Women and Heart Health: Interview with Martha Gulati, MD

Dr. Martha Gulati is a cardiologist and internationally recognized expert on women’s heart disease. Dr. Gulati serves as Division Chief of Cardiology for the University of Arizona College of Medicine-Phoenix as well as Physician Executive Director for the Banner-University Medicine Heart Institute. She is also the best-selling co-author of the book, Saving Women’s Hearts, and is a Scientific Advisory Board member of WomenHeart: The National Coalition for Women with Heart Disease. In addition, she is active on Twitter (find her at @DrMarthaGulati). In this interview, we speak with her about her work in women’s cardiovascular health.  

Tell us briefly about your medical background. 

I went to medical school at the University of Toronto. I came to the University of Chicago for my residency and stayed there for my fellowship. 

I then began practicing in Chicago at Northwestern University. Next, I went to Ohio State University, where I was the Endowed Chair in Women’s Cardiovascular Health. I recently moved to Arizona, where I am a Professor of Medicine and Division Chief of Cardiology at The University of Arizona in Phoenix.

When and how did you become passionate about making cardiovascular health for women a primary focus in your career?

It was during medical school when I decided that not only did I want to be a cardiologist, but that I wanted to specialize in women’s cardiovascular disease. When I was a medical student, I had the unique opportunity to attend a guest lecture by Dr. Nanette Wenger, who is considered a women’s cardiovascular health pioneer. I didn’t realize at the time that clinical research to date hadn’t included many women, and yet heart disease was the number 1 killer of women in Canada and the United States. At the time, statistics showed 1 in 3 women died of heart disease. When I recognized that, it hit home, because a lot of the women in my family have died from heart disease or stroke — in fact, on my paternal side of the family, there were no living women in my family above the age of 50. I realized then that I needed to do more. 

Describe some of the unique challenges that women face in their cardiovascular health. 

One of the biggest challenges is that cardiovascular disease is still perceived as a man’s disease — both national and international data continue to show that women are treated differently than men. For example, we know that guideline-directed medical therapies for heart failure or other cardiovascular disease states are not applied as well in women as they are in men. The Get With The Guidelines data is probably what I refer to the most, but this large database shows that women are less likely to get aggressive medical therapy within 24 hours of having a heart attack, and yet women are more likely to die from a heart attack. So we don’t even use what we have as aggressively in women as in men. There was an interesting study from the American Heart Association in 2017 where an algorithm versus humans chose medical therapy for patients presenting with acute myocardial infarction, and found a sex difference in the aggressiveness of therapy chosen when humans made the choice (rather than the computer). Meaning, when humans decided on treatment, women were less likely to get aggressive therapy. This shows us there is some bias in healthcare workers in how aggressively we treat women. Why are less aggressive therapies being offered to women, and why are there delays in care? So that is one part of it. 

Another contributing factor is that women have been understudied, so there is less appreciation that everything should be as effective in women. Additionally, the pathophysiology of the disease is different in women than in men. For example, women have less obstructive coronary artery disease. Women also have more heart failure with reduced ejection fraction (HFrEF) than men, as well. So there is still a lot of work to be done, because we’re really in the infancy of understanding women’s hearts, and that has contributed to some of these knowledge gaps. There are also differences in terms of how we address cardiovascular symptoms in women. There is a lot of data showing that women may not have the classic symptoms of a heart attack, which can delay diagnosis. Again, that is only part of the problem, because for disease states such as heart failure, women receive less aggressive medical therapy despite there being no noted sex difference in medical therapies. However, women are less likely to be offered devices such as defibrillators, less likely to receive advanced heart therapies such as left ventricular assist devices, and less likely to undergo heart transplantation. We have to figure out how to overcome these barriers and make sure that we are not being biased in offering therapies more often to male patients than to female patients. Heart disease is the number 1 cause of death for both men and women — each deserve optimal medical and device therapy, where appropriate, so they can live longer lives with better quality of life. 

Women have many unique risk factors. Some of these factors are related to our reproductive organs or to pregnancy, but other emerging risk factors such as hypertension (including gestational hypertension and preeclampsia) and gestational diabetes are proving to be predictors of future cardiovascular disease. Since these risk factors are unique to women, we need to identify them as being part of a higher risk group. Autoimmune diseases such as lupus and rheumatoid arthritis are also more common in women, so these are groups that need to be identified as being at risk, and we need to be more aggressive about their cardiovascular risk profile and make sure we’re screening them. I think many people might think that breast cancer is the number 1 killer of women, but women are almost 10 times more likely to die from heart disease than from breast cancer. Patients have a 90% or higher chance of surviving breast cancer, which is excellent and speaks to how far screening and medical therapy have come, but it is important to remember that these women are then more likely to go on and have heart disease. Part of this is because there are risk factors that are common for breast cancer that are also common for heart disease, but there is also the impact of treatment for breast cancer that affects the heart, such as chemotherapy or radiation therapy. We need to be more cognizant in this group and educate them about their risk for heart disease. They need to be aware that this will be their primary health concern for the rest of their life, and help them to be proactive. 

In addition, I wrote an editorial in Circulation last February during American Heart Month to address the importance of moving beyond “bikini medicine”, because the majority of women’s health centers across the nation do not treat anything beyond reproductive health. I can think of only a handful of women’s health programs that encompass every disease state. The Joan H. Tisch Center for Women’s Health at NYU Langone, which is run by a cardiologist, is a unique model. Women’s health programs should focus on all aspects of women’s health — not only the reproductive system and the breasts. In the medical community, we need to teach the next generation of doctors about sex differences in cardiovascular health, so maybe they’ll be a less biased group. Women make up more than half the population — we should know how to treat this majority.  

Tell us about your plans for creating a center for Women’s Cardiovascular Health at The University of Arizona in Phoenix. 

When I came to University of Arizona in Phoenix, I was surprised that there weren’t any specific programs in the state for women’s cardiovascular health, so I saw an opportunity. Phoenix is the fifth largest city in the United States and has an ethnically diverse population. I felt that this was a place where we could not only educate women about their cardiovascular risk, but also include these women in studies to understand differences in our Caucasian, African American, Latino, and Native populations. Some populations have a higher incidence of cardiovascular disease, so this gives us the opportunity to not only provide critical care but also conduct research to help future generations and get answers that will help us better treat women and their hearts. This a unique center for women that will provide educational and clinical outreach. 

What further cardiovascular research is needed in women? 

Everything! It’s shocking that it was only in 2014 when we realized preclinical studies had not included much in terms of female representation. It is interesting that preclinical studies had not included female cell lines or female animal models; this was brought to light in 2014 by Francis Collins, MD, PhD and Janine Clayton, MD, who co-wrote an editorial in Nature. The fact that research did not include females in preclinical research meant lost opportunities to identify differences based on sex. It was a huge gap. As of 2016, cell lines and animal lines now have to include both female and male lines. It was surprising to me that no one had previously addressed this as an issue for us to understand women or sex differences. We need these preclinical studies to include females, because that is how we are going to learn where sex differences might lie and translate that to treatment. For example, if we’re assessing nonobstructive coronary artery disease and find that based on animal studies that there is a difference in response to medical therapy, maybe we will be able to identify medical therapy that might be unique in treatment based on sex. With regard to hormone changes, it was always believed that hormones protected women, and by replacing estrogen during menopause, one could reduce cardiovascular disease. However, the Women’s Health Initiative disproved this, finding it was more harmful. But perhaps if we can find out if there is something else going on at the time of menopause in animal studies, we’ll be able to determine if there is something we can do to intervene in a new way, whether it’s a different hormone or if we’re not even looking at the right place. Clinically, we have to close these sex differences in heart disease and that means understanding any sex difference. Another thing that affects outcomes in women is simply the fact that we don’t treat men and women equally when we have guideline-recommended therapies proven in to be effective in both women and men. I think women should be outraged that they are treated differently. It’s a form of bias and discrimination, and if I hope that if I were to experience a heart condition or cardiac issue, that I will be treated with the guideline-recommended therapy. There are approximately 43 million women living with heart disease in the Unites States. If this is something that is likely to affect a woman in her lifetime, she should be empowered to ask why she is being treated differently. As women, we need to have a louder voice and educate healthcare providers, so there is no discrepancy in our care. 

I believe physicians and healthcare workers have the best of intentions, but they need to be more aggressive in their care of women who present to the emergency room with chest discomfort or angina equivalent. We also need to make sure this is part of every medical school’s core curriculum in the United States. We need to have all practicing physicians understand why equal treatment should be given to male and female patients. Only then can we positively effect change.

Tell us about some of your ongoing efforts to improve cardiovascular health for women. Why is it important to raise awareness about heart disease and the particular cardiovascular risks that women face? 

I’m certainly an advocate in many different ways. I work with the American College of Cardiology as the editor of CardioSmart, which is not just about women in cardiovascular disease, but allows me a platform to increase awareness about heart disease and risk in both our cardiology and patient communities. I also sit on the board of WomenHeart: The National Coalition for Women with Heart Disease, and we do a lot to increase awareness and support for women living with heart disease. We educate senators and Congress to help them understand why this is an important public health issue, and why funding for prevention and patient care is needed. Cardiovascular disease is highly preventable, and if we can continue to support preventive care and cardiovascular risk assessment throughout a woman’s lifetime, we could reduce cardiovascular disease in the United States, and health expenditures would decrease dramatically.

I’m also an advocate for the American Heart Association, and I sit on the heart advisory board for Woman’s Day magazine, which provides a lot of great content to women about heart disease. I work with anyone interested in educating women about heart disease and getting this message out to healthcare providers, so that we can make a change in our community. 

Why do you think it is also important for medical professionals to get involved on social media? 

You and I met through Twitter, and that is what I love about social media — it is a platform that can reach everybody. I belong to a huge healthcare community on social media, but I am also connected with many people who are living with heart disease, people who are advocates about heart disease, and people who are simply interested in healthcare. We are all able to share our message on social media in a way that we never could before, and it’s amazing to see how information can spread. For example, Twitter allows users to see how many people they’ve reached based on one Tweet. On social media, I try to share interesting statistics or infographics about the risk of heart disease and how to advocate for your health. Twitter and other forms of social media have made our world so much smaller, and I mean that in the best of ways. It’s remarkable to be able to have a conversation with someone in the UK or China without having to get on a plane. I’ve seen people translate things I’ve posted into Spanish. I’ve also been able to collaborate with scientists around the world who I’ve met on social media. It used to be that you might only briefly interact with colleagues at medical conferences, but now because of social media, I’m able to talk with my colleagues almost every day. We talk about specific cases, discuss research or even share aspects of our personal lives (everyone knows I share pictures of my dog on Twitter!). We have real discussions that are open to everyone and that have taught me a lot. There is so much information online nowadays, but being involved on social media has opened my eyes to other things I should read because of an interesting discussion about it. I’ll then read the article, and if it is relevant, I can teach my residents, fellows, and medical students. We’re all interested in continuing to learn, and we have this opportunity through social media. 

What’s next for you? 

I’m heavily involved as editor of CardioSmart; I have a wonderful team there and we have a lot of plans for patient education. We are growing our sections to include the many subspecialized areas within cardiology, such as cardio-oncology. 

As far as clinical research, I’m working with colleagues right now on adverse pregnancy outcomes and their relationship to heart disease. We’re working with the American College of Obstetricians and Gynecologists (ACOG), the American College of Cardiology, and other national and international researchers on how to educate cardiology and obstetrics/gynecology communities to be aware of this link. 

Is there anything else you’d like to add? 

I want to close with a saying I always use: heart disease is the number 1 killer of women, and lack of awareness is a close second. These are things we need to work on!