How to Care for Your Heart After 50

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.

5 Actions to Improve Women’s Heart Disease Risk After 50

This is part one 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.

Women know that preventing breast cancer is a big health issue. While that is very important, and much has been done to shed a light on the value of early detection and treatment, it remains true that heart disease is still the leading cause of death in women. We don’t talk enough about how research on women’s heart health is decades behind that of men, how our symptoms are often not taken seriously, what we can do to prevent heart disease and cardiovascular events, and how we should treat it. We want to help change the narrative around women and heart disease. It all starts with having more conversations about this topic.  

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, the 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. 

This gathering took place a few days after Rebecca’s husband had a stroke. Because of how healthy and young he was, it drove home that we need to start having conversations about heart health, cardiovascular events, and doing everything we can to take care of ourselves as we age.

Karyn: Dr. Baechler, tell us about yourself.

I’m a preventive cardiologist. I did the National Institutes of Health (NIH) scientist track, and added extra time onto my fellowship in cardiology to study the primary and secondary prevention of heart disease. I hit a wall during my intern year and thought the [healthcare] system was totally broken. How was I going to practice for the rest of my life in a sick-based system? There was no focus on nutrition, stress, exercise, ability to fill your prescriptions - nothing. It led me to pursue my interest in preventive medicine. I obtained a Master’s degree in Epidemiology and Public Policy to learn more about population health. I spent years running the Penny George Institute for Health and Healing. I’m a huge believer in the mind, body, spirit approach of Eastern medicine meets Western medicine. I currently run the Women’s Science Center at the Minneapolis Heart Institute Foundation and I see patients part-time through the Minneapolis Heart Institute. 

Karyn: What are the age-related changes that women go through that begin to increase our risk for heart disease?

Until menopause, women have a much lower risk of developing heart disease. After menopause, our risk increases to be the equivalent to the risk men experience for having a heart attack or stroke. 

I’m sure many women have heard of the Women’s Health Initiative and the research on hormone replacement therapy. There was an idea that if we put women on hormones so that menopause wouldn’t happen, that would fix things. It turns out the risk of having a heart attack and the risk of having a stroke was higher. It was back in 2004 when we first started getting this information. 

Here are some of the reasons our risk increases after menopause:

When we age, our blood vessels start to stiffen and we can develop high blood pressure. Our metabolism starts to slow and we tend to develop more central obesity and fat in our bellies. These things happen as we age, and there are things that we can do to counteract them. From a perspective of our metabolism slowing down, we can also be at higher risk for developing Type 2 diabetes because of the way our body responds to insulin and sugar in general. 

Our sleep changes. Sleep is the cornerstone of everything, and it helps to clear our brains. There is lots of data on the importance of sleep and our overall immune system and helping us to be well.

Most of these things appear to be true for men too, there just is a protective effect for women prior to menopause. We’re 35 years behind in doing research on women. We don’t know why that is, but can speculate that society has cared about keeping women healthy while we’re reproducing and then we have less perceived ‘value’ after we’re done with being able to reproduce. 

Karyn: You know, it’s really interesting that even Rebecca and I have found that there is so much information out there for women who are in childbearing years and for fertility. When you look for resources on health for women who are over 50 there is nothing. Everything that you Google is almost entirely about how to dress, how to be more attractive, or is about anti-aging. It’s fascinating, and not in a good way. We have work to do to change that!

Karyn: What symptoms should women be aware of, and when should they seek immediate care? What symptoms are different for women than for men?

Women are much more likely to have atypical symptoms. They are more likely to get jaw pain, arm numbness, nausea, vomiting, and also depression. They do get shortness of breath, and chest pain is still the most common symptom in women. However, women are much more likely to have all of the symptoms compared to men. I always tell women that you know your body best. Hands down, patient-wise, women are more in tune with their bodies. If you are experiencing something that is different and is not going away, you should get it checked out. Physicians should be grateful that you are proactive and focused on prevention. If everything turns out fine, then that is great!

Karyn: When we see our doctors, our primary care providers, what kinds of things should we ask them about to make certain we’re paying close attention to our heart health as we get older? 

One of the things that is critical for women to be aware of when seeing your physician is that you should have information about anything being done. As a patient, you should be told what your blood pressure is. You should be told what your heart rate is. And, you should understand what your medical providers are doing. Are they listening to your respiratory rate? Are they taking your temperature? All of those things are critical pieces of information that you want to be personally tracking. 

Blood pressure and heart rate are things that change over time. For example, if you’ve always had a heart rate in the 60s and now your rate is consistently in the 80s or 90s, you need to know about it. And, they should tell you that it’s better to be a little bit lower consistently. 

Body Mass Index (BMI), which is one way to look at weight, is another indicator that doesn’t get talked about much with your physician. Is your weight or BMI contributing to your level of risk and what is a healthy BMI? How do you compare to your peers? Physicians will usually tell you if there is something wrong, but they should also tell what they are looking for and why.

You should definitely get your cholesterol checked. There are advanced cholesterol profiles that we can do to tell whether the cholesterol is ‘sticky’ which can increase your risk. A cardiologist would also look at inflammation and other things. Most importantly, have a conversation with your primary care doctor about your family history and your lifestyle. Ask them about your risk of having a heart attack or stroke in the next 10 years. 

These are basic things that let you know where you fall in terms of risk and then based on these measures, does your doctor recommend that you see a cardiologist to do further testing and why or why not? Ask them what other specific things you could be doing to optimize your health. These are the conversations you want to have with the person taking care of you. 

Karyn: It is so important to have a relationship with a care provider that knows you and is willing to be a partner in your care. 

It is unfortunate but very common to be put on medication without ever being evaluated for all of these other things. It is important in those situations to ask why you are being prescribed something so you can be informed. 

Part two of the conversation with Courtney Baechler MD, MS discusses how to take care of your heart.