Pregnancy and the Heart
In this episode of Mount Sinai’s HERology podcast, co-hosts Drs. Leslee Shaw and Joanne Stone speak with Dr. Anu Lala on how heart health is affected by pregnancy—and what steps patients can take to ensure continued health and wellness both during and after pregnancy.
00:00:00:00 - 00:00:29:25
Dr. Lala
Even though many of these conditions reverse once the baby's born, they're a marker of risk that that woman may face hypertension, diabetes, potentially even heart failure later on in her life. So we have this incredible opportunity to maximize and optimize a woman's health even after that baby is born.
00:00:29:28 - 00:00:59:17
Dr. Shaw
So welcome to HERology. Another edition, another podcast from Mount Sinai Health System that focuses on cutting edge women's health, from research to really compassionate care. My name is Lesley Shah. I'm joined by two amazing colleagues here at Mount Sinai and a doctor, Arnaud Lala, who's a cardiologist and guest. If I introduce the next person because you know her from our prior episode, is our LFA chief of Obstetrics Gynecology and Reproductive Science.
00:00:59:17 - 00:01:27:02
Dr. Shaw
I've got to get the whole title in there. Doctor Joanne Stone and what's really, really cool about Mount Sinai is that we work together very, very closely cardiology, rheumatology, obstetrics and gynecology. And we have all the answers to your women's health questions and health care needs. So here we are. And we are going to talk about pregnancy and cardiovascular health, which is really the window into the future of a woman's life.
00:01:27:04 - 00:01:49:00
Dr. Shaw
So where should we start? I think what if we start with like what is the normal response? Because it's pretty dramatic, right? What happens? And we're going to be kind of informal here. So I call you Doctor Lala because I never do anyway. So why would I do here? Could you tell us what happens to the cardiovascular system through your agency?
00:01:49:00 - 00:02:10:16
Dr. Lala
First of all, I'm so excited to be here with you. So thank you so much. I think this is such a great initiative. I think we take for granted how incredible the human body is. And I think there's no better example of how resilient it is, how accommodating it is than pregnancy. So what's amazing about what happens to a woman's heart and the rest of her body?
00:02:10:16 - 00:02:32:20
Dr. Lala
And you guys know this way better than I do is these adaptive changes that are occurring as a part of the natural process of pregnancy, right. So your cardiac output, or the amount of blood that your heart is pumping out to the rest of the body is increasing by 50%. Crazy. Your blood pressure is dropping. Why? It's dropping by almost 20%, really.
00:02:32:20 - 00:03:00:05
Dr. Lala
Especially in that first trimester and early second trimester, to make it easier for that heart to pump out more blood because it has to accommodate for another human being, or maybe even more than one another human being. So these are natural changes that take place for the body to adapt to a growing human inside of her body. Not to mention the heartbeat is also increasing by ten, even up to 20 beats per minute.
Full Episode Transcript
00:00:00:00 - 00:00:29:25
Dr. Lala
Even though many of these conditions reverse once the baby's born, they're a marker of risk that that woman may face hypertension, diabetes, potentially even heart failure later on in her life. So we have this incredible opportunity to maximize and optimize a woman's health even after that baby is born.
00:00:29:28 - 00:00:59:17
Dr. Shaw
So welcome to HERology. Another edition, another podcast from Mount Sinai Health System that focuses on cutting edge women's health, from research to really compassionate care. My name is Lesley Shah. I'm joined by two amazing colleagues here at Mount Sinai and a doctor, Arnaud Lala, who's a cardiologist and guest. If I introduce the next person because you know her from our prior episode, is our LFA chief of Obstetrics Gynecology and Reproductive Science.
00:00:59:17 - 00:01:27:02
Dr. Shaw
I've got to get the whole title in there. Doctor Joanne Stone and what's really, really cool about Mount Sinai is that we work together very, very closely cardiology, rheumatology, obstetrics and gynecology. And we have all the answers to your women's health questions and health care needs. So here we are. And we are going to talk about pregnancy and cardiovascular health, which is really the window into the future of a woman's life.
00:01:27:04 - 00:01:49:00
Dr. Shaw
So where should we start? I think what if we start with like what is the normal response? Because it's pretty dramatic, right? What happens? And we're going to be kind of informal here. So I call you Doctor Lala because I never do anyway. So why would I do here? Could you tell us what happens to the cardiovascular system through your agency?
00:01:49:00 - 00:02:10:16
Dr. Lala
First of all, I'm so excited to be here with you. So thank you so much. I think this is such a great initiative. I think we take for granted how incredible the human body is. And I think there's no better example of how resilient it is, how accommodating it is than pregnancy. So what's amazing about what happens to a woman's heart and the rest of her body?
00:02:10:16 - 00:02:32:20
Dr. Lala
And you guys know this way better than I do is these adaptive changes that are occurring as a part of the natural process of pregnancy, right. So your cardiac output, or the amount of blood that your heart is pumping out to the rest of the body is increasing by 50%. Crazy. Your blood pressure is dropping. Why? It's dropping by almost 20%, really.
00:02:32:20 - 00:03:00:05
Dr. Lala
Especially in that first trimester and early second trimester, to make it easier for that heart to pump out more blood because it has to accommodate for another human being, or maybe even more than one another human being. So these are natural changes that take place for the body to adapt to a growing human inside of her body. Not to mention the heartbeat is also increasing by ten, even up to 20 beats per minute.
00:03:00:08 - 00:03:23:17
Dr. Lala
These are all natural changes to accommodate like we said, this is the part that really gets me. The actual heart muscle gets bigger. I mean, think about that. That's so crazy, right? The the mass of the heart increases by 10%. And then after the baby is born or babies are born, it regresses back to its normal size and function.
00:03:23:17 - 00:03:27:07
Dr. Lala
So this blows my mind. The fact that this is all normal.
00:03:27:10 - 00:03:45:09
Dr. Stone
Yeah, it's just amazing the changes that can occur that have to occur, really to make sure that we have a healthy baby growing or babies growing in the body. Right. They they need that extra blood volume. We need all that blood to go to the uterus, to go to the placenta, to go to the baby to support nutrients and growth and things like that.
00:03:45:09 - 00:04:06:24
Dr. Stone
So it's just incredible. And it's funny because you mentioned babies were babies. You know, when we think about twins, you said 50%. It's like 80 to 90% increase in the heart pumping out. So it's just amazing. And you also mentioned like blood pressure dropping. So one of the things that just happened recently, I was talking to a patient who fainted in the in the subway.
00:04:06:24 - 00:04:24:10
Dr. Stone
I mean, the subway. Okay. It's pretty hot in New York City subways. So people fainting all the time. But often, like, if you see, you know, a woman of reproductive age is passing out on the subway, think that they're pregnant and offer them a seat, you know, but then that happens because the progesterone relax and some of the hormones.
00:04:24:10 - 00:04:43:02
Dr. Stone
We talked about hormones in the last episode. Some of those hormones relax the blood vessels in the veins, and it causes pooling of blood in the veins. Less blood flow to the heart, less to the brain. And then people feel like they're they just ought to pass out. But but so of these changes are positive. But people do have symptoms.
00:04:43:02 - 00:04:54:09
Dr. Stone
But, but we also need to know like what are the symptoms that are okay. You can just say totally natural. And then what are the symptoms that maybe we should be paying more attention to and sending the patients like to you?
00:04:54:11 - 00:05:13:03
Dr. Shaw
It's really fascinating. I find myself I'm supposed to be the host. I find myself going, oh, that's really cool. That's really cool. And I was trying to think, Joanne, as you were talking, is like, how many babies have you delivered? I just must be like thousands, right? I'd love to know that. It was just amazing.
00:05:13:03 - 00:05:22:13
Dr. Stone
Yeah, well, thousands. But I mean, how many babies did deliver the most at one time? Which which actually was sick, so. Seriously? Yeah. Yeah, yeah.
00:05:22:16 - 00:05:23:10
Dr. Lala
Six babies and.
00:05:23:11 - 00:05:25:17
Dr. Stone
Wow. Yeah, yeah. So that helps.
00:05:25:19 - 00:05:52:09
Dr. Shaw
So. But, there's other things that go on like weight gain. Right. And changes what goes along with weight gain. Maybe either know it's you know, the average woman gains around 40 pounds during pregnancy. Not a trivial amount. So whatever you just told me about normal is now exacerbated. Right? Right. And with with the weight gain and so other things, other constellations of factors go along.
00:05:52:09 - 00:05:53:04
Dr. Shaw
Any comment?
00:05:53:05 - 00:06:16:07
Dr. Lala
Yeah, completely. I mean, I think that's the tricky part is how do we differentiate between normal changes, which are already really dramatic and changes that sort of require extra care. And to me, I think you mentioned this at the outset. This is a window into the rest of a woman's life, right? We still know cardiovascular disease is the number one cause of death in women.
00:06:16:10 - 00:06:45:03
Dr. Lala
And so this pregnancy is is that window whereby we can kind of say, okay, this is happening, what's what's normal, what's not. So I think of things as there's a huge range, right? Hypertension is probably I mean, you're seeing this this is probably one of the most common things we see in terms of a manifestation of, of, increased cardiovascular risk in pregnancy, 10%, I think, of women just exhibit sort of hypertension.
00:06:45:05 - 00:07:11:08
Dr. Lala
Where do we say this is hypertension or high blood pressure, just because of all the different changes that are occurring versus this is hypertension that needs to get treated. And I think that exists across this range of hypertension. And then there's pre-eclampsia right. Which is a complication of that. And then at the very end of that spectrum is what I often see from a heart failure perspective, much, much less common.
00:07:11:08 - 00:07:31:17
Dr. Lala
Of course, one in 1000 to 4000 births is what we call pari partum cardiomyopathy. You all know this obviously very well, but for our listeners is when that heart muscle function, it's just too much to bear. And we see weakness in the muscle. All of this happens a part of all the changes that you're talking about this we could go on and on, right.
00:07:31:17 - 00:08:01:11
Dr. Lala
Gestational diabetes or diabetes that you see during the pregnancy. But what I think is so critical is even though many of these conditions reverse, once the baby's born, they're a marker of risk that that woman may face hypertension, diabetes, potentially even heart failure later on in her life. So we have this incredible opportunity to maximize and optimize a woman's health even after that baby's born.
00:08:01:14 - 00:08:31:01
Dr. Stone
And so, so important. They say that because it's actually part of some of these history, the medical history, right, that they have to tell their internist who's following them. If they developed high blood pressure during pregnancy, they're at higher cardiovascular risk. If they had gestational diabetes, their risk for 50% chance of developing diabetes later in life. So we can use pregnancy in some of these, some of these conditions that occur to really help modify what their care is going to be.
00:08:31:01 - 00:08:33:29
Dr. Stone
And that's just what's so amazing.
00:08:34:02 - 00:08:38:08
Dr. Shaw
So at potentially during pregnancy, sorry I cut you off at the end. I'm.
00:08:38:08 - 00:08:40:22
Dr. Stone
Used to Ella's.
00:08:40:25 - 00:09:03:16
Dr. Shaw
Yeah. You're the chief. You're used to it. Right. But that's this. That's been like a trans transition for us. It used to be, in, in obstetrical care that you would think that's normal. Blood pressure goes up. It'll come back down. So this is quite new for a lot of, physicians and patients is to understand that that's not normal, and it's a flag.
00:09:03:16 - 00:09:05:28
Dr. Shaw
And how do you approach that with patients?
00:09:05:29 - 00:09:26:03
Dr. Stone
Yeah, it's such a such a good question. I mean, with we tend to think, oh, everything goes back to normal, but it doesn't really. And you know, when when you look at patients with pre-eclampsia or condition that specific to pregnancy involving high blood pressure and some other things, that heart doesn't really go back to what it was before.
00:09:26:05 - 00:09:46:04
Dr. Stone
And like you said, they're at higher risk for cardiovascular disease later. So you have to arm them with that education. Like if you had this make sure that you pass this on. Also things like if you if you went into spontaneous pre-term labor, that's a risk factor or had a stillbirth even that's a risk factor for cardiovascular disease.
00:09:46:07 - 00:09:54:20
Dr. Stone
So it's an incredible time to educate our viewers, our patients, about what's important to pay attention to.
00:09:54:22 - 00:10:17:00
Dr. Shaw
And it's interesting, we talked we started off chatting about the cardiovascular adaptations, but we have vascular adaptations. It's the, feeding the placenta and feeding the baby, the feeding the fetus. It's hard to say feeding the fetus. But for those of you, I'm obsessed. I'm a researcher. I'm obsessed with vascular effects. And so we won't talk about that here.
00:10:17:00 - 00:10:32:16
Dr. Shaw
But, but there are changes to the uterine artery that feed the baby when in the setting of hypertension, it becomes less compliant. And, you know, so, these are things that require a lot more monitoring. Yes, doctor Stone.
00:10:32:19 - 00:11:00:06
Dr. Stone
Yeah. I mean, there are now ways that we can screen for things for preeclampsia, high blood pressure earlier on in pregnancy, even in the first trimester, we can measure blood flow in the urine arteries. So cool. Yeah, it's really cool. And there are certain, biomarkers, blood tests that we can do something called as fluid, personal growth factor that affect the vasculature and can help predict blood pressure monitoring.
00:11:00:08 - 00:11:13:24
Dr. Stone
Some risk blood pressure in the, in the first trimester, combining all these things as well as a patient's history can help us predict who might develop really, you know, early onset, more severe forms of preeclampsia.
00:11:13:27 - 00:11:41:05
Dr. Shaw
So when when a woman is has pre-eclampsia or is hypertensive during pregnancy, you know, one of the big challenges you think about is how can we treat them. Because pregnancy is a contraindication for so many medications. What are really to both of you. Because this is really, really actionable information for everybody who's listening. What what do you how do you approach that and in terms of treating that that woman?
00:11:41:05 - 00:11:58:24
Dr. Lala
I love that question because and one of the things that I love that I've actually learned from MFM clinic here, is the fact that you empower women to monitor themselves. Right. They're going home with blood pressure machines even after they've delivered their baby. Just as kind of a side note to yours.
00:11:58:24 - 00:11:59:16
Dr. Shaw
Really?
00:11:59:19 - 00:12:16:15
Dr. Lala
Yeah. I mean, this is what we should be doing later on in life. And so I love that model, actually, with respect to treating. I'm so glad you brought that up. Because what happens this is we see this in clinical trials. We see this broadly. Oh. You're pregnant. I'm not going to do anything. I don't want anything to affect the fetus.
00:12:16:15 - 00:12:41:02
Dr. Lala
And we we don't recognize that there are conditions that we actually do need to treat. Because yes, on one hand, there's a fear that those medications, antihypertensive or blood pressure medications may affect the fetus. On the other hand, we have to recognize the risk of hypertension progressing on to a worse condition like pre-eclampsia and at worst case, maybe even pericardium cardiomyopathy.
00:12:41:02 - 00:13:04:13
Dr. Lala
So I think the hesitancy that we see is something we need to really kind of get rid of. And if you don't know, that's okay. That's why we have specialists, right? We've got nationally reputed, specialists in this. So I would just call up Joanne and be like, hey, listen, I've got this patient I'm worried about using blood pressure medication like valsartan.
00:13:04:15 - 00:13:08:24
Dr. Lala
What are your. When would you want us to stop? When would you not want us to stop? I just.
00:13:08:24 - 00:13:09:24
Dr. Shaw
Saw.
00:13:09:26 - 00:13:36:09
Dr. Lala
Interestingly enough, a patient who is interested in getting pregnant would be considered at increased risk. Is on medications, actually, for a history of heart failure, which would be considered contraindicated otherwise. I called up Angela Bianco, you know, MFM specialist, obviously, and said, let's talk about this together. I'm afraid that's because I don't know enough. Tell me what you feel comfortable with.
00:13:36:09 - 00:13:40:16
Dr. Lala
I'll tell you what I feel comfortable with, but let's not ignore this as a problem.
00:13:40:19 - 00:14:03:24
Dr. Stone
Well, that's just speaks to why it's so important to have the sort of interdisciplinary care, an approach, a team approach to taking care of pregnant women. I mean, just because you're pregnant doesn't mean you don't have other conditions. And you know, that affect you, right? You have back pain, you may have sciatica, you may have heart disease, you may have, hematologic, disorders.
00:14:03:26 - 00:14:23:02
Dr. Stone
We have to treat the patient, the pegging patient with all of her as a whole human being with all of her conditions. And you're absolutely right. There are people that say you. Oh, I shouldn't take anything because I'm pregnant. It's actually can do harm by not treating people. And so there's a whole host of medications that are absolutely safe to take.
00:14:23:07 - 00:14:42:21
Dr. Stone
We were talking in the hallway earlier about patients with a history of depression, let's say, or anxiety. When they stop those medications, they often will rebound in pregnancy. And we need to treat we need to treat that. I'm getting off on the heart. This is about the heart. But it's all connected. It's all connected, right? The brain, the heart that you know, or everything.
00:14:42:23 - 00:15:09:07
Dr. Stone
But, but we do need to totally pay attention to it. And you mentioned the monitoring. It's so important because we do know also, after somebody delivers, if they had some high blood pressure, developing preeclampsia, they need to get monitored for at least a week now because sometimes it tends to be that the blood pressure spikes up after like day 3 to 5 is most common and some of them will get readmitted.
00:15:09:09 - 00:15:25:14
Dr. Stone
I mean, if they're monitoring your blood pressure, if they can cool, we can sometimes prevent them from having to get admitted to the hospital and just treat their high blood pressure because, you know, we have a baby, have a newborn. The last thing you want is a warm out into the hospital. It's like, yeah, the worst. Right.
00:15:25:16 - 00:15:47:24
Dr. Shaw
You know, so you've heard it. Hear it just from world expert doctor Stone. Monitor your blood pressure. Yeah. No matter how old you are. That's really a great. You know, I've been fascinated, Joanne, with the use of aspirin and and low dose aspirin in the in the pre-eclampsia. Can you tell us? I mean, it's it's really from, from those working in the adult space.
00:15:47:26 - 00:15:55:25
Dr. Shaw
The effects on the vasculature and pre-eclampsia is, is fascinating. And could you perhaps give us a little insight.
00:15:55:26 - 00:16:17:21
Dr. Stone
Yeah. I mean, low dose aspirin right now is the only thing that we have and think it's so silly. Little low dose aspirin. Some people call it baby aspirin. It's the only thing we have right now that help that can help prevent pre-eclampsia. So we do know that it has to get started around 11 weeks. Has to get started before 16 weeks to have an effect.
00:16:17:24 - 00:16:42:18
Dr. Stone
There are certain, strong risk factors like a history of preeclampsia, which is, you know, right away, you know, that person's going to go on it. And then there's some sort of more minor risk factors. If you have two of them, like it's your first pregnancy and you conceive with IVF, those are two moderate risk factors. While the Society of Maternal Fetal Medicine still advocates, advocates for 81 milligram tablets, and I was a former president.
00:16:42:18 - 00:16:51:10
Dr. Stone
So I really feel terrible saying this, but but the data clearly shows also that you need at least 100mg to reduce the risk.
00:16:51:11 - 00:16:52:19
Dr. Lala
You know, interesting idea that.
00:16:52:20 - 00:16:53:18
Dr. Shaw
Yeah, that that I did.
00:16:53:18 - 00:17:18:06
Dr. Stone
Yes. And so a lot of, a lot of the data came out of the UK right. Where they're low dose aspirin is 150mg. So we often tell our patients to take two. So we will get some hundred 62. Yeah. Because if you have less than 100 it's not going to have the same effect. And so now it there are studies out there looking at the 162 milligram dose.
00:17:18:09 - 00:17:31:12
Dr. Stone
Does it, you know, have any effect based on your weight. Like if you're in the obese range as opposed to normal weight. So they were going to see some more promising literature on it to help counsel patients a bit better. Can I ask.
00:17:31:12 - 00:17:32:00
Dr. Lala
You a question?
00:17:32:00 - 00:17:32:17
Dr. Stone
Yeah.
00:17:32:20 - 00:17:49:04
Dr. Lala
So how often you'll see patients up to six weeks postpartum right there after a are you continuing the aspirin in those high risk people. And then how do you navigate. And this is kind of like a bigger, bigger question transitioning patients who are high risk.
00:17:49:07 - 00:18:12:23
Dr. Stone
It's a great question. Right now we're not continuing the aspirin after because it's specifically geared to a reduction in the preeclampsia risk. Would it make a difference a week for week maybe I don't know I don't know the answer to that. But I think that the transition is to make sure that they get hooked up with the cardiologist like you, you know, and say, you know, you need to get a follow up check.
00:18:12:23 - 00:18:25:22
Dr. Stone
Just like if they diabetes follow up with the dendrochronology, right. They need to get hooked up. I mean, you know, in that in that first year with the cardiologist who's going to follow them throughout the rest of the health, and this is how we can impact this is what we can do.
00:18:25:22 - 00:18:26:06
Dr. Lala
Right?
00:18:26:06 - 00:18:30:04
Dr. Stone
Totally up to it to help mitigate, you know, disease later in life.
00:18:30:11 - 00:18:39:12
Dr. Shaw
You both know this about me, but I'm a huge, huge I'll get on my soapbox. I could stand on top of this table and tell you, oh, please do it.
00:18:39:15 - 00:18:40:27
Dr. Stone
Well, yeah, yeah.
00:18:40:29 - 00:19:04:29
Dr. Shaw
But to tell you that what our health care system waits for somebody to get sick. And here we have the opportunity, really? During pregnancy, to alter a woman's life. Ever and really, I so I thought that I knew did a this great segue right to the Rowan center and how we're going to be providing lifelong care for for women.
00:19:04:29 - 00:19:31:23
Dr. Shaw
Doctor Stone is really been I'm the visionary for this and and it's it's unlike anything in New York City and really all the states around it. Maybe we could take that woman who was pre-eclampsia and, and how you envision her care and both of you really and, and and from different perspectives. But, Joanne, what were you envisioning as a maternal and fetal medicine specialist?
00:19:31:25 - 00:19:37:09
Dr. Shaw
How the Rowan Center could carry her for the rest of her life and really provide state of the art care?
00:19:37:12 - 00:20:02:02
Dr. Stone
So, so the Roman center for those who didn't listen to our former podcast, but, the Rowan Center, the Senate is going to open up next year right here on the on the Mount Sinai campus on 99th and Madison. And it's a it's a center that's taking an integrative approach to the care of the individual woman, that takes into account her history, risk factors.
00:20:02:02 - 00:20:31:18
Dr. Stone
We're going to be doing screening tests, all these different things. So some of specifically that comes with the history preeclampsia or history of some of the other things I mentioned stillbirths, spontaneous preterm labor. Look at they can enter a care pathway that's particularly designed for them. That said over maybe six month period where they're going to have their heart function measure, where they're going to have their blood pressure measured, maybe their body composition measured, they're going to see cardiologist and multiple visits.
00:20:31:21 - 00:20:58:07
Dr. Stone
If they're overweight, which is one of the, you know, risk factors for high blood pressure and preeclampsia. We can help manage that weight loss. And, you know, it's super hard to lose weight after we've had a baby. Anybody who's had a baby knows that. But you know we can help enhance that so we can reduce these risks. And the whole idea behind the center is to let's not wait to, like you said, let's not wait until somebody presents with heart disease.
00:20:58:07 - 00:20:59:13
Dr. Stone
Let's let's.
00:20:59:15 - 00:21:00:00
Dr. Lala
Prevent.
00:21:00:00 - 00:21:04:21
Dr. Stone
It, prevent it. Right. Or like optimize and optimize their health. Right?
00:21:04:23 - 00:21:28:10
Dr. Lala
I love this notion of being proactive rather than reactive. Our health care system. I would stand on the table with you, but is is reactive. We wait for disease and then retreat. But being proactive to optimize health, you know, given whatever your constellation of risk factors are, is, is so critical and it's also really personalized, right?
00:21:28:13 - 00:21:50:28
Dr. Lala
It's not a one size fits all approach. You know what you need versus someone else needs is completely different. And I think and I feel so blessed to be a part of this honestly. So thank you. On on Mike, for allowing me to be a part of this, because this integrative approach to women's health who are often ignored, especially during this period of life, is so critical.
00:21:50:28 - 00:22:10:24
Dr. Lala
Right? It's like you were talking about postpartum depression and we were saying, oh, that's getting away from the heart. But it's all related. We have to treat people as whole people, and not just, oh, I'm a cardiologist. I only deal with this where we know cardiovascular disease is connected to depression, is connected to what has happened to you during pregnancy.
00:22:10:24 - 00:22:22:07
Dr. Lala
So it's all really connected. And I think that integrative holistic approach that's evidence based is what we're going to be able to provide here. And I'm I honestly am thrilled to to be a part of it.
00:22:22:08 - 00:22:41:08
Dr. Stone
No, it's so it's so exciting to actually give people what they need. I think one of the biggest struggles people have is navigating their health care, right? They're sort of everything is so siloed. You know, the cardiologist doesn't speak to the obstetrician, doesn't speak to the end canal, just, you know, doesn't speak to the researcher to mold them.
00:22:41:08 - 00:23:08:05
Dr. Stone
And so, you know, so here we have a center where they don't have to manage that on their own. We have actually patient navigators, that are going to navigate them through all their appointments and their needs. Well, we have these pathways that, that, we're working on. So to seamlessly bring them in and create this, this pathway for, for improve care that, you know, that they can be a part of.
00:23:08:05 - 00:23:18:15
Dr. Stone
That's just going to be amazing. So it's really so unique. It's such a different approach today of different way of delivering health care and something that I think people crave.
00:23:18:17 - 00:23:20:00
Dr. Lala
I want to be a patient there.
00:23:20:04 - 00:23:21:01
Dr. Stone
Yeah, yeah.
00:23:21:02 - 00:23:43:07
Dr. Lala
Honestly, I swear, honestly, I think that the golden rule of like, what do I want? Right? I'm, Quote unquote midlife, whatever. That means. It. Like, I want that kind of care. And so I think the fact that we're building these care pathways to deliver experiences where people feel nurtured, cared for in a way that we would want is, I think, really cool.
00:23:43:07 - 00:24:19:14
Dr. Shaw
So in that postpartum time period, right. The potentially hypertensive, certainly weight gain. And and having and being now at having a transformative life with a little baby, with no time yet, we're asking women now to refocus on making them healthy again. Losing weight, you know, controlling their blood pressure, all the things exercising, changing their diet.
00:24:19:17 - 00:24:38:09
Dr. Shaw
How do you what what how do you motivate people? I know it's, like, super, super hard. I will tell you, you know, I've done a lot of, cardiovascular prevention trials we've gotten at F and F. We could do f minus. We've gotten an F in in health care up until the new drugs, that have become available.
00:24:38:13 - 00:25:00:10
Dr. Shaw
We really as a health care system, and we talk about a health care system, but we're not necessarily talking about Sinai. We're talking about every health care, system all over the world. We have flunked in terms of providing ways for our patients to lose weight, particularly lose weight. And it's projected that by 2050, 65% of the population will be obese.
00:25:00:10 - 00:25:07:04
Dr. Shaw
Crazy, crazy. So I mean, what how do you motivate people after pregnancy or, or any time?
00:25:07:06 - 00:25:34:07
Dr. Stone
I mean, I'm I'm hoping and I really have a lot of optimism about this is that by having a navigated pathway is going to keep them going. Right. So they're going to be meeting with a nutritionist regularly. They're going to get some exercise regimen. They're going to have appointments where people are checking in on them because people, you know, who just had a child, they don't pay attention to the themselves.
00:25:34:07 - 00:25:41:24
Dr. Stone
They have no time. But if you can make it so that some of these visits will be by telehealth will be easier for them, they won't have to exist in.
00:25:41:26 - 00:25:42:28
Dr. Lala
Virtual option.
00:25:42:29 - 00:26:04:22
Dr. Stone
The virtual assistants. Yeah. And having and having nutritional support. Right. This is what you should be eating. This is take time for maybe for some meditation. I mean, you know, it's it's funny because I have two kids. I remember my first child, I thought I had no time for anything. And the second one was like, yeah, you know, like, what do they do?
00:26:04:23 - 00:26:20:10
Dr. Stone
They sleep well, but, you know, I feed them. I said, you take you could take the time to really take care of yourself. We have to get that message through. But I think through that support that we're giving those pathways the navigators, making sure that somebody is touched, like touching.
00:26:20:13 - 00:26:21:02
Dr. Lala
Each point.
00:26:21:02 - 00:26:21:26
Dr. Stone
With them. Right.
00:26:21:27 - 00:26:40:23
Dr. Lala
I think that's part of it. Right? I love what you said. Part of it is just this overwhelm. I just had a baby. I know I need to take care of myself. I know I need to stay healthy and I don't have time and I don't know where to go. I don't know where to start. I'm going to follow up with my OB because I know I need to do that.
00:26:40:25 - 00:27:01:18
Dr. Lala
And then what else, you know, do I need to make an appointment with my cardiologist? Do I need to make an appointment with my primary care doctor? Do I also have to see endocrinology and the overwhelm of having to see, you know, 4 or 5 different specialists? When I have a newborn at home? It almost seems like comical that we're asking people to do this.
00:27:01:18 - 00:27:21:06
Dr. Lala
And so I think the model, the goal, the intention, the prayer of the center is to, like you said, provide that integrated model of care, which is like, we've got you. We know you just went through this life changing event quite literally. We've got you leave this part to us. Just come show up, engage.
00:27:21:09 - 00:27:42:05
Dr. Shaw
So I know, can we talk a little bit about some of the new drugs for weight loss just for a favorite topic? And I knew you would like this, but, tell us, tell us your thoughts on on how that would be helpful and what are patients expectations or any kind of kind of advice you give people as they embark on these new medicines?
00:27:42:05 - 00:27:42:10
Dr. Shaw
Yeah.
00:27:42:10 - 00:28:10:25
Dr. Lala
Thanks, Leslie. I think this is such a revolutionary moment for us, for cardiometabolic health, for health broadly, like you said today, 40% of us adults are obese or overweight. I mean, that's staggering statistics, right? And we constantly say like we need to improve our diet. Of course we need to exercise more, of course. And it's not always as easy as it sounds, right?
00:28:10:25 - 00:28:36:11
Dr. Lala
It's about access. It's about time. It's about, health literacy awareness. And there are certain biological predispositions for individuals carrying excess weight. And I think so much of it is stigmatized, right? When you're looking for new clothes, you have the skinny model who's trying on new, new clothes, and you're like, I want to look like that person. And then you buy clothes accordingly.
00:28:36:14 - 00:29:15:22
Dr. Lala
That's not reality. We have many different body types, and there's a lot of underlying pathology there, you know. And so these new drugs I one class certainly of which is these GLP one receptor agonists or the Ingleton based therapies. What I'm not saying it's a quick fix. This is always alongside lifestyle optimization. Right. And these drugs are teaching us and reminding us of how everything is connected and that obesity itself or being overweight itself is something to modify.
00:29:15:22 - 00:29:40:22
Dr. Lala
It's a disease entity in and of itself to modify. And these drugs lead to substantial weight loss in a way that we haven't previously understood. Whereas there's fat stores that are on top of our organs. Right. And we call that visceral fat. These drugs are helping us get rid of that pathologic fat, that fat that is like an endocrine organ in and of itself.
00:29:40:22 - 00:30:14:13
Dr. Lala
It's secreting these hormones that create problems for our body, increase our cardiovascular risk that we're not able to, quite frankly, see. And so I think these drugs being on board, of course, if you have diabetes, it's it's known we have clinical trial data that shows this. If you are overweight and high risk for cardiovascular disease, again shown to show benefit in my world of patients who are living with heart failure now, improvement in quality of life, improvement in having poor outcomes, meaning you're less likely to have poor outcomes.
00:30:14:13 - 00:30:40:28
Dr. Lala
So it is revolutionizing, I think, how we approach health more broadly. And it's not just cardiologists who are using this. This is endocrinologists. This is ObGyn, this is rheumatology, this is orthopedics. This is reminding us that what was or what was what is old is new again, in the sense that, you know, 50 years ago we had one type of physician, really, we didn't have a whole lot of subspecialists.
00:30:40:28 - 00:30:49:10
Dr. Lala
And now we're recognizing that we need to see people as whole body systems and provide that integrated model of care.
00:30:49:12 - 00:31:12:29
Dr. Shaw
Yeah. I mean, it's it's totally fascinating. And you didn't even chat about liver fat, right? Cause your new clinical indication for that FDA indication for reducing liver fat that the fat surrounding or any organ, there's tremendous crosstalk between that people I don't think are only beginning to understand this. And so 80% of the heart is covered in fat.
00:31:13:02 - 00:31:42:07
Dr. Shaw
And so in you talk about weight gain during pregnancy. So you can expect this visceral fat, would increase everywhere on top of, of of where however much fat they had to begin with. It's really fascinating. So as you move towards this, we we also know from these new drugs that people lose muscle. And so that that's a that's where the lifestyle it becomes so critical maybe chat with a minute about.
00:31:42:09 - 00:32:03:02
Dr. Lala
One other thing that, you know, there's also this emerging literature and growing. You probably know this way better than I about treating individuals with PCOS or polycystic ovarian syndrome, which is also this metabolic syndrome with GLP one receptor agonists as well. To to your point, really quick, I sorry, I mean that digression because I think it's so interesting.
00:32:03:02 - 00:32:04:20
Dr. Lala
Did you want to say anything on that or.
00:32:04:21 - 00:32:22:08
Dr. Stone
No, I think so. It's, it's it's phenomenal because it's for so long so many people have PCOS. There are overweight, they have acne, they can't get pregnant, you know. So this is remarkable to have something that can really, really help them to achieve whatever outcomes they want to achieve and get better.
00:32:22:08 - 00:32:38:05
Dr. Shaw
So now it's bringing just I'll let you get back to that. But now it's bringing these new GLP ones into the infertility specialist. Right. So it's now it's another whole gamut of of of physicians who are guiding, our patient population to become healthier. Yes.
00:32:38:05 - 00:32:43:28
Dr. Stone
Really awesome. It's amazing because, you know, with people with weight loss, people are gaining the fertility back.
00:32:43:28 - 00:32:48:21
Dr. Lala
Right? Crazy. It's it's crazy not to say it's crazy. No. It's smelly.
00:32:48:21 - 00:32:49:13
Dr. Shaw
It's awesome.
00:32:49:13 - 00:32:50:03
Dr. Lala
It's great.
00:32:50:04 - 00:33:01:28
Dr. Stone
I mean, we're seeing so many, so many things. Benefits that were surprising, right. So people who have, you know, alcohol, you know, addiction. We're seeing there's an effect of tips on that, right.
00:33:01:28 - 00:33:02:26
Dr. Lala
Smoking, small.
00:33:02:26 - 00:33:03:22
Dr. Shaw
Gambling and.
00:33:03:22 - 00:33:05:02
Dr. Stone
Locally. Yeah. Yeah.
00:33:05:05 - 00:33:06:20
Dr. Shaw
It's it's a really incredible.
00:33:06:21 - 00:33:27:27
Dr. Lala
I think your point is such a huge one though. Like we as human beings, we have too many things to do. We're too busy. We want a quick fix. I need to lose weight. I want this GLP one, I want a shot a week and I'm done. We have to do it alongside strength training, mobility training. It's not a small thing I like.
00:33:27:27 - 00:33:51:09
Dr. Lala
I wish we could do prescriptions with it alongside the GLP one agonists, and in many cases we do. We do send them to rehab. We do, you know, offer physical therapy. It's sometimes an access issue, but I we can't emphasize enough how important it is to again, still follow the right diets, you know, that are optimal for us and then also really emphasize physical exercise and strength training in particular.
00:33:51:09 - 00:34:13:10
Dr. Shaw
So anybody listening to this podcast, we should tell them when you lose weight, it's the it's the just the small things you add on top of that make small adjustments. When I was doing a lot of prevention work, I would always tell patients small adjustments, you know, stopping eating one thing every week and cutting down can really make over the course of a year, can make big changes.
00:34:13:10 - 00:34:42:07
Dr. Shaw
That's that's again, I'm standing on the table again. But so but our health care system has become very specialized and very expensive. And it and it leaves us particularly where we are in, at Mount Sinai, at I think we're at 105th Avenue between Madison or whatever, where in Harlem and, our patient population, not necessarily afford all these very expensive.
00:34:42:07 - 00:35:06:04
Dr. Shaw
Although the GLP wants have come down in price. Can we talk for a few minutes about health disparities? Because in many ways, they've been a bit under attack. But yet at a critical time when we know I, I know you talked about pericardium cardiomyopathy. It occurs ten times more likely in an African-American woman than it does in a Caucasian woman.
00:35:06:07 - 00:35:28:06
Dr. Shaw
And these are important biologic differences. If we don't understand them, we can't help to correct that. I mean, I know and again, I'm standing on top of the table. But what do you what's her next steps in? And really correcting the world of women's health for all patients. What are your thoughts? I know you both are very passionate, right?
00:35:28:07 - 00:35:55:02
Dr. Lala
Yeah. We should all just get on the table. Yeah. I mean, I think that's such a critical and critically important point, right? How can we offer these models of care that are accessible to everybody? And I think that's the beauty of the Rowan Center and its vision is to make this integrated model of care equitable and available and accessible to broad populations of individuals.
00:35:55:02 - 00:36:40:18
Dr. Lala
I think with respect to affording medications, of course, it's a huge, you know, limitation of this. Of course. Now, the the indications in terms of what insurance will cover and not they're broadening slowly but surely, thank God. But we have so much more to do. I think in addition to, you know, building the center, I think also our prayers that it will serve as a model, you know, for for health care broadly to for everyone to recognize that women, particularly really need a place where they can feel like they're going to be addressed for all of their varying needs, not just one part of their body or one issue in a proactive way.
00:36:40:20 - 00:37:09:17
Dr. Stone
And I think also, patient education is a really important part of it. I mean, certainly educating our health care providers, recognizing that we need to listen to women because I think a lot of women who are underserved don't feel listened to. It might be a language barrier. You know, I've had patients who come to me who are black and say, I'm worried I'm going to die because we know that black women die at a much higher rate in the United States than white women, and are worried about it.
00:37:09:17 - 00:37:36:22
Dr. Stone
And we have to make sure that we're putting into place, ways that we can pay attention to their needs. We don't know often what the reason is. You know, there's there's a lot of it's not about the race itself. It's about a lot of other, you know, other factors there. But I think as, as care providers, we can pay attention to sort of make sure that we're not, you know, having that bias, making assumptions about patients.
00:37:36:24 - 00:37:42:29
Dr. Stone
And really, you know, that's that's first step, I think, in terms of trying to reduce the disparities.
00:37:43:02 - 00:38:09:17
Dr. Shaw
It's there's just so much biology we don't understand. And I think the PCM, let's call it that because people won't remember pericardium cardiomyopathy is just one great example. I mean, there has to be some genetic aspects to this which have yet to be elucidated. What? It's interesting though, if we shift maybe for a few minutes on what's going on up amongst the three of us that were involved in research.
00:38:09:19 - 00:38:36:26
Dr. Shaw
That includes what's the focus of what's going to go on at the Rowan Center? And I'm segueing into genetics, but we're going to include, as many participants who want to be involved in what's called our Mount Sinai Million, which is looking at the genetics of diseases in trying to keep people healthy, and importantly, the genetics of diverse patients, not just most of the genetic information that we know.
00:38:37:01 - 00:38:53:09
Dr. Shaw
This is not about me talking. So I'm going to shut up in a minute. But most of the genetic information we know is from European white men, which is not helpful, not helpful to women. So what else is going to go on in the Rowan Center for research that we could really would be cool to, for people to know?
00:38:53:10 - 00:39:17:06
Dr. Stone
Yeah. Well, I mean, we're hoping the patients will enroll in our when they walk into the room, that they'll enroll in longitudinal studies so that we can track outcomes. We can track these clinical pathways, see what differences we can make, have them give blood to to the medicine and millions to different repositories. If they if they have obesity, if they've had a history of stillbirth.
00:39:17:10 - 00:39:39:13
Dr. Stone
So that we can ultimately look at some of these and in a much larger model using AI. Now, you know, when we have somebody in our department who is A or B, Joanne, an AI expert using big language learning and models to try to have more prediction and then treatment for for these conditions. But I think research is essential to improving health.
00:39:39:13 - 00:39:52:14
Dr. Stone
We're not going to get anywhere without the research behind it. So I think enrolling our patients in a way that they or feel comfortable and can consent to, they're going to consent to the research that they want to be part of.
00:39:52:14 - 00:40:17:29
Dr. Lala
And it's all anonymous, right? I mean, we if we have this attitude of I am contributing to this collective purpose to gather more data on women like me, then it's not there's no guinea pig aspect of this. This is let us gather the data we need to inform how we can better risk stratify. People like me. Right. Well, you talk about this all the time.
00:40:17:29 - 00:40:49:23
Dr. Lala
We have these risk scores. What is your likelihood of developing a heart attack? What's the likelihood of you developing heart failure? These risk scores and models are based primarily on men and data on men. Right. So if we want to personalize risk and we want to talk to women, if I had a sister and she's coming and she's asking me, I know what's my right, what's my risk of of having a heart attack, I'm going to give her the caveat of saying here, if we use this risk score, it comes out to x percent, but it's based on a lot of data from men.
00:40:49:26 - 00:41:06:01
Dr. Lala
So it would be wonderful if we could gather your data, eventually aggregate it, pull this data, and then be able to communicate with the rest of the world as to what actually does dictate risk or inform risk for women like us.
00:41:06:03 - 00:41:29:17
Dr. Stone
So it's so important. And I think, and Leslie, correct me if I'm wrong, because I think we had a conversation not long ago that, for some of the for some of the Mount Sinai minions or some of the blood tests that were running, if if they identify something and a patient consents to be contacted, that can be actionable, they can, you know, we can let them know.
00:41:29:21 - 00:41:33:27
Dr. Stone
Right? So so I think that's that's also in the works for the Rowland Center.
00:41:33:27 - 00:42:01:12
Dr. Shaw
You know what's really cool? A and Joanne and I know we've been working so hard to bring so many different types of specialties together. Joanne, maybe you could highlight some of the work you've done because you're you're really reinventing health care for women in not an in, in, in the department, but also the Rowan Center and then taking it other places as well.
00:42:01:14 - 00:42:27:09
Dr. Shaw
Throughout the health care system, you know, neurology, autoimmune diseases, you know, maybe you could kind of talk because and when you sit in these rooms where like, for so long we've been reinventing the wheel, they've invented it. We've reinvented it. And, and now when we all sit together and really it's part of your vision is to say it's not just ObGyn, it's not just cardiologist.
00:42:27:11 - 00:42:33:21
Dr. Shaw
It's every. Maybe you could just chat for a minute. It's it's cool. It's really cool. It's cur ology. Yes, it's her.
00:42:33:24 - 00:42:37:07
Dr. Lala
But, she's
00:42:37:10 - 00:43:03:19
Dr. Stone
Yeah. I mean, what's first? First, what's great is that it's not just a virtual center, right? I mean, we will have some telehealth, but it's a brick and mortar build. It's a beautiful place that people can come to and feel, you know, embraced. And the warmth and have again, these navigators will take them through. So we'll we will have other specialties, will have mental health services.
00:43:03:22 - 00:43:16:13
Dr. Stone
We'll have, orthopedics to evaluate bone health. I mean, you know, people don't typically it's not really bone density is not really recommended until in the 60s. Well, that's way too long, right?
00:43:16:14 - 00:43:17:21
Dr. Shaw
Totally too late.
00:43:17:21 - 00:43:20:02
Dr. Lala
What are you reactive rather than proactive?
00:43:20:02 - 00:43:50:03
Dr. Stone
Exacerbating. Let's identify if you add bone. If you have bone loss at age 35 or age 40, and we'll have physical therapy in the center with three rooms. I mean, that's pretty amazing. You know, in some other countries, women after birth are told to use physical therapy for a year. Yeah. So we'll we'll yeah. I mean, you want to prevent frights, uterine prolapse and, you know, leaking urine and, you know, peeing while you're laughing when you're old or life.
00:43:50:03 - 00:44:14:17
Dr. Stone
Right. This, you know, this is aimed to help with that, right. We'll have, we'll have, endocrinology in there. We'll have liver disease and GI in there. So you talked about the fat around the liver. We'll have ways of looking at that. But whole body composition, I mean, eventually we would like to also have some other services like acupuncture and things like that.
00:44:14:24 - 00:44:44:22
Dr. Stone
That's in the planning in the future. We have a conference room that we can convert to a studio. Yoga, holidays. We're looking at, you know, having, ways to educate people about strength training, which is so important for so many things. But, you know, bone health especially. And also, like you mentioned, if you're in groups, once you if you lose, you know, muscle mass, you need to work at work out and build up that muscle mass.
00:44:44:25 - 00:45:04:03
Dr. Stone
So it's really bringing all these services together in a very, in a very collaborative way. And not having patients have to say, oh, you know, doctor so-and-so in my endocrinologist, can you possibly tell me what to tell my or, you know, ObGyn or my cardiac, you know, like that does,
00:45:04:06 - 00:45:05:10
Dr. Lala
You talk to each other.
00:45:05:10 - 00:45:17:15
Dr. Stone
And talk to each other, right? Like, why don't people want to talk to each other? So it's a way of having people in one place to like having that conversation and giving the patient, you know, a whole plan of care.
00:45:17:21 - 00:45:37:03
Dr. Shaw
Yeah. It's just like you said, the whole plan of care. Right. And, and and to the extent possible, having it done as promptly and as early as possible along the life course. Why are you. I'm we're almost we're almost done here. But why. And just I know we could I swear we'd the three of us could sit here for ten hours, right?
00:45:37:11 - 00:45:38:02
Dr. Shaw
100%.
00:45:38:02 - 00:45:40:29
Dr. Stone
We would. We would need a little bit of alcohol. Yeah, well, I'm.
00:45:41:01 - 00:45:43:01
Dr. Lala
100% on that as well.
00:45:43:03 - 00:45:53:22
Dr. Shaw
So why are you on again? Tell us, tell us about just a little bit. And then, you know, we'll we'll give us some more information about the Rowan Center. But tell us about your journey to the to where you are now.
00:45:53:24 - 00:46:12:14
Dr. Lala
Well, you've been such a huge part of it. So it could feel like I could hug you. I think for me, as a as a person who specializes in heart failure at the end of the spectrum of disease, so to speak, in cardiovascular disease, I have developed, you know, these are people who need replacement of their heart, right?
00:46:12:14 - 00:46:39:18
Dr. Lala
Heart transplant or pump to take over for the heart. And I love it dearly. And I have this completely new vantage point on, yes, we've got all these amazing therapies and surgeries and devices and medications to treat reactively. But my goodness, we got to move way, way, way earlier in the game. And we really need to focus on prevention.
00:46:39:21 - 00:47:07:04
Dr. Lala
We actually just put forth a scientific statement between the American Society for Preventive Cardiology and the Heart Failure Society of America to advocate for that approach, which is really how can we optimize health care? How can we talk about whole body health? And then, you know, Joanne, you know, this Anna Barbieri had influenced me years ago to do a fellowship in integrative medicine, because this is so near and dear to my heart and how I see patients in general.
00:47:07:04 - 00:47:36:21
Dr. Lala
And so I'm in this integrative medicine fellowship now, and it's really been so transformative in terms of how I think, how I approach patients, how I approach my own health, my family's health. And so honestly, it feels like the biggest blessing to be a part of the Rowan Center initiative, to be able to offer. Sure, my expertise in cardiology, but also hopefully integrative health and to to to make women like me feel seen, to make them feel heard.
00:47:36:24 - 00:47:45:29
Dr. Lala
I think to be a part of that effort where there's higher purpose is like what we all strive for, you know? And I feel really blessed to be a part of it. So big. Thank you again.
00:47:45:29 - 00:48:06:20
Dr. Shaw
But you guys are both, the two people that I, I just have so much, I'm just so impressed with both of you and what you bring to really revolutionizing women's health care. And, you know, I think that, we have just such a bright future. And, I can't wait to do more of these podcasts. And I hope all of you are listening.
00:48:06:23 - 00:48:27:24
Dr. Shaw
Can can wait with bated breath about our next, episode. And, and but if you really want to know more information about the Rowan Center, there's going to be a QR code, I guess stamps right over my face somewhere on the screen. And that you can, you can use your phone on and, scan it and find out more information about the Rowan Center.
00:48:27:27 - 00:48:49:13
Dr. Shaw
It really will be the place to have women's health care in New York City and the surrounding areas. Nothing is is going to be close to this. It's going to kick butt in relation to anybody. So and in large part related to, these two, fine physicians on either side of me. Thank you guys so much. We look forward to seeing you soon.