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Podcast: Why Black women are at higher risk of heart disease

Feb 14, 2023

Stacey Rosen, MD, joins the 20-Minute Health Talk podcast during American Heart Month to address the disproportionate impact heart disease has on Black women

Stacey Rosen, MD, joins Sandra Lindsay on this 20-Minute Health Talk to discuss why heart disease disproportionately impacts Black women, what factors contribute to their risk and what health systems like Northwell are doing to change the statistics.

Stacey Rosen is the senior vice president of Katz Institute for Women's Health at Northwell Health, where she oversees the development and coordination of a comprehensive and integrated approach to women’s health services at Northwell Health. In this role, her mission is focused primarily on the elimination of healthcare disparities through comprehensive clinical programs, gender-based research, community partnerships and education. As a practicing cardiologist, Dr. Rosen previously served as chief of cardiology at LIJ Medical Center and associate chair of cardiology at Northwell Health.

Currently, she also serves as a partners council professor of women's health at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; and a spokeswoman for the American Heart Association.

Podcast transcript

Host: 00:08    
February is American Heart Month, and today I have the pleasure of speaking with a woman who I admire, Dr. Stacey Rosen. She’s the Senior Vice President of Katz Institute for Women's Health at Northwell Health, and the Partners Council Professor of Women's Health at the Zucker School of Medicine. She’s also a Spokeswoman for the American Heart Association. Dr. Rosen, thanks for being here. 

Dr. Rosen: 00:36    
Oh, it’s my pleasure. Thank you for having me. 

Host: 00:39    
So as a Black woman, I’m concerned about all aspects of my health, especially heart health. The statistics around Black women’s heart health is just startling. Black women are disproportionately affected by cardiovascular disease. Why is that? 

Dr. Rosen: 01:00    
It’s a very good question, and we are actually, unfortunately, over the last few years, getting worse rather than improving. So you go back decades, maybe a century, and all of our healthcare model was focused on men. And in cardiac disease, that was the most notable area where only studying men, particularly white men actually, of a certain age and body size led us to believe, erroneously, of course, that women didn’t get heart disease. So for decades we studied men, we minimized symptoms in women. We didn’t appreciate differences for almost 20 years. Death rates for women went up, and death rates for men plummeted. And it became the classic example of why sex and gender matters. 

When we started studying women specifically, we realized that they’re different than men. And we looked sociologically that women have a tendency to put themselves last on their to-do list or not even make it on their to-do list. And so a disease that is 80% preventable, we lost the opportunity.  Then when we started looking at Black women versus non-Hispanic whites, Asian Americans, we started to see even more of a discrepancy. And again, the answer is multifactorial, Sandra. It is increase prevalence of many risk factors, hypertension, inactivity in the Latinx population. Increased prevalence of diabetes, obesity in Black women. Then you put on top of that societal issues relating to accessing care. And finally you put in that mom always—or women always taking care of everyone else first, and it becomes this tsunami of additive problems. 

Risk factors in Black women

Host: 02:50    
So among Black women ages 20 and older, nearly 59% have cardiovascular disease. You mentioned some risk factors before, but I think it’s worth stating again that maybe driving this startling statistic. 

Dr. Rosen: 03:05    
There were the traditional risk factors for heart disease that we talked about. And unfortunately, most of them are far more prevalent in Black women. So if you look at women over 20, 40% of non-Hispanic white women will have high blood pressure, but almost 60% of black women will have high blood pressure.

When we look at diabetes, when we look at inactivity, when we look at overweight or obese, all traditional cardiovascular risk factors for heart disease and stroke, the prevalence of Black women in the US who have these far exceeds white women. And for something like diabetes, the Latino population is worse than both, non-Hispanic whites and Blacks. 

And again, that is something that we can’t shrug or shoulders up and just acknowledge; we need to study. We need to do basic science, we need to do some clinical work, and we need to do implementation science. Why if we know that we can treat hypertension, why are two-thirds or Black women not controlled? There’s something that that we have to fund, ask the questions, and make the science better. 

Host: 04:14    
Absolutely. So there may be a gene that makes Black population much more sensitive to the effects of salt, which in turn increases the risk for developing high blood pressure.

As little one extra gram, that’s a half a teaspoon, of salt could raise your blood pressure by as much as 5 mmHg, according to American Heart Association.

Dr. Rosen: 04:39 
Absolutely, and that is the classic fact that makes it important to study populations and report the data independently. So that fact goes a long with the data that shows that there are certain antihypertensive medications that are more effective in Black individuals than whites for just that reason, that there is something different at the cellular level, the genetic level, and we need to study that. 

Host: 05:08    
The risk factors that you mentioned, a lot of seemed to stem from socioeconomic status, perhaps where you live, your culture, the risk factors that you mentioned that are 80% preventable, obesity, diabetes, hypertension. So how do we begin to tackle those? 

Dr. Rosen: 05:31    
Absolutely, and we first start by studying it, honestly, because we know that socioeconomic issues and social determinants of health as we defined these have a huge impact. In fact, the NIH and the America Heart Association have put out very firm commitments to focusing on this sort of research and not throwing our hands up, it’s too hard. Food insecurity, education, access to care, even language barriers, we can’t say there’s nothing we can do.

But we also need to study genetics. In the field of hypertension, there has been some interesting work done on understanding are there really differences in hypertension based on where you’re from, what your background race and ethnicity is. So I think there’s so much fascinating opportunities for us to study this more and not just put our hands up and say this is too hard. 

Making research more accessible

Host: 06:26
So I agree with you, but you and I know when it comes to anything that says research, how especially Black people, people of color are so afraid. 

Dr. Rosen: 06:38
With good reason. 

Host: 06:39
With good reason, not trusting. Then you throw on top of that access to research and how people know about these research opportunities. How do we navigate that? 

Dr. Rosen: 06:56
Absolutely. And I’ll tell you that we add onto that having researchers who look like the patients, right? 

Host: 07:02

Dr. Rosen: 07:04
So I think the first step is acknowledging that it’s a problem, and I think that the funding sources, certainly the federal government, most of the important foundations have acknowledged that this is a problem. And number two, you identify ways to get past those barriers. And it’s hard, but it’s valuable. So it includes appreciating how do we mitigate some of the expected lack of trust that exists?

How do we tell Black women that in order to come for the trial, you need to come to someone’s office three times a week when they’re taking care of a job and family? So we need to look at what the barriers are and really realize that that hard work is worth doing. 

The social determinants of health

Host: 07:47    
And we need to do it quickly because cardiovascular disease has killed more than 50,000 Black women annually, and stroke is the leading cause of death among Black women. 

Dr. Rosen: 08:00    
That’s right. 

Host: 08:02    
So along with all of this, cardiovascular health, let’s talk about the social determinants of health. We talk about it all the time, but for our listeners, can you please explain what that is? 

Dr. Rosen: 08:16    
Absolutely. So the American Heart Association came out with an extraordinary statement about the prioritization of social determinants of health, and I like to define that for people as just the comment that your zip code is more important than your genetic code. And we look at certain areas and a three-mile difference in Boston, in New York City, in parts of Los Angeles, that there can be as much as a 20-year—or more—difference between white and Black life expectancy. It is your access to healthcare. Not just insurability but the ease with which you can access healthcare. Is it respecting of your social background, of your language preference? 

Secondly, levels of education. Really important. Food opportunities. The issues with salt, issues are so compounded by the fact that we have areas where fresh fruits and vegetables are either unavailable for unaffordable. So we know something, yet without the implementation science, we can’t improve upon it. Even air pollution in the cardiac world is a social determinant of health. 

Prioritizing yourself

Host: 09:29    
Yeah, so speaking about something that needs to change is for us to prioritize ourselves. 

Dr. Rosen: 09:35    

Host: 09:36
Some me time, if you will. For example, I meditate

Dr. Rosen: 09:41
Wonderful. Love. 

Host: 09:43    
Love transcendental meditation, but sometimes I fall off. And then I just feel like my head is cluttered, there's no clarity, and I have to then say, Sandra, you got to stop. You got to make time. You got to make time. So are there any strategies for women? 

Dr. Rosen: 09:59
That is a great — I’ve actually just taken up meditation. It's fabulous. 

Host: 10:03
It is. 

Dr. Rosen: 10:04
And I like to do ten minutes a day. And then ten minutes doesn't seem like a lot, but our days are crazy. I think for — three suggestions I have.

  1. Acknowledge that every little bit counts. Women are also perfectionists by nature. If I don’t do it perfectly, I’m not doing it at all. If I eat one cookie, I’m going to eat the whole box. But the truth is one minute of meditation matters. So you're sitting at a red light, and maybe there's a breathing exercise that you can do. So that's number one, is to be proud of everything you do.
  2. Figure out a way to not fall off the wagon. I have patients who are able to stay on track by doing so with their friends. A long-term patient of mine the other day said that she's been walking with a girlfriend every day for 12 years. She hates every minute of it, but they do it because they know it's right for them, and the friends keep each other going.
  3. Cut yourself some slack. There's days you just can or don’t or won’t. Fine. Tomorrow’s another day. 

Host: 11:19
Absolutely. Also, I would say that refrigerator where you have the big calendar with everybody's schedule, make sure you put yourself on that calendar. 

Dr. Rosen: 11:28
Exactly. And put it on top. Some of my colleagues at the Center for Wellness and Integrative Medicine have a lovely slide that says, “The grass is greener where you water it,” meaning if you don’t take care of yourself, you can't take care of others. 

Host: 11:42
Right, and you can no longer be the CEO of the family.

Dr. Rosen:11:45

Host: 11:46
A position that women are proud to have. 

Dr. Rosen: 11:48
We’re born to. 

Recognizing symptoms

Host: 11:51
So let’s talk about knowledge deficit, because for many black women, particularly those who consider themselves perfectly healthy, their perception may not always equal reality.

Dr. Rosen: 12:05
Absolutely, and so since I think it was 2009, there’s been a publication put out every couple of years questioning women as to their understanding of what their biggest risk for death and disability is. And we started with only about 50% of all-comers knowing that heart disease — when you look at Blacks and Hispanic women, the number’s even lower. And so there were campaigns, the media's been great. Newspapers, women's magazines. 

But for the first time a few years ago, the numbers are dropping. So we’re actually going in the wrong direction, and it's now fewer than 50%. And when we look at Black women, fewer than 40% know that their number one risk is heart disease. So you think if I don't have symptoms, if nobody in my family, maybe I’m slender, there’s nothing you can do, you’re not going to get heart disease. And that's a problem. Ninety percent of women have a risk factor, and it's never too early to start understanding them and impacting on them. 

Host: 13:11
Right, because only 39% of Black women are aware that chest pain can be a sign of heart attack

Dr. Rosen: 13:18
In the past when we had these crazy statistics, again instead of throwing up our hands, we thought, well, how do we get to women? And an interesting questionnaire went out, and 45% of women at times, a few years back, got their health information from magazines and the media. So here we were focusing on community groups, doctors, clinicians, hospital newsletters, but no, we needed the media. We needed Women’s Day and Essence magazine and the newspapers to be trustworthy sources then. So again, that fact should ring urgent bells, fire alarms and that we need to do better. 

Where should women get their health information?

Host: 14:10
So where should women be getting their information? 

Dr. Rosen: 14:13
Yeah, that’s a great question. I think it starts by, to the best of our ability, find a clinician who becomes your partner, nurse practitioner, obstetrician, gynecologist, internist, cardiologist, somebody who really—who you trust, who trusts you. Secondly, make yourself a better patient advocate for yourself. We would never go to do our taxes without all or paperwork. We would never go to a parent’s doctor’s appointments without all of the information, yet we come uninformed and not as an advocate. 

So know your family history. Keep a log of your medication use, your procedures, things you're allergic to, and go for that well woman checkup. It doesn't even have to be annually, but it could. Know what things you’re at risk for and be the advocate that you would be for family members. Community-based organizations help, faith-based organizations help. And for heart health, we need to partner with trustworthy local programs to really get the word out. 

Host: 15:23    
These stats get even worse because only 33% of women recognize that pain spreading to the shoulder, neck, or arms is another potential sign of a heart attack. 

Dr. Rosen: 15:38 
So the data gets worse and worse. So you learn these frightening facts, and then you see women not taking care of themselves. I'm busy. I'm sure it's—I’ll take Maalox. They get to an emergency room if they can, and then there are some challenges receiving the appropriate care. Women, Black and white, are far less likely to the receive the appropriate treatment when they show up in emergency rooms. And all of this then starts layering on for more and more bad outcomes. 

Host: 16:09    
So how is Northwell Katz Institute of Women's Health continuing to raise health? What are we doing to change some of these statistics and issues we’re having in women's health? 

Dr. Rosen:16:27    
Thank you. It’s a wonderful question. So I think firstly, it's acknowledging that we need to look at women's healthcare differently, that the old days of looking at women's health as simply the bikini medicine, as Dr. Wenger has called it, of just reproductive organs and breast health. And we know at Northwell that we go way beyond that.

Our clinical programming and our preventive strategies really look at the whole women. We get out of our silos. I'm in internist cardiologist, but I spend endless hours with my OB/GYN colleagues, with my cancer colleagues, with the behavioral health professionals. Because to optimize women's health, they don’t care what my board certification looks like. We are figuring out and figured out the way to work together in a novel model. We are focusing on sex and gender research. 

Again, if we don't ask the question, not only how do we improve on salt sensitivity in Black women, but how do we get everyone to take their medications? How do we teach people to take blood pressure cuffs at home? There have been some really cool programs with that. How do we train the next generation of clinicians and scientists, so we don't make the mistakes we made when I was younger? And then finally, how do we partner with our communities, especially with respect to the heterogeneity of our communities, to really make them truly our partners and to listen to what they need as individuals, as community members, as groups to optimize health? 

Finding your healthcare partner

Host: 17:58    
Absolutely, so you also mentioned that it's time for us to not work in silos, and that we all need to come together. So I've been going to my OB/GYN for a number of years, Dr. Ketly Michel, just a shout out to her. She is fantastic. And she does more than just reproductive health. She takes my blood pressure. She asks me about stress. We talk about everything. We talk about life. I trust her. Should we be partnering with our OB/GYNs where women seem to go probably more frequently? 

Dr. Rosen: 18:41    
One of the taglines that was started years ago is, “The heart is a lady part.” And there’s actually some fascinating research that when even as few as three or four additional questions are asked by the gynecologist of the woman they see for their visit every year, cardiovascular health improves. So Katz has a massive partnership with Michael Nimaroff, MD and Frank Chervenak, MD and our OB/GYNs focused on making that well-women visit something that, as you said, is more. I have two daughters, one 30, one 24, and their only doctors are their gynecologists who are superb. But I’ve asked, are you asked about our family history? We've got stuff. Are you asked about sleep, blood pressure, stress? You are absolutely right. And one of our primary priorities in Katz is to really further align and integrate. 

And another interesting — if you go in the reverse way, cardiovascular adverse pregnancy outcomes, even something as simple as mild hypertension during pregnancy puts even a 20-year-old woman at much higher risk for cardiovascular disease in as short a period as five to ten years. So the cardiologists and internists need to ask women about pregnancy or pregnancy loss, or not having had a pregnancy, when they got their first period, when they got their last period, because all of that impacts on the other parts of them. 

Host: 20:11    
So it sounds like all these specialties, everyone needs to look at health more holistically. 

Dr. Rosen: 20:19    
As I joke every day I wake up, I’m a woman. And you guys need to figure it out, independent of what your degree is, because the one stability for us as women is every day I’m a woman. 

A roadmap for heart-healthy living

Host: 20:33    
So if you had to give us a roadmap for women for heart healthy living, what would that look like? 

Dr. Rosen: 20:44    
And there’s also so much information that is language accessible, culturally appropriate, so start with knowing that we’re all at risk for heart disease. If you're in that 10% that isn't, well, okay still some of the things we’ll do will keep your brain healthy or avoid cancer over a lifetime. So go in with the assumption that we’re all at risk. Go in with the assumption that there’s something you can do about it. Not, oh, my gosh, everybody in my family had a heart attack or had a stroke; there’s nothing I can do. There's always something you can do. Find a clinician whom you trust. 

Your description of your doctor is, mwah, it is perfect. That’s what you want. You want a partner who you get, who gets you. I joke if that doctor is not the person you're seeing now or the clinician, find somebody else. We joke women will fire a hairdresser in a heartbeat. But find that clinician who's your partner and spread the word. Again, the partnerships amongst women is particularly strong and also been studied. We joke that having dinner with girlfriends one night a month is as good as other medications, the laughter, the shared issues is really important. We’ve also unfortunately seen in the COVID era how loneliness and isolation has been devastating for heart health. 

Host: 22:05    
Dr. Rosen, thank you so much for being my guest on 20-Minute Health Talk. It’s a pleasure to meet you in person. 

Dr. Rosen: 22:12    
Thank you, Sandra. And I’m delighted and honored to be here. As you can tell, my enthusiasm is boundless, and the ability to share our information with our community is just a priority of ours. Thank you.


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