This is part two of a two part series of a conversation with Courtney Jordan Baechler MD, MS, a preventive cardiologist and a Medical Director at the Minneapolis Heart Institute Foundation. Part one can be found here. Edited and condensed for readability. 

Disclaimer: Nothing in this post is intended to diagnose or be a substitute for medical treatment. Always consult with your healthcare provider before taking any supplements, particularly if you have any medical conditions or take prescription medications. 

As part of the Minneapolis Heart Institute Foundation’s (MHIF) women’s health event called Hope, Health and Humor: At-Home Edition, we had Courtney Jordan Baechler MD, MS join us for a small outdoor gathering of women and a conversation about women’s heart health. This conversation is critical for women over 50 because many women think that heart and vascular disease only impact men at this age. However, once women reach menopause the level of risk, number of events, severity of heart disease, and even death rates are the same. Yet, our symptoms may be different, are often not taken seriously, and we’re not researched as much as men. 

Karyn: Social connection is one of the foundational principles at Rumblings, and there is more and more research showing social isolation, loneliness and the impacts on health being as great as smoking, obesity and other health risks. Are you starting to see this impact in your practice as well?

The Inner Heart Trial was a study across 52 countries and 6 continents. It looked at causes of blockages in the arteries and also if there was anything else that we did not yet know. It found that one-third of all blockages in coronary arteries result from poor mental health: from social isolation, anger, depression, anxiety, and anything in the mental wellbeing category. As strong as abdominal obesity, smoking, and high blood pressure. It’s a really big deal. There are many non-pharmaceutical or non-medicine based things you can do. At Minneapolis Heart Institute, we talk about Tai Chi, social connection, sleep, nutrition, music therapy, and acupuncture for example. It’s fascinating that across all generations we have a world that is quite lonely. Even if you’re on social media all the time, people don’t feel connected in an intimate sense with their friends. We have a tremendous interest in ways to be well other than just seeing a doctor and getting drugs. 

Karyn: Are there certain lab tests, heart tests or calcium scores that we should be asking for as we get older?

It really depends on what you will do once you have the information. The analogy that I use are genetic tests you may get when you are pregnant, especially if you are considered at ‘advanced maternal age’. Are the results of the test going to change your behavior or will they just worry you? I have pretty strong beliefs about doing the tests that we do for the right reasons. For example, a calcium score is determined by what is basically an x-ray of your heart to look at calcium production. A calcium score is not usually covered by insurance. It is the first sign of build-up in the arteries, and it will compare you against women of the same age. A calcium score of 0 - meaning no buildup in your arteries - is rare. Everything else in our mind is considered heart disease, even if it’s the beginning of heart disease with a buildup of 10 percent. Then the recommendation of the guidelines is to prescribe a statin drug. From a cardiologist perspective, once that happens, we do not pass go without being on a statin medication. The recommendation is to repeat the calcium test in 5 years to see if it has changed. There is not a lot of data to suggest whether or not a repeat test should be done or if the score changes for many people. 

I have some patients that tell me their calcium score is single-handedly the most impactful things that caused them to change their behaviors on what they eat, when they exercise, how they sleep and moderate their stress. If that is going to happen and it will drive you to do the things that we need to do for health, then it’s super helpful. But, 85% of coronary artery disease or blockage in the arteries are lifestyle based and preventable. Even if you get lucky and get that ‘0’ [score], it doesn’t change the need to do those things. It’s definitely very trendy right now, but it depends how your brain works and what kind of information is helpful to you. 

There are other things we do that are more commonly covered by insurance. A high-sensitivity C-reactive protein (hs-CRP) is a blood marker for inflammation. There has been an association between higher CRP levels and heart disease. When I am risk-stratifying someone and they have a very low high-sensitivity CRP level, it indicates that their body’s sensation of inflammation is low. My prediction is that in 20 years, heart disease will be much more about inflammation. Inflammation in the body leads to high blood sugar, which leads to more diabetes. Inflammation leads to high cholesterol, which  itself is an inflammatory marker. Inflammation also leads to high blood pressure and the list goes on. This is one of the few ways to test for inflammation and most preventive cardiologists will do that as this blood marker can be lowered with statins. 

Some other markers I usually get are Lipoprotein A (Lipo A) and Apolipoprotein B (Apo B), which are ways to look at the cholesterol breakdown to look at size and stickiness of the cholesterol. These things are a little more genetic in nature. We do not have any drugs as of yet, that can change those numbers. It can be helpful to reassure someone who has a strong family history or is nervous about their levels. 

There are more advanced [tests] to gather even more information about the cholesterol breakdown, many of them are not super helpful beyond the 3 that I get on most of my patients. 

Most of the studies that we have are on [the effect of] drugs, not lifestyle. We are hoping to change that. Today, the way that we use statins in our society is that everyone should be on them, and most physician’s intent is that you should be on them until you die. I try to tell patients they get to choose what they want to take, as nothing we put in our bodies is perfect. If a patient tells me they want to do everything possible to decrease their risk of having a heart attack or stroke, and they want to do everything by the book; for most people that will mean a statin, and they’re doing ok. 

Other patients may say they want to do everything else but that, and there is a lot that can be done on the behavioral side. I have many patients that have a pristine diet, they move a lot, they really moderate stress and how they manage it. They sleep well, social connection is a huge part of their life - they have a purpose. They choose not to be on statins and they’re doing ok. It’s about tradeoffs and thinking through what will work best for you long-term. I have people who do both and they’re doing pretty well. 

Karyn: What about supplements? Are there supplements that we should be taking?

I am definitely a fan of supplements for a specific reason and not just taking them because your friend does and they work for her. CoQ10 and Vitamin D are two that I use routinely.

For instance, if I have someone on statins, I always put people on 100mg of CoQ10 twice per day. In Europe, this is standard of care. Statins deplete mitochondria, which are the energy producers of our cells and CoQ10 helps to replete them. For some patients, I have found they are much less likely to get muscle and joint aches. There have been trials that have found it doesn’t matter, but for some it seems to help. Trials have shown that CoQ10 lowers blood pressure. I have people looking for natural ways to lower blood pressure to try it first, and it’s great for energy. 

It is important to ask your primary care provider about checking your Vitamin D levels.  Vitamins A, D, E, and K are fat soluble, so you can get too much, but 85% of Minnesotans are low. In the Winter, 5000 IU per day is recommended. The sweet spot for Vitamin D levels is in the 50-70 ng/mL range. I will see people come in as low as 10 ng/mL. We call Vitamin D the ‘happy vitamin’ because people feel off without it if they are low, but too much can be toxic. 

For [high] triglycerides I use fish oil. There are studies on lowering triglycerides with 1000mg, 3 times per day. It’s a big dose, and it has to be the right type of fish oil - Nordic Naturals is a good one. Fish oil is also good for mental health. I use red yeast rice for lowering cholesterol. I have found that most people’s cholesterol will go down with a 2400 mg supplement, but there are no studies to show if it reduces risk for heart attacks or strokes.

I have many supplements that I may recommend for individuals with anxiety, stress, or problems sleeping. For palpitations, stress, or help falling asleep I use L-theanine. I will use melatonin to help people stay asleep.  Depending on the time and reason for a patient visit, I will sometimes recommend Ashwagandha during menopause as women’s bodies adjust to the new normal. 

Everything is connected in our bodies. Sometimes our heart feels off because our gut flora is off. I may put people on probiotics for a month to see if we can refresh their natural flora. I always try to introduce them one at a time so that you don’t have too many different things at once to try to figure out if it is working. 
Karyn: I’m pleasantly surprised to hear you say that there are supplements you recommend. I’ve always been hesitant to tell my healthcare providers about the supplements I take, but now I definitely will. I have always felt that supplements have helped me to feel my best. 

Karyn: Let’s talk about how the gap in women’s cardiovascular health research impacts recommendations for women. What can we do to advocate for getting more research on women’s heart health?

We’re 35 years behind in research on cardiovascular disease compared to men. Women weren’t even allowed to participate in studies due to regulations set by the Food and Drug Administration (FDA) for a long time*. There is less research funding for women in all areas—whether it’s how women respond to valve surgery, bypass surgery, stent placements, if we’re more or less likely to have a procedure after a heart attack, or are we more likely to die. I firmly believe that closing this gap will be a woman-led solution. Currently, 12% of cardiologists are women. As that number grows, we’ll have more women physicians and researchers leading the efforts. Women being engaged participants in designing where and how they want to receive care, what that care looks like, and what the wellness efforts and how they want to be treated will also be critical components too. 

Not only are we not small men, but the way that care was designed was predominantly for well insured white men with a wife to take care of them. Men tend to enroll in studies immediately, while women are more likely to take time to consider participating. Boston Scientific has done great research on how to get women to participate in more research studies by designing brochures to resonate with women and taking an extra step to continue to reach out to them. Once women have a chance to ask questions and speak with their trusted network of friends, they are more likely to participate. This approach is considered ‘soft’ academics, and is not how it’s often done, but it will be a big part of the solution to get more participants. 

Women’s heart disease rates started to go up in the 1950s, correlating with women entering the workforce, and slowly their rates began to equal that of men. We don’t want women working to change, but the idea that we [as women] can do everything all the time for everyone with the idea that we’ll take care of ourselves last is a cultural value that has to change before we can actually thrive. We have a lot of work to do on that. 

Karyn: We do have a lot of work to do. But, I think we can do it. I believe marketers are realizing women in our age group have tremendous buying power and by hiring millennials that focus on marketing to other millennials, they’re missing out on a huge marketing opportunity. I also hope with more women who are reaching midlife and increasing numbers in professions that were traditionally male dominated, we’ll see rapid change. 

I graduated from medical school in 2004 and ours was the first class with 51% women. These changes are recent. 

Karyn: Is there a difference between a standard cardiologist and a preventive cardiologist and how do you get to see a preventive cardiologist? 

Preventive cardiologists usually do extra training and it takes more years [in school]. They would usually have extra training on lipid and cholesterol profiles and in areas of nutrition, exercise, stress. A focus on the different types of lifestyle contributors to give a more holistic view of health. At the Minneapolis Heart Institute, we are planning to start a prevention fellowship within our cardiology fellowship. As of now, it is mostly a certificate, but what you can expect is someone who is focusing on prevention. It doesn’t have to be primary prevention, it can be about preventing a second event after someone has had a heart attack or stroke. 

*In 1977, the FDA issued a guideline banning most women of ‘childbearing potential’ from participating in clinical research studies. In 1993, the FDA issued a new guideline and formally rescinded the 1977 policy that banned most women from participating in studies. The Congress made this policy law in 1993. Source: U.S. Department of Health & Human Services Office on Women’s Health.