healing Power of Resilience, we really talk about changing a stress response to a resilient response. And so what does that mean? In my opinion, it is sort of the eight tools that I outlined in the book that start with, you know, acceptance of something that happens. So a lot of us rail against negative things that happen. We fight against them. We don't accept them. And that leaves us in that state of chronic stress. So acceptance is really one of the main keys to being able to move on to the next steps. But things like social support, so buffering stress by building your social connections, that's really important. Of course, how you treat your body physically is also going to affect your mind. So the same way that there's crosstalk from the brain to the body by exercising and eating well and sleeping, we physically have the power to kind of dial down that stress response. Things like therapy, I'm a huge advocate for therapy. I think can go a long way in terms of helping people, whether it's just have a place to unload your stress or to work through things like anxiety or fears. That can be really powerful. There are lots of different ways that we, tools that we can use, but it's very important that we start to think about that. In the book, you talk about how also traumatic events are stored in the physical body and how that manifests. And I thought that was really interesting to hear from a cardiologist. You don't hear that. I mean, that's like really the next frontier of medicine. So I was really fascinated by that. Can you tell me how you arrived at that thought? Yeah, you know, for me, it was this kind of work in stress and resilience was so important because I've seen it obviously in my own life. I have witnessed stress and resilient responses in my family and in my friends. But I think because I straddle these two worlds as a journalist, you know, covering stories and interviewing people. Yes, on CBS news and you've won an Emmy and everything, haven't you? Yeah, I was at CBS. Yes, for eight years now at ABC. Okay. But in doing that, you know, interviewing and telling stories of people who have really survived unimaginable things, and looking at how they were able to move forward in their life was important for me to talk about what are those factors that help people do that. And then I would leave and come to my office and walk in the room and see patients who had just had a heart attack or a stroke or told they had heart failure. And it suddenly became apparent that we just, we need to do a better job really connecting what's happening in the mind and what's happening in the body. And I think the other main thing was I noticed when I would talk to patients about their new diagnosis, I realized that that is is a traumatic event. And we never say that out loud. We never say that being told you have breast cancer or you've had a heart attack is a form of trauma that causes a stress response in the same way that having your home burned down in a fire is a form of trauma or your business failing, getting a medical diagnosis upends your whole life. And you know, my patients would look at me and say, "When am I going to be myself again?" Over and over, I was hearing this. And it just became apparent that we need to tell people you're not going to be yourself again, but we can help you find a way to still enjoy your life and move forward from this traumatic event and become resilient. And my hope with the book is really that hospitals and medical centers everywhere build resilience training programs for patients to really buffer them and protect them and scaffold them. In those moments where we hand them a diagnosis, we hand them a prescription to learn resilience. How awesome would that be to really help shuttle patients forward and protect them mentally because we can't really help them heal. We can't get them to go to their appointments and take their medicine and do all these things if they're frozen with fear or stuck. Right. And I suppose, you know, if you can leave feeling like you're a participant, like a true participant in your healing and that you have the power and capacity to do that, I imagine. I mean, that would be great to have that kind of, I don't feel yet that in Western culture we're good at that yet, you know, like arming a patient sort of with a bigger picture. But I mean, I think your book goes a long way to that end, you know, I think it's very like the synthesis between a patient and their experience and the idea that they can bring on a set of tools to help them. And yeah, maybe they're not going to be the same as they were before. Maybe that's the wrong question. It's like, what is the blessing of this and, you know, how, how can you kind of fold it in going forward and become who you want to like this next incarnation at this, at this point? Yeah. I use the quote in the book of Michelangelo carving the marble and setting the angel free. And it's this idea that we are constantly being shaped and evolving based on things that happen to us in our life that we can't control, but it doesn't mean our life has to stop and that we can't have joy in our life in meaning and thrive. We have to learn how to do that because the insults and the challenges are going to come at us forever at over all different angles. But in the end of the day, people want to enjoy their life. They want to derive meaning from every single day. And so my hope is that we help people do that by teaching them that they can be, they have resilience inside them that is an innate gift that most of us have, but we can actually strengthen it and build it just like we build a muscle. Yeah. You mentioned as well, the importance of heart rate variability, what is heart rate variability and why does mine suck and how can I get better? So what do you measure your heart rate variability with? A couple devices, I have an ordering and a mattress and an eights leap. So heart rate variability is sort of the range of your heart rate that we assess over time. And generally, it's a marker of our underlying kind of nervous system. We call it the autonomic nervous system that controls the kind of excited tone and the quiet tone. And, you know, you want to see a more varied sort of higher heart rate that generally indicates kind of a better fitness level, at least cardiovascularly, better ability to have recovery or from stress, whereas that low heart rate, but we don't see much change in the heart rate over time during the day or night would imply that you're less cardiovascular we fit or able to kind of manage the challenges or stresses of your daily life. So it is a helpful tool for someone. And so how do we improve it, is it more cardiovascular activity, is it, you know, in some cases, yes, for some people, it is improving or cardiovascular fitness can help with the heart rate variability. And in some cases, things like meditation and breathing and some of these other exercises that work our kind of parasympathetic nervous system can also help us as well. So what is this VO2 max thing, and do I need to go put that alien thing on my face and run on a treadmill? Yeah, it's another measure, another exercise, another test that we do to kind of get a sense of your cardiac fitness. I don't tend to send patients for their VO2 maxes, that's not something I do in my practice, but some of the cardiac pulmonologists or heart failure doctors will use VO2 max or exercise physiologists as well. So it's, again, another tool in the toolbox, but these are not things. I think generally, for most people, the advice is pretty straightforward. We talk about getting, you know, cardio exercise, a moderate amount, about 150 minutes a week or a vigorous amount, about 75 minutes a week. And that's kind of an easy number for most people to think about targeting and starting with. I mean, that seems pretty doable. Yeah. I feel like I used to do, I used to do a lot of cardio and now I'm just so old. You can't, you can't be older than me, so you know, I'm like, do I really need to bounce all over like, I'm just like, oh my god, but I guess it's important to do. I mean, resistance and strength training is important too. And you know, we are talking about that a lot more now, generally in the cardiology world, we talk about two days of resistance training or strength training being built into your overall cardio. And they're important for different reasons, you know, especially as women, we tend to lose muscle. It's important for our bones and aging to kind of retain that as we get older. And is there some trick like, okay, you know, be out of breath for 20 minutes? Like, is there some rule? There's no trick. Okay. The trick is to do something you like. So I usually tell people find something you enjoy doing. So if that's swimming or running or biking or dancing or the rolling machine, whatever you're going to be consistent with, and doing it to the degree that you're, you are a little bit out of breath. That's the kind of pace you want to think about. Okay. So it's not like gasping for air. No. You do not have to. Yeah. Well, I think that's important because I think in the culture, we think, you know, for those of us, it's like, okay, you have to be gasping for air in order for it to be like true heart healthy cardio, but it's, it's good to hear that's not the case. What happens to the cardiovascular system during parimenopause? Are there changes? Yes, sadly, you know, we do see, for example, risk of cardiovascular disease go up in women post-menopause. So when we take a history of someone and we ask about the risk factors by virtue of being post-menopausal or, you know, being over the age of 55 as a woman, you know, is generally considered an increased risk factor. We see things like cholesterol levels go up post-menopause, blood pressure sometimes goes up. So a lot of these things change around that time. And that's why that's another great time point for women. If they haven't been plugged in with the cardiologist, you get plugged in to make sure that their risk factors are really well managed. And does estrogen, you know, you hear about estrogen has a protective role in brain health, dementia stuff like that. Does it have a protective role as it pertains to the heart? It's such a complicated, you know, question, I think there's so much interest right now when hormone replacement is going to be in. You know, I think the best guidance we have now is that, first of all, it's individualized. And so you really have to look at a woman's risk, does she have a history of breast cancer or blood clots or, you know, anything that would preclude hormones. But in general, you know, part of the reason why women's risk starts to go up post-menopause is because we do lose estrogen. And estrogen does, in some respect, have protective effects on the blood vessels. But what we think happens is that, this is why we call it sort of the timing hypothesis, that once you're 10 years out of menopause or over the age of 60, the blood vessels change. And at that point, if you're at estrogen, there may be increased risk. So that's why we sort of say if you're doing it more around the time of menopause in someone who's low risk, you know, then it's probably fine. Maybe there's some protective effects on things like cholesterol and blood vessel health, but as you get older, it definitely can shift and change. And certainly, if you're a higher risk woman, so we know that women, for example, who have cardiovascular disease, so let's say they have plaque in their arteries or they've had stents, they are not really candidates for hormone replacement therapy because that can actually be associated with increased risk. So I see a lot of women in my practice who come and say, can I take hormones? My GYN is sending me to you to make sure from a cardiovascular standpoint, it's safe. And you have to assess, there's no kind of. you want to make sure there's no underlying cardiovascular disease do they have high blood pressure cholesterol what are your risk factors before we kind of make that decision? I get the heart palpitations at night they say it's perimenopausal like what is what are they why are they happening. So palpitations are really common phenomena and they're scary when they're strong like they are they hurt they feel very weird it feels like almost like you're on a roller coaster and suddenly your heart kind of just jump. The most often when someone says they have palpitations it's extra beats that the heart is giving off so the heart gives off what we call premature beat. Those are not generally considered dangerous at all we worry when people have a lot of them so for example when we give people a heart monitor to where we can count how many extra beats they're having. If they're having you know a thousand in a day or even 15,000 not as worrisome as someone is having 20,000 so first of all identifying what the palpitations are is key and that's really with a halter monitor that we would give someone to where and that kind of records their heart rhythm and it lets us see a tracing of what's happening. The reason it becomes the concerning part is if they end up having irregular heart rhythm so there are sometimes where people say I have palpitations and we do a heart monitor and we find they have irregular rhythms like atrial fibrillation or atrial flutter and those carry with them a stroke risk. So usually if you're feeling palpitations getting a heart monitor to kind of identify exactly what they are is really one of the first steps again off most often it's not anything concerning but there are times where where it could be we hear a lot about palpitations around menopause around periods with caffeine lack of sleep thyroid problems alcohol. Viruses a lot of these things can trigger them so people may not have them for a while and then suddenly they have them and then they kind of go away and they come back very, very common to palpitations. Speaking of viruses you just reminded me about a question that I wanted to ask you which was this kind of post covid it you know we heard a lot about people who had contracted covid having more heart disease is that is that correct to that end up being right. So we think that covid virus did affect does affect can affect the blood vessels no question but the big finding was really with the vaccine and the concern for myocarditis which is like inflammation of the heart muscle which we saw in younger boys more often any virus can damage the heart muscle or cause myocarditis and covid itself can do that can cause inflammation of the heart muscle. But that is one of the things that we did see with covid and now we have long covid so I have we see a lot of patients sometimes you have. That autonomic dysfunction we call long covid where their blood pressure might be low their heart rate might be up they feel tired they feel dizzy and it's all sequelae or phenomenon resulting from covid so covid did a lot of things it taught us a lot as well about virus and how how are you able to pinpoint it. The cause to covid as opposed to you know other you can't you can't really I mean obviously the timing if you know if they got covid and then something happened right away but if it's something where you're sort of putting the pieces together and saying well you had covid and now you have this maybe it's linked but there's no way to definitively link sometimes these things together. You know you talked about the sort of finance bro that you have in your office this this whole fascinating cadre of of men this new breed of what is the kind of female equivalent of that like are you seeing. Sort of a hyper achieving you know woman come in like what do you think culturally the equivalent of that is on our side well if you're in New York City I think it's different than if you're in some of the country but yes I see a lot of women too who you know what's interesting is they come in and they're you know thin and they're fit and they exercise and they eat healthy and they feel good. And then I'll send them for a calcium score which is a screening test for heart plaque and it comes back showing they have heart disease and they're shocked because they say I was doing everything right and I feel fine and how can I have heart disease and that's where you know a lot of these screening tools can be really powerful. But yes I see a lot of women New York City women who you know think they have their everything together and they're really surprised when they find out that they might have heart disease so is it I mean I know partially can be genetic but what what's the common denominator is it stress why are they why are they all having it I don't think we know a lot of it can be family history or genetics and that's why it's important to know your family history. Because you can be doing everything right but if you have a very strong family history or really heart disease that can be enough to sort of tip you over. But certainly things like sleep I mean I asked everybody about sleep and I was a 90% of my patients tell me they're not getting 7, 8, 9 hours they're getting much less sleep is a risk factor for cardiovascular disease stress as we talked about diet I mean a lot of what we eat that we think is healthy may not be healthy. So all of these factors may play into why we see coronary artery disease or plaque in people who we otherwise would have assumed would not have it right right probably a lot of its environmental yeah. So if somebody comes in and they have early heart disease and it's a surprise right like they thought wow I thought I was healthy and I I run and I eat well et cetera like the sort of the profile that you just mentioned. Is it reversible when it's early and no it's not. That's that's the hard part of cardiovascular disease you know is that once the plaque is there in the vessels that to your heart arteries you can't take it away right there with you forever and that's why it's so important to start this process early of prevention because once the disease is there you can't really get rid of it. You can maybe have a little regression or pulling back at some of the plaque with medications and lifestyle but essentially once the disease process is there you can't change it. And at that point it's about managing the disease right going forward but you can keep it from getting worse yes you can keep it from getting worse and you can keep it stable. So I have a lot of patients who have heart disease and they're worried you know what if tomorrow I have a heart attack or am I going to live to 100 and the answer is it depends I think there are a lot of people who have our disease and live to 100 and continue to run marathons and you know live a wonderful life a lot of those people are doing everything right at that point it's really a turning point where you have to look at. Am I taking the right medications am I living the right way in terms of my lifestyle so that I can prevent my heart disease from progressing and getting worse. Tell me a bit about why you decided to write the book what what happened what was the combination that you thought you know what I need to really sit down and and do this. As I said I think it was just an accumulation of interest in this concept of what what allows us to move forward when bad things are difficult things happen to us in life you know my father is an immigrant from India I grew up really seeing his stories and hearing his stories of resilience. I had my own episode in medical school where I lost vision and part of my eye and nobody knew why and that became a period of time for me where I had to really find my way through something that was the most challenging thing I've ever faced. And then as I said being a journalist and being a doctor and seeing it all around me I just became fascinated with this and so when I was at CBS I said I want to do stories a couple stories on resilience and I ended up interviewing psychologist to their whole world is about studying resilience. And they they said to me you know number one most of us are really a lately resilient and I thought that's such an amazing fact that we don't tell people wouldn't be great if we told people how strong they are because so many of us think we're not that strong and we would really fall apart of something happened. And then in the same breath they said and we have all these ways we can build it and we know this because we studied it in Navy SEALs and we studied it in POWs and I thought if you have all these tools why are we not getting this out there for everybody to use in their everyday life and for our patients to use. And so it was so important for me to then say let's just put this information out there in a relatable way as a road map for people to easily use step by step to think through what can I do to build my resilience and explain to them why stress is bad. And so it was really a passion of mine you know I just like approach to write a book about COVID and diets with the initial call and I said well I can do that but I really want to write about resilience and thankfully that Simon and she still let me do that so it was a labor of love getting this book out there. Well it's a beautiful topic and it's a very universal topic and I think it's great I just it makes sense about about your dad I wondered if there was some yeah thread that ran through. He always told my brother and I you know no matter what happens you'll you'll be fine you'll survive it's like I hear him in my head and I thought that just those words are so powerful just being told you can get through it sometimes it's just those words the shift in our perspective. Um, that helps us through challenges. Is there like a particular one or a few wellness practices that really bug you? Like when your patients come in and they're like, I'm doing this and I'm trying that whether it be, I don't know, IVs, hyperbaric, chambers, whatever, I don't know. Probably all of those. Yeah, I mean, I think, listen, everybody's entitled to want to improve their health and to try things. And I think as long as it's not anything dangerous, I don't have a problem with people trying to do better for themselves. I think I get concerned if it's something that might cross the line that might actually harm them and that's, you know, what would that be? Well, like I said, some of the supplements certainly that can cause liver injury or damage that's, you know, might be concerning, but a lot of the other things that people do, the cold plunges and, you know, the sonnas and the probably not harmful for most people. Right. And when you see like, because did you see that big finished study that came out on sonnas that said like reduces all cause mortality by like 30% is that true? Is that can that be true? I mean, maybe probably has to be replicated. It's very hard to control for all the other variables that people who use sonnas might actually be living healthier in other ways and didn't make sure to be sure it's the sonna that's doing that. Right. But certainly, you know, there may be something to the heat and how your blood vessels respond and maybe they end up responding in a healthier way because they're exposed to heat. Yeah. Who knows? Tell me what your day looks like. You have two little girls. I have two little girls in a golden retriever that's six months. And two careers. So I'm up at five and I walk the dog while everyone's sleeping because, you know, they're sleeping and I want to let my husband with a coffee or a green tea or that's a very kind of you. Yeah. I know. Wow. I walk the dog and then I exercise. So my time for exercise for me is like my wellness practice and stress relief. So I'm up in the gym from like 530 usually to, well, if I don't have TV till like 630. Okay. At which point, I'm go back downstairs and get my kids up and start to get them ready for school. If I have TV, then I'm usually out the door by 710 in the morning. So. Oh, you mean, yeah. Because you're going. I thought I was picturing you like watching TV on a treadmill, but you mean, no going on TV. Right. So for the last, so I was at CBS for eight years and then briefly NBC and CNN. And then I've been the chief medical correspondent ABC for the last year. And so I never know from day to day if they're going to want me on the next day, usually find out the day before. And so yeah, so it's a lot of preparation the night before to kind of prepare for the segment the next day. But typically, so I'll be up at five trying to get lunch boxes packed breakfast for the girls, flat ironing my daughter's hair, which she requires me to do in the morning, eating my oatmeal and coffee and then heading to Hudson Square for a good morning, America, usually do my segment around 805. And then I'm heading uptown to my midtown practice. And I see patients here Monday, Tuesday, Wednesdays from 930 to five usually about 18 patients. And then big day. Yeah, it's a long day. And then Thursdays they do telehealth for half a day in the morning and then I'm from home. I do that from the office here. Oh, well, okay. And then I do some administrative role. So I help run the do direct communications for the cats Institute for Women's Health, which is Northwell's big women's health program. Right. So that we have meetings for that. So the days are really busy. And then my husband works across the street from me. He's a plastic surgeon. And so we leave. We take one as six, yes, then we take the subway home and we all try to have dinner as a family. That's really important to us. So we sit down, have dinner and then make dinner. So I have a nanny who who does it, yeah, but I order hello fresh. So she has all the ingredients she needs and all the recipes and so she prepares the food for us while we're at work. And then we have a we have goop kitchen opening in New York City very soon. So that this is our food delivery service. That's healthy and delicious. So that that will help you out. I will love to try that. Yeah, I mean, I wish I have number one. I don't know how to cook, but I have no time. But the kids are really awesome. So yeah, and then basically we're hanging out, relaxing together, you know, for the next hour and a half, usually television and then trying to usher my kids into bed, which is like a process. So and then my husband are usually in bed by like 10 30. Okay. So yeah, it's a long day, but a full day. Well, thank you so much for joining me on the podcast today. It's been so interesting to talk to you and the book is fantastic and I'm so glad you wrote it. And I highly encourage everybody listening to read the book and don't forget to go to the cardiologist. That's right. Thank you. Thank you so much for having me. Oh my gosh, such a pleasure. Thanks for tuning in. This has been a presentation of Cadence 13 Studios. I hope you'll listen, follow, rate and review all of our episodes, which are available for free on Apple podcasts, Spotify, Odyssey, or wherever you get your podcasts. The good holiday gift guides are our calling card. We scour the earth for the best options in every category to make it easy for you to find the right gifts for everyone on your list. 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