Beth Oliver, DNP, RN, Chief Nurse Executive and Senior Vice President of Cardiac Services at Mount Sinai Health System, recognizes American Heart Association’s National Go Red Day with an esteemed panel of Mount Sinai Heart leaders from across the Health System. Our experts discuss cardiovascular disease including: symptoms, risk factors, disparities within the disease, medications and the latest technological advances.
Chapters (Click to go to chapter start)
How can women control their risk of developing heart disease? Dr. Kini shares updates on her latest projects and apps Dr. Fergus discusses a new analysis showing disparities in cardiovascular risk factors between black and white adults in the United States Dr. Kini discusses how women can work out and exercise safely after a heart attack Dr. McLaughlin highlights cardiovascular risk factors which are unique to women, and ensuring that providers are aware of these health care disparities Dr. Langan discusses factors which can contribute to inequities between men and women in managing cardiovascular disease Dr. Mehran talks about The Lancet Women and Cardiovascular Disease Commission and its recommendations to reduce the global burden of heart disease in women Dr. Croft discusses the rise of cardio-obstetrics and cardiac-imaging in managing pregnant women with known or suspected cardiovascular disease Dr. Contreras on the continuing battle with the COVID-19 pandemic and its impact on the heart and recovery Interventions to help reduce 30-day readmission for women Dr. Mehran discusses techniques to help improve mental and emotional wellness for better cardiovascular health Dr. McLaughlin shares support methods in educating the next generation of Cardiologists Final Question: What advice would you give women who are living with cardiovascular disease?
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"Refer a Patient Online" button. Good morning everybody and welcome to our second annual Go Red for Women Webinar. My name is Beth Oliver, I'm the chief nurse executive and the senior vice President for cardiac services. I'll be moderating moderating today's panel. As you know, we have been hosting this event for the past 15 years in honor of American Heart Association's National Go Red Day, although this year is virtual um and not hosted in our Hatch auditorium. Like we normally do, we look forward to hearing some of our esteemed female Mount Sinai leaders that I'll be introducing in a few minutes. So let's talk a little bit about the Go Red campaign. It's Go Red for women. It is an initiative of the American Heart Association that seeks to raise awareness of heart disease among women and provide them with the knowledge and tools to control their risk factors and improve their health. The red dress that I have on here is the symbol and why is it the symbol of women and heart disease? Well actually in 2000 and three, the National Heart lung and Blood Institute known as the N. H. L. B. I. And the american Heart Association and other organizations came together that were committed to women's health. They joined together to raise awareness of women and heart disease. The N. H. L. B. I introduced the red dress as the national symbol for Women in Heart disease awareness and the H. A. Adopted this symbol to create synergy among all organizations committed to fighting this cause by working together to advance this important cause the american Heart Association, the N. H. L. B. I. And other women's health groups will have a greater impact than any one group could have alone. So our Nationals Red Day, it's usually the first friday of february. Um, it's an annual celebration that raises awareness of cardiovascular disease and the importance of saving lives. The key messages that cardiovascular disease is continues to be the number one cause of death. For women. It claims more lives than all forms of cancer combined. It's not just a problem for older women. Heart disease and stroke can affect a woman at any age. In fact, new research shows that heart attacks are on the rise in younger women and that's why it's important for all women to take charge of their heart health and to encourage others to do the same. Just to give you some sobering statistics. Cardiovascular disease, like I said before, is the number one cause of death. It causes one in three deaths each year, every woman every minute rather, a woman dies from heart disease. In the United States, heart disease is a killer that strikes more women than men and is more deadly than all forms of cancer combined. In fact, 64% of women who die suddenly of cardiac coronary heart disease had no previous symptoms. But on the positive note, 80% of heart disease and stroke can be prevented and that's through education and lifestyle changes alone can reduce the risk of cardiac events such as moving, exercising, eating healthier and managing one's blood pressure awareness among hispanic women. That cardiovascular disease is the leading cause of death has declined over the last 10 years, though their risk continues to remain high. Hispanic women in their twenties are nearly eight times more likely to die from cardiovascular disease than breast cancer and more than three and four that 77% of hispanic adult women are overweight or obese. Cardiovascular disease claims the lives of all black women that all forms of cancer accidents, assaults and alzheimer disease combined, More than 57% of black women have cardiovascular disease. Among women, black women have the highest prevalence of stroke And more than half or 56% of black women aged 20 or greater have high blood pressure And more than 80% of adult black women are overweight for obese. So it's important for awareness and and to talk about treatment. We know that disparities continue to distrust when it comes to symptom recognition treatment and even life saving support measures. But it's important. This is where nurses can really focus and as well as practitioners on educating that women have, you know, that that women can reduce their risk factors through education That women having heart attacks. These are sobering against statistics that women having heart attacks may wait more than 30% longer than men from the moment they begin experiencing symptoms to the time they arrive at a hospital. So it's don't deny your symptoms and really educating everybody in the emergency rooms to take these symptoms seriously. Wait, women are less likely than men to receive. Bystander Cpr and female heart attack patients may have better outcomes when treated by female physicians, media attention to heart disease. Disproportionately focuses on men perpetuating the myth that heart disease is a man's disease, although I think that that is changing. Um as we continue to focus on this and that really the most important thing and that you'll hear later with our esteemed panelists that the symptoms of heart disease can be different for both men and women and often misunderstood and that fewer women than men survived their first heart attack and I'm really thrilled to introduce our esteemed panelists Dr anna porno Kinney Dr I see Fergus dr Noel langan dr Roxana Moran dr Joanna contreras dr mary Ann Mclaughlin and Dr Lori Croft. So let's get started. Our first question is, you know, as we know heart disease is the leading cause of death among women and one of the most preventable. How can women control their risk of developing heart disease. Now I'd be happy to talk about that beth so first of all, women need to understand early on that what their risks are of heart disease um and educate themselves about the risks. We know that the common risk factors include high blood pressure, smoking diabetes, family history. They need to know their family history. They need to talk to their doctors about their risk. They need to get their cholesterol checked and their blood pressure checked. And importantly obtain a healthy lifestyle starting at the young age, starting with their Children, starting with exercise daily, starting with healthier foods. Um Less preservatives, less smoking less alcohol. Um And finally to really find a doctor, usually it's a cardiologist that will really take this under there their venue and really do some screening testing. Screening testing is at different ages for different risk factors. But starting in our twenties blood pressure and cholesterol being checked and then going through changes of hormones. Having having a discussion about what that means to your doctor and having an evaluation by a cardiologist is important. Can I add um there are also some unique cardiovascular risk factors for women including pregnancy and hormonal things. So um any kind of adverse pregnancy outcome can influence your cardiovascular risk later such as like preterm labor, gestational diabetes, gestational hypertension, pre eclampsia and preeclampsia. So these are all natural stresses to our body that we don't think of when we're going through labor and delivery. We're going through that pregnancy process. But later on in life these become cardiovascular risk. So when you speak to your primary care doctor, your cardiologist, they should be taking a good pregnancy history to see that these unique cardiovascular risk factors can influence what happens to you later in life. Also you should also think of women that have like lupus or any kind of dermatological disease. Those are unique cardiovascular risk factors um if they have any kind of radiation to the chest of breast cancer, so that can affect your cardiovascular risk. So these are other unique risk factors that women should be aware of as they go forward in their life. And doctor Croc, we're gonna ask you a question later on exactly about that more about that anybody else. Before I go, I just want to buttress on what Laurie just said was to remind everybody that actually women are actually more complicated than men. And that is because we actually a multitask. But there's a reason we multitask is because we actually have to multitask as we bear Children, which is a very unusual thing. And so that actually changes a lot of things. We have very more way more complex hormones and it affects how we have palpitations. And that's the reason I'm raising it. But it makes it much more difficult to diagnose symptoms because they are much more complex. And so also in terms of understanding risk factors, you have to have more depth in your thought process about what you're facing when you're talking to a woman because she has more psychological complexity, more physiologic complexity, more hormonal complexity and therefore the diagnosis is actually often much more complex. And I would just like to add to that. I mean, I think it's excellent. We've already laid the stage. But I've always said women are not little men, so don't handle them that way. So everything that that dr lori dr Marianne and Noel said absolutely true. But the one thing is that women I find tend to minimize their symptoms because we're used to being the caretakers and the caregivers of our Children, our our institutions, our work, our parents, uh you know, everyone else. And so we tend to minimize our own um risk factors and our own care. And also women still do not regard heart disease as the leading cause of death. In fact, um multiple different studies have shown women still fear breast cancer more. And you know, even after the american Heart Association major campaign, we had seen an uptick in awareness that heart disease is the leading cause and that has diminished again. So, you know, almost one in three women do not actually recognize that heart disease is the leading cause of death for them. And I just wanted to expand a little bit on top of everything that everyone has said so beautifully and eloquently regarding the well established risk factors, those sex specific risk factors that dr croft brought on, and very important under recognized risk factors that we don't often talk about. And that's the psychosocial risk factors, the socioeconomic deprivation that we know exists right here in the United States in a very well developed country as well as things like intimate violence, intimate partner violence and poor health literacy. These are really important risk factors as well as environmental risk factors that have an important impact on cardiovascular risk for women especially, I mean there is no better reminder than the COVID-19 pandemic and it's exorbitant um stress and anxiety that it caused disproportionately in women. And so those will have later on risks. So I think each patient has to think about these in a compartmentalized way. The established ones like hypertension, diabetes, obesity, um you know, sedentary lifestyle, smoking, the sex specific ones like premature menopause, gestational diabetes, preeclampsia, hypertension during pregnancy and pregnancy related complications. And then these under recognized no one talks about them, but they're really important for women. Thank you dr Maria. We're gonna go right into the second question if that's okay. Um and this one is to dr Kinney um you've really been at the forefront of revolutionizing cardiac care, utilizing technology, advanced technology and more importantly apps can you share with us some of the latest projects um that your team has worked on. I know that you have the stem e Cathey Aid, which I think is amazing and how have these applications, improved teamwork and communication. Thank you beth for organizing this, especially for the upcoming uh you know february heart month. Um If you remember the, what we focused on is uh you know how to improve communication between the various themes which is physicians, nurses, technicians um that will help expedite ation care. And as a team we thought that let's use an uh technology to help patients who present with the heart attack which most of the time we discuss a lot about about presentation about heart attacks in men as well as women. We know women represented a typical symptoms. But either way when the president, how can they come to the Cath lab if it's a true stemming, that is what our goal was. And we've made this uh communication platform. And right now we are doing a pilot between Mount Sinai Queens and the Cath Lab. It's essentially as soon as the patient presents we take a picture of the E. K. G. And the E. K. G directly comes to the attending on call review it and then we transfer the patient transfer centrist involved. But the great thing about this just with one press of the button, all the people involved which includes uh detaining that fellows, the nurse's technician, then the transfer center and iCU doctors all are on the platform so they know what is happening the patients. So and so it's coming patient is having a heart attack um then we can track the patient on the Gps and as the patient arrives when a patient has arrived procedure is happening, procedure is done. So I see you people also know when this is done. The bed is ready. One other issue we were having is that even if the patient uh procedure has been done, then we're waiting for a patient bed to be prepared. But right now, all that has been taken care with this. So that is just the beginning of this kind of uh communication platform. We are doing. We have several other projects that are ongoing, which we will probably discuss in our ongoing meetings. Thank you. I mean, it truly is revolutionizing heart attack care. So, really, thank you. Um next question is for dr Fergus. Um, unfortunately, we know that a person's race or ethnicity may put them at highest risk for developing cardiovascular disease. A new analysis has shown that disparities and cardiovascular risk factors between black and white adults in the United States, that there are disparities that may be largely attributable to social determinants of health. Can you tell us a little bit about that and how we can bridge this disparity gap? Oh, absolutely. That's a fantastic question. Um, but I do want to say that with the changing demographics, we have to also look at women. Um South asians and I've been spending or asians have been spending a lot of time doing that because they also have um certain risk factors that may be mitigated by socio economics and of course the hispanic group as well. But I think that um in having that conversation, it's very important to understand the differences between equality and equity. So equities where you want to get to in terms of reducing or Ameliorating disparities, equality just means that everybody's getting the same treatment. But the same idea applies to women versus men, where you've got to look at sex, sex specific risk factors and other things that people talk about. Roxanne already talked about about psychosocial and social determinants as it relates to women. So the same thing I think applies for women of different populations. And I think that there I find that there are other additional risk factors that are more important in certain groups of women. So for instance, in african americans, I focus a lot on blood pressure. Blood pressure is a big issue, weight diet. Um you know and access and stay with the um you know with my hispanic patients, I know that the culture, the language etcetera is very important. And now with South asian women, I'm finding that many of them have certain issues related to lipids, rich pathogenic plaques. Um they tend to have visceral out deposit e um a lot of issues that lead to increased metabolic syndrome which of course will later on add to uh you know uh worse outcomes in terms of dealing with this, you know, the social determinants of health, those relate to who one is, where they live. Access okay. Language as well as you know their their success in um in this the United States economy where they're working, whether they're educated etcetera. So I think that when you meet um women of color, you have to look at all of these and take them into context. The reason why someone's blood pressure may not be controlled is because one um let's say in the case of someone who is hispanic, they don't understand or you know, the language in terms of what they should be taking. Maybe in someone else, it's an insurance access that it's too expensive, they can't afford the medication and so they're not taking it. So you gotta just don't assume that they're not being not inherent. You really have to take into consideration all these factors which of course um you know, will humiliate these disparities as it relates to socio economic uh contributors. Thank you. I know dr Kenny, I know that you're the chief wellness officer for amounts on a heart. I know that you are very much into yoga. Um how can you, what can you offer to women um on you know, advice could you give on working out and exercising safely after a heart attack. So patients after having a heart attack or country artery procedure, it's very important that they get to the rehabilitation. Uh This is a key and more important also is education that how they can go back to normal life. Um It's it's a big deal when patients have had a heart attack or even telling them that you have a blockage and now we did a stent that the entire life has to change. So the education is very important. We try to do as much as possible. But then we then refer them to rehab. So I think between rehab and our education patients as well as the family has to be involved. So they understand what's the lifestyle change that they have to make with regards to nutrition. And then while exercising especially tweets after a heart attack it has to be monitored. You know that what they do in the rehab up to six weeks and later on gradually they start doing whatever kind of exercises that we recommend. Anything. Do you want to put a plug in for yoga or um that's a good question. You have um Yes we can recommend but I think what what happens is many people have not done any kind of exercise. So I think when we're recommending we will tell them more of uh some kind of a cardiovascular fitness exercise. And then I think there is um there are more studies coming towards meditation is a key which helps them in their lifestyle, their job depending on what kind of job they do and also maybe uh that um if they have hypertension that will help them um if there is a part of a meditation that's included, I just want to um mentioned this and a lot of other, you know my physician colleagues are there we are starting in the cath lab boards call us a slim trial where patients who have some kind of metabolic syndrome, certain risk factors, they will be randomized to chair yoga versus standard of care. Standard of care is the usual book that we give for patients who have come to the Cath lab um which includes uh you know, regular exercise that we recommend versus chair yoga. We have created videos and meditation sessions for them. So we have an app. So they will get this app and they will follow the videos on the app for the patients and then we will be doing blood tests with various biomarkers and micro RNA level at baseline and after 16. This is why I had to be approved and we are ready to enroll now. Great, thank you. Next question, Dr Mclaughlin. We know that research and some some of you have already touched upon this, that we research does demonstrate that a women's symptoms are often different from a man's. Many women report that their providers unfortunately never talked to him about cardiac risk and sometimes don't really recognize the symptoms or mistaken them for panic disorder in some extreme cases. Even hypochondria. What cardiovascular risk factors are unique to women. And how do we ensure that all providers are aware of these healthcare disparities? Alright, so I think we've talked a lot now about the other risk factors for women but about symptoms. It's also important because um women more than men will often say that they have some overwhelming fatigue that preceded their event. Um Often they have things like sweating and nausea as more of a primary symptoms, sometimes more than men. Um It is true that they do get the typical chest pressure clutching their chest in the middle of the chest. Um but sometimes they can come and go and not be as consistent and so they might not be quite as sure, they might think that it's more of a gi illness. Um And I would also say from palpitation perspective and dr langan will get back to the arrhythmia risk. Um Women are often discounted when they just say they have some um palpitations and they're thought to be just anxious. So we would encourage people that if they do feel that the heart is racing or having palpitations, they come to a doctor get evaluated so we can actually monitor the rhythm and see if it's real. Also to not wait to come into the hospital when a patient is having symptoms such as sweating, nausea, an uncomfortable sensation in the chest. I had someone recently and basically, she just said she was very healthy active walking up and down the stairs and she started feeling this uncomfortable sensation. She was walking through the city and doing some shopping and she just didn't feel well, she ended up coming to amounts in the emergency room and um the initial exams looked quite good, Even the initial stress test was not terrible but based on her symptoms, which was so unique to her and she's not a woman who would ever go to the emergency room and she was one of those tough, strong, like, don't go to emergency room and here she is in an emergency room. So we sent her for a ct angiogram and actually did find very significant blockages in three arteries. So that's why the stress test didn't look as suspicious because it sort of balanced the the abnormalities. So women can present differently than men and they can have classic symptoms as well. Dr Langan. I know you touched on this, but we'd like to hear more, what factors do you think contribute to the inequity between men and women in the detection and management of cardiovascular disease? I think we've touched on it on a number of fronts. But I I think that what we're seeing when it comes to this concept of equity is that these are actually extremely complicated constructs And their multi, multi layered, You know, and they first start in the fact that the way that we think about medicine has been built over like 15 hundreds of years. But the actual leaders of medicine have been doing it for 30 to 40 years. And if you think of how they learned and how they built and what the world was like when they started their way of thinking about healthcare and what's happened in healthcare in that time. It is kind of mind boggling how much has changed and what the tools we have. So I think the first message, you know, the women in cardiology was, hey yo you're missing the boat because we've fallen so far off of the boat and everybody was following one track, it needed to be completely redirected, I think at this point, maybe even 15 years ago, everybody kind of got the message that there was a problem and now we are starting to see and you can hear it in this conversation which is so much, has so much more depth and more interesting ideas Then we, you know, had maybe 15 years ago because we're all starting to see, you know what it isn't that people don't care. It's that they don't have the right tools or thought process of how to actually address it. So some of it is don't care. A lot of it is financial and structures that have been put in place for a long time that need to be a little bit deconstructed. And then a lot of it is for us to now start recognizing that there are differences and to highlight those differences, um both in how we look at the patient and also how the doctor can have tools to better understand what mary ann just said about the symptoms, you know, look for nausea, lecture or whatever. These things are extremely important to redirect. So when you see a woman in front of you, you have to start thinking, okay, this is a different construct of a number of layers of construct. And then one of the things that I find um we've all kind of got bad habit on is to recognize the guy, the person that lay that out lied And who came with the palpitations and had something bad. But we forget for us who see lots of palpitations, 99% of the palpitations have nothing. So we have to be very careful about how to to not ignore everybody. But then start realizing who should triage win and putting our tools to the maximum use so that that triage is done early easily and well. And the last thing I want to say is that we have a very, very new set of constructs to one is electronic electronic records. And dr Keaney just showed you how, you know, women in power are going to be able to use their multitask skills to start saying, hey, how do I put this information that all day long? I'm always triaged as a woman, You're always trading. Do I see the kid now? Or do I do my uh do I go check on the meal or do I, you know, make sure my boss is happy with me, We're doing that all day long. And so we learn to put an app together in our brains now using putting that into electronic medical records and into apps will be extremely useful. And then we should give those tools back to us because you heard Marianne trying to learn how to put her zoo on. I do the same thing because I have a son and my son says, Mom, what do you mean you can't do this? You're an electro physiologists. The reality is it'll take me 10 minutes to do it. It'll take you one minute. I'm not going to do it. So we get to the point that we're on a zoom but we don't know how to blur, you know, because we haven't had time to learn that. So give us tools really early to do that. It's not because we can't do it. It's because we're triaging. And so I think this equity conversation has come a long, long, long way and it's very exciting time to get into some depth and fix some of the real on the ground problems. Right, Thank you. I'm really thrilled. First of all. The next question is to Dr Roxana Moran. We just first of all want to say congratulations for being the League commissioner on the Lancet Women and Cardiovascular Commission report that was authored by 17 senior experts in 11 countries. Our own Dr Roxana Moran is number one leading it as well as along with the icon skull of medicine. I think what's so amazing is not only are we looking we know the evidence based risk factors, but now this study. And I'd love to hear more about it is specifically looking at stress psychosocial economic deprivation in addition, really looking at socio economic factors that you have pointed out at the beginning about education and access to care and that that role that it plays. So I think that that's really an incredible work that you guys are doing and based on your findings, I know that you have an ambitious 10 recommendations for us. But the question that is, can you tell us a little bit more about what you're doing and your recommendations to reduce the global burden of heart disease in women by 2030. Thank you beth thank you so much for leading the way on go red for us and for always collecting us together at Mount Sinai leading I think what we are doing in in the global fight against heart disease in women as the number one cause of death in men and women, but especially women. We heard from dr Fergus, speaking about the under recognition of this important risk factor. And when we put together a four years of work in which we were commissioned by the Lancet to look at all of the data, all of the evidence and think about where are the gaps. It was daunting daunting to see that everything we've been talking about is really not moving the needle. In fact, we found that in certain countries, younger women are presenting with acute myocardial infarction and that the recognition of heart disease in women is not as well as it was a decade ago. And that just is the fact is that these are daunting statistics. So what did we do as a global community with experts? And I want to say that I think it must be understood that what Mount Sinai is doing is something beyond what others are doing. And I think it's important to note that I can't school of Medicine underwrote this important commission. This is our medical school and we are devoted in working together and with one of the most the leading place with the most number of female cardiologist devoted to heart disease in women right here in the in in in the city of new york with a lot of not just talking but actually doing something about it. We're going to be putting putting together the cardio oncology and the importance of cardio obstetrics that we just heard from Dr Croft. So this isn't just Hearsay and speaking about things, these are actions and plans to be done. We put out 10 recommendations and we at Mount Sinai are devoted to make sure that all of them are paid attention to. We will bring together yearly follow up we have a website now the Lancet Commission dot dot com that will give you all of the details that's being run right here at Mount Sinai. We are putting in all the information with the help of all these amazing women that you've gathered here but also the incredible men here at Mount Sinai, male and female cardiologists all devoted to this. So what did we do? Why is it so important? Why is Mount Sinai in the center of this? It's because our communities are those who are suffering, those women. Our communities are the ones that we could get to. And we're thinking about all kinds of access to care and having someone like dr Fergus, doctor Contreras in the latin american and african american communities delivering care, educating and allowing access to care and giving those access to care is just tremendously helpful and incredible. And we will be making important impact to the commission sign, I will be leading it through action through action plans that we have planned together as this incredible team that you always have gathered on a yearly basis for us to have a conversation. But now the world will know that we are totally dedicated with a very, very important cause And we will we will fight this, we will reduce the global burden of disease by 30% by 2030. But we will also make those huge impacts in the communities that are most needed. And it's right here in New York City and we're right there in the center of thank you dr Murray and I look forward to having you know, having you back next year and hearing an update. And I'm really hoping that we can bring nursing along particularly in our in our health assessments to really look at stress. Um you know access educational level when we're talking about risk factors. So thank you so much. Um Next question Dr Croft. Um I know that we talked before um at the beginning that maternal you know this is a country that spends the most on healthcare and we have the worst outcomes in the developing world. We know that maternal maternal maternal mortality rates have been increasing in the U. S. For several decades Unfortunately. And that cardio obstetrics really has emerged as a specialty in response to the rising rates. How does cardiac imaging play a role in the management of pregnant women with known or suspected cardiovascular disease? Um you know pregnancy is an important topic because about 2% of all pregnancy involves some kind of maternal cardiovascular disease and cardio imaging in particular plays an important role in these women. So as you said, cardiovascular disease is the leading cause of pregnancy related mortality. United States and it's particularly on the rise I think because maternal uh maternal mortality is attributed to maybe an increasing number of women that advanced age undertaking pregnancy. These women have usually can have preexisting conditions like diabetes or hypertension, which puts them at an increased risk. And finally there's a number of women now because our healthcare system is so wonderful to have congenital heart disease that survived to childbearing years. Which puts those pregnancy at high risk. So cardiovascular risk does not preclude women from having a pregnancy but it does impose a increased risk to both the fetus and the mother. So where does imaging come into play? We use certain modalities to look um at the heart. So we use echo to look at LV function and valve disease. We look at M. R. I. To look at congenital heart disease. We look at C. T. A. Or coronary angiogram to look at um for people who have suspected cardiovascular disease or that have cardiovascular disease. And ideally this should be done prior to pregnancy. With that being said there are certain physiological changes that occur with pregnancy that it can affect you during cardiac disease. So as you know, during pregnancy your blood volume increases which tends to increase to an increased heart rate and increased cardiac output. And this is tolerated women without disease. But when women with pre existing disease it's important to identify these women because it may not be so well tolerated once you're pregnant. Um And you have we use cardiac imaging in particular to kind of sort out symptoms and and findings on exam for instance um a murmur or a heart sound or a normal finding in pregnancy. But they can also be seen a certain cardiovascular disease. So we use echo to image the heart during pregnancy to make sure we evaluate whether this is a normal physiological change or normal symptom or if it's some kind of some underlying cardiovascular disease, we didn't know prior to prior to pregnancy. Also, women with pregnancy get tons of symptoms they get short of breath, they get palpitations. Shortness of breath can be caused by hormones. It can be used by the decreased lung capacity of the growing uterus, but palpitations that can be caused by increased heart rate, which is a normal physiological change of pregnancies. But these symptoms are also seen in other cardiovascular disease. So, by using echocardiogram, we can sort out whether these are actual pregnancy symptoms or symptoms of underlying heart disease. Um We follow these women closely during pregnancy and I can't I can't stress enough that we have a wonderful cardio obstetrics team. We have interdisciplinary meeting. So if you are a woman with cardiovascular disease, it doesn't preclude you from having a pregnancy. But these things need to be in place so that we don't have a higher mortality as these women go along in their disease and their pregnancies. Thank you Doctor Contreras. We know that you're the director of the ambulatory heart failure program. And this question is really um you know, we have to of course 21 we're still talking about Covid um as we continue to battle the Covid 19 pandemic, What impact have you seen of Covid? 19 on the heart failure patient. Both. I mean men and women, but I know that this is go red for women, but what have you seen on the patient's recovery, tremendous impact. We have actually been looking at the people after covering infection and have evaluated patients that complained with this long. Covid symptoms like fatigue, shortness of breath, worsening heart failure symptoms and explained by the typical factors that we look forward. We have discarded from Grand Extra testing and M. R. I. Pet and we found that these patients can have a significant reduction to exercise that is not explained by just the heart failure. We don't know exactly what it is, but we have been in the whole expect from from like, yes, decreased exercise tolerance all the way to chronic fatigue syndrome, very difficult to treat heart syndrome like the land that we have seen that had to be treated. The person that had to be put on medication significantly decline in function in patients that made them very frustrated. Um a lot of political do myopathy, probable disease, a lot of increasing popularity and hypertension. And a lot of these patients obviously on top of that the obesity epidemic, patients are using more tobacco. They're using more alcohol. There are more sedentary because they're not outside working. A lot of patients, especially our minority patients, they love their jobs. They're working from home and don't have a job. So they don't have healthcare. They don't have access to medications. So it's a significant impact in patients for long term. We are not we I think we're going to continue to think and find more and more things after the school infection that is affecting patients enormously. I agree. Thank you. This question is to everybody. Um at Mount Sinai and within Mount Sinai heart we're committing we are committed to analyzing quality performance through a diversity and inequity lens. We've noticed that for certain quality indicators such as acute M. I. Infarction with 30 day readmissions. Women have a higher readmission rate compared to men. What interventions or initiatives do you think that we could put in place to help reduce this performance gap and say one thing that we have seen that to be very successful here in our cardiac heart failure program with DR Contreras is to have appointments for readmissions that are the patients are called immediately after they leave and they're seen within a two week period and they're encouraged to come in and when they do that and DR Contreras can fill you in on the heart failure group. But that has resulted in reduced readmissions. We just need to broaden that to all the cardiac patients. Anyone coming in with coronary procedures etcetera. So that that is really throughout the whole system. You know that the Cath lab here at Mount Sinai has full as you know, after every procedure for both men and women. There is a beautiful discharge um you know, education And plan for them and then we call them within the week to 10 days and then again in 30 days to see how they're doing because of the fact that we're following these patients on a on a prospective, in a prospective fashion. But nonetheless, I think what Dr Mclaughlin is saying is incredibly important reaching to those patients sometimes, you know, if you're just giving wrote education that is basically the same thing to everyone, it doesn't fit, you have to kind of reach the patient on an individual level, understand what's going on in their home. And those are the things we need time and efforts for. I know we're doing a lot of this at Mount Sinai, but I can tell you that many places don't do that and I think what we have to do is this very, very customized. So if it's you know, a patient who doesn't speak english, the it has to be in the in their native tongue, there has to be someone else who understands and explains things to them, understanding what's going on in the house in the home, who's delivering the care, who's and and making sure that the prescriptions are being filled. These are all of the methodologies that we've undertaken here at Mount Sinai and continue to do. I know that the arrhythmia services doing the same and I know that we're doing that in the cafe, but I think it has to be across the board standardized, but also individualized. So those are the those are the things that I know we're doing here at Mount Sinai I think for heart failure with with bad teams and the help we follow every single president after they get the chart, they get educated during the hospital stay by one of the nurses and they spend at least an hour or two. We have english and spanish. We also have a text program where patients are being texas, they leave the hospital to in front of the symptoms, how they're feeling. The reason that we have been very proactive is sometimes the patient lives but he doesn't have transportation to come back to the hospital or he doesn't have child care for example in women. So we try to adjust those factors with the social workers to be able to make sure that the patient can actually come back and for some questions we actually made them to bring a family member and we have to work with the insurance to allow a family member to communication because sometimes very difficult for the patient for himself alone doing this, we see the patient within seven days in the clinic and we do a full assessment in the clinic and we usually have a second visit at seven days because we learned that a lot of the time they get lost and then they get a stick and back into the hospital. So we have been trying to do that more and more and Montana I think um an important addition and I think everyone said exactly right and I love the whole idea of a family member or someone else attending the visit. But the one thing I think that we need to maybe do a little bit better with is to making a connection with the primary practitioner primary provider. Because what happens is, and I've gone out into the community and I hear a lot that the patients get admitted, they don't know what's going on. Um, the patient comes back and oftentimes what happens is they're putting the patients back on the old regimen that they were on. So they may be in the hospital place on interest or whatever the whole heart failure regimen. And they go back to DR X in the community who says all your, your medications have changed, I don't know why and they're putting them back on. So it's important one to have that communication with, you know, finding out who's the, you know, the primary provider making that connection and having them, you know, be in partnership because otherwise it's a lose, not a win situation. And the other thing I think that we could do a better job with is, and I've always said this, we have fantastic programs within the institution, grand rounds, symposia conferences. But a lot of the primary practitioners in in and around Mount Sinai Central Harlem, you know, um spanish Harlem, they can't come into the institution for these uh symposia. So they're not up to date sometimes with the treatment and the clinical trials and the recommendations. So we have to figure out how to get education out to them, whether it's going into the community with dinner imposing or whatever so that they can really understand, you know, what are these treatment protocols that are being instituted for their patients while in the hospital? Thank you. Dr Ferguson agree. I think, you know, virtual is is like what we're doing here would be a great way and can't agree with you more on the transition of care. That's something that we worked on in 21. And we're certainly working on it in 22 is really closing the gap between inpatient and outpatient and the primary care provider. So um great points made. Thank you. Um This question is for dr Moran. Um we know that the pandemic has contributed to increasing levels of stress, anxiety, insomnia and depression. And many people your risk for heart disease increases if you're depressed or feeling chronically stressed. What techniques could you recommend to improve mental and emotional wellness to improve cardiovascular health? Yeah, I mean, I think we talked a lot about this dr Kinney spoke about yoga and meditation. Um and I just think, you know, we as women uh take on the burden of stress for our entire families and a lot of it is um you know, just the multiple multitasking that we have to do in terms of not only most women have jobs, most women are providers for their family as well as providers of the care of the family and the function of the family. So I think in so many levels we are were were very, very much um uh you know, involved and of course the stress and anxiety levels are tremendously high for women. We've never seen it as we've done as we have seen in the covid pandemic, think about the the depression, the anxiety and we've seen we're seeing a sex differential for women because it's dual triple and think about right now about just the Children going back to school and the fact that they have to worry about how to, how to work, how to take care of the house, how to take care of those kids. And then by the way, are they being educated? Two years of being, having remote for young Children is not a good thing. So think about all that stress and anxiety on women and I think on families in general and and we don't want to underestimate that are male, um that males, that partners, men are not involved there also there, but you have to know that the burden and the anxiety level is much higher in women. So how do we, how do we overcome this? And I think mental health and mental well being is extremely important. I know that many in there. There are every place you work as a woman if you're a woman and you're feeling stressed, know that there are places to go to and you need to reach out? Think about that? It's physical being is important, but your mental well being is also extremely important and I think they're so interconnected that we have to make sure that we address them together. So when I see a patient who opposed heart attack patient or a patient in my office, I often ask them, how are you? And I look at them, I take away from epic and look at them and just say, how are you doing? Are you feeling sad? Are you feeling stressed? And then if there is all of that, if you're feeling it across across the table as you'll see in these patients, you've got to you've got to refer them, got to help them got to let them have some tools and I think there's a lot of tools now and but remember that our mental health care workers are also overstretched. It's almost at appointments now for those for those things. So any technique that helps with relaxation meditation and reduction of anxiety we know is important. And I think the work that we're doing with dr Kinney is incredibly important and so hopefully we can continue on that great, thank you Dr Mclaughlin, those questions for you that you know, I know that all of you really participate in educational initiatives, Educating the next our future cardiologists and female cardiologists, but what methods and this is really for both men and women, what methods can we put in place to support those who are underrepresented in medicine to move forward and moving forward. What's important is to start with the youth. Um Mount Sinai Medical School School of Medicine has a wonderful program starting for the disadvantaged community for students who are in their high school aged groups to come for a mini medical school during the summer where they are exposed to working in a lab, seeing patients, they wear white coats, they really get a broad exposure and then that continues that mentoring process we have in place here for people in the basic science labs. Many of our colleagues have committed their time and energy to take students under their wings, starting at very young ages. I personally do clinical research and have have had then he's starting in high school and just this weekend I was rounding with a young resident who I met when she was in my office in high school through college through medical school now residents, so hopefully she'll go into cardiology. But the american College of Cardiology has a formal program also for mentoring for cardiology. Um dr Jackie thomas is very involved, she leads that program and I've helped her a little bit with giving some talk to those students who are really you know young in their early college years trying to figure out what career path through opportunities are good for them. So I think that, you know, we have a slice of the pie here in new york where we we do reach out to our committee members and schools um and other of you can please add to this answer, That's excellent. I additionally I think that um and I think to enhance what Maryann said, working with community groups um to ensure, so what I'm finding out when you look at, let's say african american um and hispanic um Providers in terms of cardiologists, they make up like one and 2% of the pie. Now I'm finding out that their reduced um admissions to medical school, even college right with all the pandemic and even before that people are just not, you know, going into college as much as they used to be. A lot of work and research has been done on that and one of the things is people can't afford the tuitions. So I've been working with people that build scholarships um Yes, so you have the mentoring is one piece, but actually how do they even afford and how do they get into school? So, working with local organizations such as the sorority, the links um they're supporting these kids as and and teaching them to go into these programs, but they're also, You know creating avenues for scholarships that they can one get into these schools and two. I'm also finding out that graduating is a big issue where they have the skills and the education etc but they're not graduating because they owe between and the numbers of small. Their startling they are between $52500. And because of that they're not able to graduate. So I'm also working with Jack and Jill of America Foundation where we've actually raised over $600,000 for um the HBCu schools which a lot of these underrepresented minority um you know students attend but they can't graduate because they owe money for books or for tuition in a small amount. So we've been you know trying to find out where these students are and just to raise that amount of money so they can actually graduate out and go on you know into medical school and and further training. So we have the same thing with the american heart, we found that the hispanic group to also help help Hispanic with american heart Association had hispanic students to be able to know that they have access and a lot of them wanted to just be able to connect to something they can actually do especially with hispanic women they have been underrepresented in in cardiology. So we are actually launch, launching a campaign that we launched last year to be able to increase them and an hispanic women into specialties into medicine into different things because the DNC. The possibility and there were not many mentors. So we're trying to collect mentors across the country to be able to help women and to find somebody that they can actually relate to, to know that they can actually follow that pathway. Great. But to say that the american College of Cardiology as well has a program that will bring high school students and college students to the meeting um free of charge actually if you apply for it. And it's a very, very interesting program. I'm on the board of trustees and we know that this is an incredibly important arena that we have to kind of start to think about how could we interest more women to go into cardiology and why is that important? Because there's really good data about sex concordance of care of women with heart disease for with female cardiologists taking care of them. And in fact we see that there is an improvement of outcome and it's not just in fact it's now in the surgical literature as well where female surgeons take have um the female patients undergoing surgery with female surgeons have a better outcome than undergoing surgery with male surgeons. And I think it makes a lot of sense about how important it is to have more women in cardiology and leadership positions. And of course, you know that I'm I have a not for profit foundation that is just completely committed in in raising women and in medicine in general. And I think we really have to focus on cardiology as an important broken house I center here offers um summer internships. We have somewhere between 15 to 20 summer interns here in my center with incredible access to the data that we have here and their ability to publish and get into their um not only the colleges of their choices but also medical schools and we've helped a lot of that and medical residents also come through here to try to make sure that they get an interest in cardiology and have a successful outcome in their career. So Montana is offering a lot of opportunities for the younger generations and women in stem. That's great. So we're coming to the end. This is our last question and this is open to everybody. You know, just one or two words. You know what what advice would you give women who are living with cardiovascular disease? What advice would you get? All right. Um um learn your risk factors. Be inquisitive, ask questions of your doctor if you're not happy with the answers, keep asking, don't give up and don't don't give up that if you're feeling like you're not being paid attention to. I can tell you here at Mount Sinai, we are listening, come to us. We will care for you. I would say be optimistic and do not be afraid that it's not a death sentence to have a diagnosis and that with all the treatments we have available and things are coming down the pipeline. We can keep you alive for a very long time for a healthy productive life. So get seen. Don't be afraid to be seen. Don't be afraid to be examined and also be optimistic that you will do quite well and will help you there dr Fergus. And I would say women put your own mask on first. You know, when you get on the airline on an airplane, they tell you if there's no oxygen put on your mask so you can get oxygen and help others. And I think that a lot of us and a lot of us touched on it, we're taking care of everyone else and not ourselves and I know each one of us here can attest to the fact that we ourselves may have gotten ill or were not in optimal health because we're so busy doing everything else. So at the end of the day to better take care of our patients and our communities, um us, our faculty here, but all the women, please, you know, listen to your body, take care of yourself first so that you can you know, then be there to take care of everybody else. That's my message. Thank you Dr Langan, I would say no yourself and get yourself a daily routine that includes something a little difficult. So when it changes, you can be very clear that there was a change and that's a change for you and the doctor will be able to understand that this is a marker that is of relevance. Um and I don't gain weight because it will hurt your Children. Thank you Dr Contreras. I said no, your risk factors, there are many ways and china will do a lot of activities that you can come now you respect and now you have diabetes, family risk factor. We're happy to help you because the best way to treat heart disease is to prevent to have heart disease from the beginning. Thank you. Dr Croft, last word. I think everyone should listen to my amazing colleagues with all their wonderful advice. Um, don't become a cardiac cripple. Many people live fulfilling lives with heart and vascular disease, and you just need to keep moving forward and enjoying life, enjoying your family and taking time for yourself. Okay, so that concludes. Really want to thank our esteemed panelists, Thank you all for tuning in and we'll see you next year. II