E36: 7 Domains of the Heart

Today, we're going to talk about your heart and my heart and our hearts and the 7 Domains. It's a huge subject for a fist-sized organ that plays such a large part in our health and our emotional life.

Our language has so many references to the heart as more than just a pump. "My heart was in my mouth," meaning I was afraid. "It made my heart sink," I was sad. "I was heart sick." That's sad again. "It gladdened my heart," happy. Even Brené Brown's recent bestseller on language of emotions is called "Atlas of the Heart."

So, to narrow it down a little, we'll be talking about coronary heart disease or heart problems that arise from blood flow to the heart. We're not going to talk about heart birth defects or physical trauma to the heart. And we're going to focus on women's coronary heart disease. Because the risk of these problems, heart attacks and heart failure starts to rise at midlife, we'll have a little focus on midlife women.

And to help us with this, Dr. Camille Moreno is in the Virtual Scope Studio. Dr. Moreno trains as a family physician and has a subspecialty training from the Cleveland Clinic in midlife women's health. She's on the faculty at the Department of Obstetrics and Gynecology at University of Utah Health. And she's the director of the Midlife Women's Health Program.

Dr. Jones: Welcome, Camille.

Dr. Moreno: Thank you, Kirtly. Very happy to be here.

Dr. Jones: Great. So this is going to be the Camille and Kirtly show. And we're going to start with the physical domain. And so now we're talking about the number one killer of American women, right? Coronary heart disease?

Dr. Moreno: That's correct, Kirtly.

Dr. Jones: Normally, we think of heart attack as being less common in women than men until menopause. Can you talk a little bit about that?

Dr. Moreno: Yes, that is absolutely true. There are hormonal changes that occur during perimenopause and menopause that can bring increased heart disease risk in the form of high blood pressure, high cholesterol, diabetes, pre-diabetes.

Dr. Jones: So our risks go up and then the events start to go up after that. Can we talk a little bit about coronary heart disease? We're talking about heart attacks and women have a little bit of a different way that they present and women are a little bit more likely, instead of having a horrible chest pain, to end up with smaller heart attacks that lead to heart failure. So heart attacks and heart failure, can you talk about those a little bit in women?

Dr. Moreno: Yeah, absolutely. Just to give you a broader overview of what coronary heart disease is, or heart disease for short, it refers to the reduced blood flow and oxygen supply to the heart. And that could be because, a majority of the time, from plaque buildup. And that plaque buildup could be cholesterol that builds up on the walls of the arteries or the blood vessels.

You're absolutely right. Women present differently from heart attack symptoms that are common in males, and it's more than just the chest pain. We actually refer to this as atypical chest pain. So I studied that in med school and in my training years. Angina is another word for chest pain. And the common anginal symptom in women is discomfort in the upper body, such as the shoulder, not necessarily in the middle of your chest wall.

Women also can break out in really cold sweat, which is not typical for heart attack in men. Women can experience nausea, even vomiting, shortness of breath, and overall feeling tiredness and fatigue, which, again, are very atypical heart attack symptoms.

Dr. Jones: As we get to midlife, we kind of blow that stuff off. It's like, "Oh, I've got this little cold pressure, but maybe it's indigestion." We're always feeling guilty about what we eat, so we know that has to be indigestion instead. Or, "I'm tired, but I haven't been taking good care of myself." And so women may show signs after the fact of a heart attack, but they just say, "Oh, I'm fine."

Dr. Moreno: Yeah, that is true and that is a common story I hear. We think of the non-less-threatening thoughts first because who wants to think heart attack first, right? And so a lot of these symptoms really can mimic other conditions, including acid reflux, including not sleeping well last night. So there are a lot of different things that we should be thinking about when it comes to women's heart disease, including symptom presentation.

Dr. Jones: So if this is the number one cause of deaths in women . . . And women don't always know that. They unfortunately, I think, think that breast cancer is the number one cause of deaths in women. In fact, we're doing great on breast cancer and women are not dying of breast cancer, although some women do and it's a heartbreaker. I'm using that word.

I think that there are about three or four critical transitions in women's reproductive life that are opportunities for education. And first, of course, is when we're born. And when we're born, we teach the mom how to take care of little girls and little boys.

The second is at puberty where it's an opportunity to talk to women about safety and sexuality and contraception. We might come to the doctor for irregular periods at 13, but that's a teaching opportunity.

And the third is after the birth of a baby because that is the time women are most interested in setting their life straight again. They're overwhelmed. It's a teaching opportunity.

And number four is at menopause. But when we go in for hot flushes, does our OBGYN or family doc talk to us about this stuff, or they're busy? How do we get the word across?

Dr. Moreno: Yeah. So one way is really truly education, right? Education of the public, similar to what we're doing now. So being able to address to women that the number one killer of American women is coronary heart disease.

And just to also prove the point that it is not the same for women, that women are not small men in fact, is half of women diagnosed with heart disease do not have the typical blockage of your arteries, what we call atherosclerosis, which presents classically in men. So education is important when it comes to that.

And as we see our doctors annually for our physical exams, for example, to get that annual blood work, it's important for medical providers, the medical community, to address these individual risk factors, because it is different for women.

These individual risk factors could be a woman's risk at menopause for high blood pressure, high cholesterol, diabetes, and even valvular heart disease that we do not know about can cause heart failure in women. And that is mostly related due to a stiff and inflexible heart muscle that often is linked to heart disease.

And so those are important conversations that we should be having at our doctor's visits every year or every couple months whenever you see your healthcare provider.

Dr. Jones: I think at 50, there's an opportunity to intervene. The American Heart Association has this Simple 7, and it caught my eye because this is the "7 Domains" and we are talking about how to manage some of these risk factors, which includes improving your diet, being physically active, getting your sleep, making sure your blood pressure is under control and that your glucose is okay and that you're not too overweight, and you're managing your emotional life.

So when we talk about what the American Heart Association says, these are the Big 7, sometimes we only in the clinic say, "Oh, your blood pressure is okay and I'll check your cholesterol and we'll see you in a year," or not see you in a year because nobody's getting annual exams anymore. So we've got to get the word out in another way.

Well, I was thinking that as a hot flush specialist . . . That was my research throughout a great deal of my career, were hot flushes. And it has been noted that women who have a lot of hot flushes are at greater risk for coronary heart disease. Do you have any bright ideas about that?

Dr. Moreno: Yeah. So that is an ongoing question that researchers are trying to study, and it's really hard to answer that just in one sentence or in one statement.

From my perspective, I do think that women who are having terrible hot flashes, night sweats that cause really sleep issues, cause a cumulative stress load in our bodies. We call that the allostatic load, and that does exist, it's not just in our heads. And with that allostatic load, that can lead to increased risk for the changes that happen in our cardiometabolic health realm in our health.

Dr. Jones: The term allostatic load is one, Camille, that you talked about and I want people who are listening to hold onto that, allostatic load, because it's going to come up under the social and financial domains.

When bad things are happening, you're having a lot of hot flushes and you're not sleeping well and you're not functioning as well and you're stressed out about it, all those things actually increase your glucose a little bit. So being stressed out increases your glucose a little. You get a little pre-diabetic for a minute or 2 or 10 or 20 or all day.

And so I'm just thinking about the things that go along with hot flushes rather than saying that hot flushes are a sign that my coronaries are in bad shape.

But I had always wondered about that one, about why people with hot flushes . . . And I'm very glad that I think I've had three hot flushes in my life. I'm not sure about two of them, maybe only one, but maybe I was drinking too much. I'm not sure.

Well, at this point, I want to switch to the emotional domain a little bit. And I want to take us back to the '70s or '80s when Bonnie Tyler came out with this amazing song, "Total Eclipse of the Heart." About the same time, I was beginning to understand you could die of heartbreak, you can die of a broken heart.

Song:Forever's gonna start tonight. Once upon a time I was falling in love, now I'm only falling apart. There's nothing I can do, a total eclipse of the heart.

Dr. Jones: And when she's talking about total eclipse of the heart, I think you can die of a broken heart. You trained at the Cleveland Clinic, which is like the heart center of the United States. Have you ever seen anybody with this or just read about it and heard about it?

Dr. Moreno: Yeah, I've definitely seen one case when I was actually in medical school, and I thought it was pretty unusual for someone to be so stressed and then end up with a heart attack, or similar to a heart attack.

And really, we call it broken heart syndrome because it is caused by this really intense, either physical or emotional stress that not just destroys the heart physically and loses its function, but it can be caused by one's increase in adrenaline levels causing this to decrease blood flow to the heart.

So there are a lot of explainable and not-so-explainable understandings as to why this happens, but it is true. It is something that happens commonly in women because of too much stress that she experiences.

Dr. Jones: Well, back in the olden days, this was seen as an atypical heart attack, where women would come in with a heart attack and they would have some of the changes in blood work and their EKG, but when they did the angiogram, they had clean coronaries. There were no blocks there. And it was usually women. In fact, it's about 88% of these episodes of broken heart are women.

People kind of said, "Oh, she's just being emotional. This is just an emotional thing." And the answer is yes, it is an emotional thing and she is a woman, but this is a real disease that can cause heart failure and death, this broken heart syndrome.

The other thing that's interesting to me is that it's usually midlife women or slightly after midlife. The mean age of women who have this broken heart is 58 to 77. So they're post-menopausal women.

And of course, that gets down to my favorite hormone, estrogen. So estrogen vasodilates, makes the vessels of the heart get bigger, which is really good for your heart, at least in a young heart. And when your estrogen runs away, there you are left with this big emotional stuff that your heart gets broken, a total eclipse of the heart, and then your heart wants to try to die on you like that.

Not only that, if it happens once there's a tendency that it might happen again, and you can't go in . . . With guys who have a clog, they go in and Roto Rooter through their blood vessels and make their coronary arteries young again, or they bypass them. You can't fix this. You have to hope that the heart heals and then you have to hope that someone doesn't get broken hearted again. It's kind of scary, I think.

So in the emotional domain, your emotions can break your heart and make your heart sick. It looks like a heart attack, it can feel like a heart attack, except it's a sudden flood of this epinephrine, of this adrenaline surge that makes your heart stop getting blood. It's one of those emotional stuff.

In the social domain, there's really good evidence that a good social network is good for your emotional life and your heart. So we're told that the number of friends that you have is important for longevity and wellness. But there are a lot of people who live in a toxic environment.

And you talked a little bit about allostasis. What happens when you're living in a toxic social environment, either immediately in your neighborhood or in your culture, or there's someone dangerous in your home? All those things keep your stress levels high all the time, right?

Dr. Moreno: Exactly.

Dr. Jones: It makes your blood pressure go up and it gives you a little bump in your sugar. It's just a bad thing.

Dr. Moreno: Yeah. Our bodies are in constant what we call fight and flight. We're ready to go. We're ready to attack. We're ready to protect our families. And women really as caregivers, especially in midlife, when you're taking care of your elderly parents, you're taking care of your children who are still living in your household, you're at the peak of your career, or maybe when you are working two to three jobs just to make ends meet, that all leads to chronic stress. And that doesn't do our bodies well.

Unfortunately, because of that chronic stress, we see a rise in inflammation. Not just at the level of the heart, but inflammation at the level of our gut. How we have bowel movements every day is affected by inflammation, right? How we're sleeping at time.

Dr. Jones: And our joints.

Dr. Moreno: Exactly. So that is a common thing.

Dr. Jones: This isn't so much about midlife women exactly. It's just that we know that women who are pregnant and are experiencing a great deal of stress when they're pregnant . . . And of course, the first studies were done in women who were starving during World War II in little villages. Then when the war was over, immediately the food came back. So it wasn't a chronic stress, but they were stressed during their pregnancy.

The babies of those women turned out to have more heart disease. When they got older, they had more diabetes, hypertension, and heart disease.

So the stresses that make you at risk for heart disease can be transmitted when you're pregnant to your baby. I think that's a powerful thing.

Dr. Moreno: Yeah, that is a powerful connection between mom and baby that . . . Again, women are affected across the lifespan, and that starts in utero, in the womb. So that is a very powerful message and take away from this.

Dr. Jones: I don't want to let guys off the hook because there's some evidence in rats that if you really stress out a male rat, the sperm that he makes a baby with, his babies end up being more stressed out.

Now, these are rats, not humans, but there's some stuff with obesity too. Obese men have different markers on their sperm that make their babies potentially more likely to be obese. So I don't want guys getting off the hook, but it is transgenerational, this stress thing.

So the social domain, when I think about what we should do about that, I think about social safety nets so that people who are really having a lot of stress in their life financially or emotionally or they're not safe, that if we make a society where there are safety nets so that people have a place to go and decompress or they can get a little financial help and . . .

Anyway, onto the intellectual domain. People with higher educational attainment have lower rates of coronary heart disease. Now, people who have more education, they tend to be thinner and their blood pressure is better and they usually have more income. All those things have a little bit more control over your life. And it's lack of control of your life, I think, that seems to be the stress.

But I think in the intellectual domain, the very things that are good for your heart, which are exercise and a helpful diet, and the social domain, and the control over your emotions, and getting good sleep, all those things are critical for your brain function too. So things that are good for your heart are good for your brain.

Dr. Moreno: Yeah, which brings us to the first point I think we made, is that education is important amongst all of us, right? And I do think that the higher educational attainment you've achieved and received, the access to the resources to live an overall heart-healthy lifestyle is there. So there are more accessible resources for that population of women who have higher educational attainment.

Dr. Jones: There are some efforts in, I think, immigrant communities or cultural communities to have community health workers. So to have women who are not necessarily trained as nurses, but they're trained as community health workers and get women together and work on their diets together and they chitchat together and they share their difficulties together.

And there's some suggestion that women who get together in some domain, I would say book club or maybe with these health workers, their blood pressure goes down and their weight goes down. It takes a long time to show that coronary heart disease goes down.

So being able to get together with even just a local healthcare worker in a group with other women sometimes can be very helpful for people.

Well, in the financial domain, it gets back to this allostatic load of stress. We know that people who are poor have more coronary heart disease, and it's not just lack of access to healthcare. It's the stresses of always worrying.

I was talking to my sister about our growing up and we were under financial stress all the time. It seems like it was always kind of a trouble. And I know that my mom really struggled with how she was going to be able to get the groceries the next month. And those kinds of things can be pretty stressful.

Dr. Moreno: I can definitely relate to that. I remember my mom cutting out coupons for 2-for-$5 burgers at Burger King because that was, again, $2.50 for a burger and that will feed 2 of us.

She had four kids and being a single mom, that was her priority, was to put food on the table, whether they were 2-for-$5 burgers or . . . That was her responsibility as a mom, for us to be fed and she had to do what she had to do at that time.

And now, looking back at it, yes, it wasn't the healthiest meal I've eaten, but, again, she was trying to provide for her children the best way she knew how.

Dr. Jones: Right. And I don't know that she shared her financial stress with you, but I'm sure that making paycheck-to-paycheck and even thinking about rent or all those kinds of things. And when school comes around, getting books or signing your kids up for stuff.

Once again, it gets back to the policies. I would like to see us have a community where there were financial safety nets for people. That doesn't mean that people aren't working hard, but sometimes people are working as hard as they possibly can and they just can't make it. And if we had some help, that would take such a burden. Fewer heart attacks in older women.

Well, when we get to the environmental domain, I have to talk about air pollution here. In Salt Lake, we've had a good year so far this year because it's been a lot of snowstorms, but we can have some pretty bad air.

The World Health Organization estimates that air pollution is the primary cause of about 25% of deaths from coronary heart disease. That means a quarter of heart disease can be related or linked to air pollution.

And we think about, if we're not going out into the air pollution, how do we keep our indoor air clean? So, Camille, how do you keep your indoor air clean?

Dr. Moreno: I, myself, use a humidifier in the room. It's mostly because my skin stays dry all winter. So that is one way to prevent that from happening.

Dr. Jones: So here's what happens at our house. Now, I will admit that my husband and I are total freaks about this. Anyway, we would never actually burn wood in the fireplace in our home because wood smoke is particularly toxic. We do have a super-duper filter on our furnace. So we have a MERV, which is an environmental filter of your indoor air that is a MERV 16. Usually, they say a MERV 12 is good, but we've gone well beyond.

And then we have our own little local air purifier, so if things get pretty bad in the Valley . . . And once again, it's been good this year, but some years it's pretty bad.

Then I don't fry very much. Sure enough, if you're going to be cooking, if you're going to fry stuff or broil stuff, you want to make sure you use oil that has a low smoke point so you're not polluting the house.

You know how if you're frying something and your whole house smells like fried food for a couple of days? Maybe not yours, but ours does. So I don't fry very much. It's better not to probably because I want to keep my indoor air as clean as I can because of this connection with heart disease and air quality, particularly particulate stuff.

Well, as we wrap things up and think about all the domains of our heart, I think of the spiritual domain. I'd say that people with strong spiritual life, and I don't mean this necessarily has to be a religious affiliation, but people with a strong sense of spirituality are more resilient in the face of life's stressors. So they have a better way of dealing with allostatic load.

They have a better way of backing off their stressors if they have a way of either deep breathing, or prayer, or going out for a walk when the air is clean, being with others who share your faith. Those are all resilience factors that help people have less heart disease and less cancer.

So I don't know how you talk with your patients. How do you talk with your patients about if they have a spiritual tradition?

Dr. Moreno: Yeah. I talk about the importance of being in a shared community, in a shared space with others who are going through the same kind of life stressors you are, whether it's in different severity or situations or not. But I do feel that there is a powerful insight that we get when we know that we are part of something bigger, a larger community that is there for us when things don't go the right way or things don't go the way we expect it to be.

When you are suffering from a death of a loved one, you know you can reach out to your community or church members. When you need someone to talk to, like what you said, going outside for a walk and maybe running into a neighbor of yours you haven't talked to in a long time, those situations I do feel are one way to . . . You are not going through this journey alone.

And whether it's a menopausal journey, whether it's a life stressor journey, again, whether it's a death of a loved one, someone can relate somehow.

Dr. Jones: I've become a bigger fan of structured breathing as well. So when I think about reducing my allostatic load, or if I feel pretty stressed out and I can feel my heart rate up, I know I can lower my heart rate just by the way I breathe.

I'm personally a fan of the 4-7-8, meaning you take a deep breath in for 4, hold it with a little bit of a Valsalva for 7, and let it out slowly for 8. And I can show that my heart calms down. My heart slows down, and there's some evidence that your brainwaves slow down too.

So finding a way through some spiritual practice or some community or connecting with your higher being, those things help reduce allostatic load, help you come back to baseline so you're not carrying such a burden. And I think that your heart will respond favorably. Your blood pressure will go down and your heart rate will go down and your stress hormones will go down. All those decrease your risk for heart disease.

So not being someone who has a religious practice myself, I do have a spiritual practice. That helps me, and I think it helps the people I love. I don't know if you and your family have a spiritual practice, but . . .

Dr. Moreno: My way of de-stressing or coping with stress in general is actually going for a run on a trail where I am one with nature. I can smell the fresh air hopefully when it's not polluted and when there's no inversion going on. But really, even hearing the leaves rustling in the background, that that to me brings inner peace.

We can find that in our own unique ways and it's very different amongst all of us. But I do think that once you find that and once you are able to use that as a coping mechanism or a coping tool for you, like what you mentioned, Kirtly, the stress levels will go down, the stress hormones such as cortisol will go down, and our risk for overall heart disease, which is the number one killer in both men and women, will go down.

Dr. Jones: Well, I want to thank you for your time this afternoon, and you've been generous. I thank you for your wisdom in our Midlife Women's Clinic and think about all those women's hearts that you hold in your hands on a weekly basis. So thanks so much for joining us, Camille.

And I'll end with the "7 Domains of the Heart" haiku.

Each beat of your heart
Tethers you to the earth's pulse
Red rhythm of life

So thanks again for all of the listeners who are listening to our "7 Domains of Women's Health." You can listen to some of our former podcasts if there are topics that will spark a conversation with you and your family or your girlfriends. Or take a deep breath. Usually, our topics are not too stressful. And at the end, you might feel just a little bit better. Thanks for joining us.