Introduction to Personalized Risk Assessment

It's not just about the numbers, right? If you have a high LDL and a low inflammatory marker, but you had blood pressure through the roof and you sniggers that are elevated, you know, there are other factors here.

But if you a have high LDL, and high inflammatory markers, what's going on? And you really need to understand what other risk factors there are. We cannot determine risk on two points.

we have to determine risks by the entire person that we're seeing in front of us. You're listening to the Lifestyle Medicine podcast with Dr. Ivan Rusilko, brought to you by Access Lab, where we explore new perspectives at the forefront of personalized health care.

Welcome back to the Lifestyle Medicine Podcast. I'm Dr. Ivan Rosilko, your podcast host, and we're powered by Access Labs. If your doctor's not checking your labs, they're not a doctor.

Today we got Susan Steinbaum, a preventative cardiologist. She's got books out. she is the sensei when it comes to women's health, when comes your heart.

And I can't wait to get into the weeds with her. So how are you doing today, Susan? Oh, I love it. I loved it, but first and foremost, can you tell me about your book?

It's super, super unique. It is all about women's cardiovascular health, which again is much different than men's, right? The scariest thing about my book is that I wrote it a long time ago.

And so we're talking about like women's health today. When I wrote this book, it was like 10 years ago.

Women and Heart Disease Awareness

And when we talk about this women and heart disease problem, more women started dying of heart diseases than men in 1984. Really? Yes. Okay. This is not a today problem.

We're talking about a Today problem, but this has been a long standing issue and we know more women die of heart disease than cancers combined. So we got a big problem and that's why I wrote a book about it and why talk about.

I've been part of Go Red for Women through the American Heart Association since it started 24 years ago and this is been my whole deal. No, I think it's fabulous.

And the biggest thing is, you know, when you think of heart disease, again, just me, my mind goes to like an overweight man eating burgers and smoking cigarettes.

You don't really think about women, You know what I mean? Like, and again not saying that in a bad way. It's just you'd think men are more predisposed to it.

So can you tell me just in your opinion, why is it that women are having such a hard time with heart diseases compared to men? Well, there's so many different reasons.

And I'm going to tell you a little bit about the infrastructure, like the facts around this, which are so scary. From that moment in 1984, for the 20 years before all the research was done on men and the data was like extrapolated to women's hearts.

If you don't actually do the. On that cohort of people. You don't know what the deal is. And so all the statistics and all of the research that was not done on women's hearts caught up to us in 1984. It wasn't until 1993 that the Office of Women's Health opened up through the NIH that research started to be done in women hearts.

it takes about 20 years for research to hit clinical practice. So it's been about 30 years now that that office opened up and that's why we're in this situation.

That's the first thing. The second problem is in medical school, we were never taught that women got heart disease. Very true. genuinely taught that it was a man's problem.

And I don't know, someone said something about it for like 10 minutes, I think, but I remember the context, like it wasn't even a thing. So that's the second thing, and then the third issue is that women literally do not believe that heart disease is her own issue.

When you ask a woman what her biggest fear is, she's going to tell you 9 out of 10 times it's breast cancer. There's actually a study done. It was a thousand women.

They were like smart, educated women and the study was survey and it said, hey, out all of you women, how many know heart diseases are greatest health threat?

90% raised their hand. We know it. Great. Then they said, how many of you think that it's your problem? Only 13% said anything to do. Like it is everyone else's issue.

It's not my problem. And for those three reasons, we're sitting in this. My opinion, if you thing about all the media, all of the movies, television shows, it like that overweight guy having a It's like this salacious affair in a hotel room, like some great, fast out, eating steak.

Cholesterol, Inflammation, and Risk Markers

That's the image. It is not of a thin fit, super high powered executive woman who enters the emergency room with a little fluttering in the chest and shortness of breath and fatigue.

that's not the story. And so we don't see it and we do not think of it because it is just not part of our culture. Now, when it comes to heart disease as a whole, I mean, it's very mixed up with how people kind of view it.

And, you know, one of the biggest things obviously is diagnostic testing. So when comes the cholesterol, because everyone's got their panties in a bunch, excuse my language, about LDL versus VLDL, this, that and the other.

What's your opinion as preventative cardiologist on cholesterol versus like things like inflammation markers and like homocysteine and things that? I mean, we have got to understand that this prevention situation has been going on for decades and decades.

We're calling it longevity now. When I started, there were tons of research out there about really how to prevent heart disease. And it all starts with understanding the risk factors.

How we know those, some of them are basic. You step on a scale, but how do we the major risk factors, cholesterol and sugars and inflammation is we get our blood drawn.

I mean, the primary stuff, we have vital signs. We need to know your blood pressure. All of that. It's really, really important. Here's the deal. The way that it's been done is that the cholesterol situation has been four numbers.

Cholesterol, HDL, the good cholesterol. Put a pin in it. I like this. This is good. LDL. and the triglycerides, which is often associated with bad diets, processed foods, high sugar diet, right?

Which is also associated, with belly fat, huge risk factor. But when you look at that LDL, part of the problem with prevention, the issue that happens with women and heart disease, and I'm going to go back to one thing.

Remember people would talk about ratios? In those ratios, it was the HDL. So every woman who was premenopausal, who had estrogen, had low ratios and they were always told they're fine.

We have set up women to get sick when it comes to how we've defined heart disease. For sure, for sure. So when we look at LDL, it's not just LDl. It's VLDl, its IDL.

Its all of these other parts. The small dense LD l is the ones that can get in the lining of the artery. And the way that we can figure that out is with one value.

There we go. So sorry. He's just very enthusiastic about cholesterol. I love it. That's great. Perfect. Very funny. Again, a video with her. It's like, what do you think about women at heart disease?

She's, like. Touché, touché. There is literally one number that tells us the major risk when it comes to cholesterol, and that is apolipoprotein B. Big time.

Because that's going to tell the story. And then the other thing, which has been called a novel risk factor, is Lp little a. This is not a novel risk factor.

this has been tested and known about for decades. It is associated with making LDL cholesterol sticky and when LDl gets sticky, it leads to plaque formation.

Here's the deal with this one. it is genetic. You can't exercise or diet your way out of it. This is something you were born with. But if you have an elevated Lp little a, we know the importance of getting that apolipoprotein B really low.

And now there's some medications out there, rapathaprioline and inclusoran, which can actually decrease that LP little A. So it's important to know that.

And then the last one I'm going to talk about under this cholesterol umbrella is APOE, which is another genetic marker. It tells us how we metabolize fats.

And this is about what our bodies does with the food we eat. If you have an APoE 3-4 or 4- 4, when you eat fats, your body absorbs it, but it can't package it and get it out of your system.

And so that fat sits in the lining of the artery, leads to coronary artery disease in your heart, or in you brain, it leads Alzheimer's or dementia. Pretty scary, yeah.

But you know what? It's so scary. At the same time, if you knew it, then you're going to be somebody who is not getting your protein sources from meat, from chicken, turkey, tons of eggs, cheese.

You're gonna get it more from other sources. So we're all fixated on this high protein diet, but with that APOE, you better figure out how you're going to get your protein sources, and it's not going be from saturated fats if you have an APoE 3, 4, or 4. No, for sure.

Menopause, Hormones, and Cardiovascular Risk

And again, just the breakdowns in general, HDL, LDL VLDL SDL. I mean, there's so many L's in there. Your head starts to spin. You know what I'm mean? But when you start to look at it as a preventive cardiologist, so you've got the whole umbrella of actual cholesterol, correct?

Then comes in the PLAC, the HSCRP, and the sedrate, all those kind of different things which shows the actual inflammation within the cardiovascular system.

If you're looking at somebody and they have a high LDL, but their HS CRP and their PL AC are all just completely bottomed out and normal, are you as concerned if it was the other way around?

If they had high HS-CR-P a PL-AC that's through the roof but all their cholesterol is completely normal. See, this is when the story gets interesting and complicated, because we are all three-dimensional beings, right?

And we can't look… If it was four, it depends on the night. I mean, like… It could be six depending on night, but let's… Oh, let's just say this, that it's not just about the numbers, right?

So, if you have a high LDL and a low inflammatory marker, but you had blood pressure through the roof and you've got spigots that are elevated, you know, there are other factors here.

Very true. But if have high LDL, and high inflammatory markers, what's going on? And you really need to understand what other risk factors there are. We cannot determine risk on two points.

Bring this up when it comes to women. It's not just cholesterol and blood pressure and sugars and inflammation, which is what this HSCRP and all of these markers that you just talked about refer to.

And it's just the sugars. But in women, it is adverse outcomes of pregnancy, complications of pregnant, preeclampsia, gestational diabetes, things that women have often thought about or have been told.

Treatment is giving birth and then you're fine. Not the case. Any autoimmune diseases, rheumatoid arthritis, ulcerative colitis, anything like that, lupus that happens more often in women, that increases a woman's risk.

And this is the other thing, depression, anxiety. Depression has an increased risk of coronary artery disease, specifically in woman. PTSD increases the risk, so you give me an inflammatory marker and you gave me high LDL and then let me figure out the rest of the story is because then you're going to know what you need to do.

Do you find certain risk factors in men versus women different? So when men say testosterone levels are more predictive of high blood pressure or maybe you know cholesterol issues versus in women progesterone and estrogen imbalances or is it kind of uniform across both sexes?

You're again like bringing up this really complicated thing because I think one of the issues that happens is that and I see with my patients they'll get focused on that one thing like men will be like my testosterone it's the testosterone I'm like well I I don't know.

It might be that you need to lose 20 pounds. Do you know what I mean? Exactly. So we have to like look at the whole story. With women, it's so much more complicated because we go through this period of menopause, perimenopausal, right?

Which is like hormonal torture. You won't that, but I'm going to tell you. Touche. Good for you, lucky me. There's like literally this period of hormonal torture where you're like, I don't know what's going on.

I remember one of my patients saying to me, don t know, what s wrong with me. But I d n't recognize my own feet. And I was like but that was really like this, this feeling of like she was getting swelling.

All these weird things happen during perimenopause. And then you go through this thing called menopause, which literally is like one year from having a missed period.

That is how menoppause is defined. I personally think that is just like a ridiculous definition. Thank you. Yeah, I kind of agree with you on that one for sure.

It literally makes no sense, but okay, here we are. This is science and this is what we know right now. Exactly. What we understand is that through that period of perimenopause, there's drops in estrogen.

There's actually spikes in estrogens. It's like this weird dance and then you hit this one year after menstruation and there is a decline in Estrogen.

that literally can take 10 years. And so what you're talking about is, is it estrogen? Is it progesterone? It is all of that and testosterone for women and it depends exactly where she is in this entire like menopause conundrum.

I don't even know what to call it. It's a disaster. I could say a tornado, it sounds like. Yeah, some days. Some mornings, Some evenings it's better. You know, It depends on the day.

For men, its a little different than that, right?

Comprehensive Patient Intake and Testing

No, no, but yeah, big time. And again, so I'm curious, when you see a woman who comes in and she's kind of exhibiting all kinds of, you know certain symptoms that we all kind-of relate to.

When it comes to your actual diagnostic testing, what do you, are you doing just a cardiovascular? Are you going to throw some hormones in there? Autoimmune markers?

You looking for heavy metals? Like, like what, What do, do as a, as, a preventative cardiologist to really kind, of give the best first shot when it, comes, to, helping, Tell me your story.

That's the first… That is a good one. Very true. Exactly. Let the patient tell you. Yeah, tell me everything. I want to know everything and it's not just what you did the past five years.

What did you do 10 years ago? Tell about trying to get pregnant, telling me about pregnancies, miscarriages. Telling me all of it. Did you like chain smoke or are you still social smoking in the closet every so often, two or three a week?

Like, I just want to know all of it, you know? No, do you vape? Are you smoking pot? What's the deal? I want all. And I think that's where you start. Because in my opinion, we can test for 9 million things that are completely irrelevant.

you're going to miss the most important things. And so I do test for the basics and I look at sort of things in like eight different groups. It's like, tell me your genetics.

What happened with your family? Like who had heart disease? Who had Alzheimer's? Whose had diabetes? Whos obese? You know, what's the story? And tell their cardiovascular history.

Was there sudden cardiac death? Was their heart… you know I need all the… So that's where it starts. Then tell me your history. What's your deal? So for somebody who said, you know, I've had achy joints and I'd had some allergies.

You know you're going to start saying, hey, do I go down this? They're allergic. Maybe they have food allergies or their autoimmune diseases. That would be sort of the testing I would go.

If you start talking to them and they're like I've been great, I been fabulous, have a family history of heart disease, i'm fine. We're gonna check cholesterol, we're going to check blood pressure, you know, but for everybody I look at genetics, metabolism, And that goes down to what is your hemoglobin A1c?

How do you process sugars? how do process fats? That APOE I talked about, we want to talk about that. I want know your diet, I wanna know how you sleep.

Like all of those things go into sort of metabolism and inflammation. I want to test that. I wanna know any oxidized LDL. For sure, that's a huge one.

That's part of the inflammatory process, right? So we're gonna check all that in the blood. Then I'm going to go on to hormones and really understand.

But let's talk about hormones. There we go. Let's about the endocrine system. People miss that because hypothyroidism is associated with high cholesterol.

We gotta understand that piece of it also, right? Keep going through the process. Then I really want to understand the anatomy. So like we might have an understanding, hey, there's some calcium on the aorta.

Anyone else in your family have any aortic valve replacement? We got to make sure we check that. We've got a look at that also. You know, I really want to understand the anatomy and I want understand that physiology.

And this is something that most of us can do on our watches or our rings. I doubled up here. I was going to say you are a wearable queen there. You got everything going.

Wearable Queen. What we can look at is HRV. Really understand the sympathetic, parasympathetic nervous system. These numbers, these values really tell us who we are physiologically and they do matter in terms of recovery, in term of how you're doing.

If HRB is low, blood pressure is up, I'm going think of something like sleep apnea. Sleep apneas increases the risk. hypertension and atrial fibrillation.

If I see the atrium in the heart, we go back to anatomy, big. I want to look at for things like sleep apnea and hypertension. So you see this puzzle piece and how they all fit together and this algorithm.

One of the things that I'm just going to throw out there, as much as you go into ChatGPT, As much you understand about these numbers, it took about 12 years, just saying, for me to figure out what this You know I mean I think diagnostic testing is so important, but a lot of people miss what you take a good intake form You, know i mean like, what do you do during the day how, do?

You feel how do You sleep how's your sexual health all these different things doctors don't really understand and like you said how Do you feel as part of the most important things or what makes it better or worse?

So I think to be a true clinician, you have all these diagnostic tests, like with me, I test through the roof just because I want to know more about my patients than God does.

But at the same time, is I also have this gigantic patient intake form, which is asking everything, rating your sexual health, Which is also a gigantic portion when it comes to cardiology.

You know what I mean? Sex is usually the first thing to go, erectile dysfunction and all that kind of stuff. So it's super important to kind to learn.

It's interesting. Do you want talk about sex for a second? You came to the right place, my dear.

Sexual Health and Vascular Function

You know, because it's one of the things like no one kind of talks about except men. Like, you know. Guilty. We know erectile dysfunction is one of the first things that happen.

If a man comes in and says anything to me about it, and by the way, they usually do, it's like, okay, what's your blood pressure? So here's the thing.

And one in the tests that I do is a cardiopulmonary exercise test that is queried in a very specific way to look for microvascular disease. When a man has erectile dysfunction and he has normal coronary arteries or a normal stress test, it doesn't mean it's not from his vasculature.

It doesn' mean he doesn''t have a problem with his arteries. And I test for those small arteries I have, wow, what I was going to say was coming out so inappropriately.

Please go ahead. If that got clipped, I don't know. I've gotten more men over their erectile dysfunction than I can count. Put that in the book. is that, you know, improvement of their, their vasculature improves their erectile dysfunction.

And it might come down to treating their blood pressure and actually treating the cholesterol and their weight and sugars and guess what? Making sure that they're exercising in the right way for them.

Okay, what is it? I'm curious. Expand on that please. But exercise is like literally to me the most potent medication that we have. Okay. I love that.

Which type? High intensity, low intensity jogging, weight training, paddle ball. There's all kinds of different things out there now. That's part of what this is for.

So this like live in action heart rate monitor, right? So I want to finish the thought on the sex thing because women are underestimated in terms of their sexual dysfunction when it comes to their arterial health.

And I will tell you that it is equally as important in women in really desire, satisfaction, and all the other things. And when women go through this menopausal situation, one of the things that happens is, let's say, sexual dysfunction.

It is hormonal, it's physiologic, It's functional. and in men, its just more obvious. So we get what the problem is. Its easier to diagnose that one. And so when it happens in women and you're in a partnership and men just get mad, they just can't see it.

But it's for the exact same reason. So shout out to the women who are going through this and their male partners. Be a little more patient because it might just happen to you.

And you've got a pill to fix it and we don't. And there's no out there that actually does. It is very new, FDA approved, but talk to your doctors about it because it's real.

it is not in your head. You're not miserable. Tell your partner to calm down. you're working on it and go get help. Again, sexual health is almost wealth because again, like, you know, everything kind of leads back to that mental, physical, emotional, all that kind stuff.

You know if you have a good sex life, Everything kind gets a little bit better. And another important point is, so for the women who are watching this, what are some of the symptoms?

What would you classify erectile dysfunction in women? Is it pain with sex? is it poor lubrication? Like what? Decreased desire as a whole or all of above?

All the above. whatever your deal is, and if it's in the right time in life." It was so funny. I was talking to one of the patients and she's like, I really have no sexual desire with my husband.

And I said, okay, let's work through it. She goes, no, she actually thinks it was him. That's a super- I'm good, it is him, you know what I mean? I want to have it with other people, but not him- That is a very good gauge for all the clinicians, listen to this one.

And I bring that up jokingly, but I really think what I'm trying to say is that the conversations between partnerships, it's communication. And if you lose communication, you're going to lose this part of your relationship because it is a challenging time.

It is not an easy time and it not easy for women to really become different beings within the same body and that's kind of what's happening. No, for sure.

Plus, it's just such a sensitive subject. You know, I mean, like, you know it is a shot to the ego. It's kind of taboo in certain parts of the country, unfortunately.

And it shouldn't be. But when it comes to even menopause and erectile dysfunction and all of it, the way to actually keep your arteries healthy is through exercise.

So, if I'm going to tell you what longevity is about, It is really about figuring out the best ways to keep you arteries health and dilated. For sure, and we'll get into this a little deeper too, but how you do that fundamentally is exercising in that moderate intensity heart rate zone.

Okay, so I'm curious, moderate versus high versus low. So moderate is the way to go.

Zone 2 Exercise and Arterial Health

I want to explain this, doctor. Ready? I love it, let's hear it. Here we do it! We're gonna go into exercise physiology. Beautiful. Your heart only fills with blood during what we call end-diastolic filling time, when it relaxes.

When it's pumping, it does not fill with the blood. The arteries do not feel with flood, only when its relaxing. So when you're exercising like this, I promise you, you are going to go into anaerobic activity because your arteries cannot fill blood to deliver it.

That's aerobic. When the arteries filled with blood, the heart pumps it up. That, that's, aerobics. You're like this, you're going to go anaerobic and you are going develop lactic acid.

Your muscles hurt and your done. Now, if you, are in your zone too, and it's kind of slow and feels like you aren't doing anything, your arteries are filling with, blood and they are now, functioning in you aeróbics zone.

That's why you don't push too hard. And when you push to hard, you are dilating your arteries. It works on a really easy system. When volume goes in, pressure happens.

when there's enough pressure in the arteries, they start to get pushed and they dilate. Arterial dilatation is the sign of arterial health. So if you exercise the right way, your arteries start dilating and your heart becomes more efficient.

And you will not only have less erectile dysfunction, you'll have better sex across the board for both people. Win-win, I love it, that's fantastic. That's a circle right there, and I gotta say that was a perfect circle.

And by the way, you will have better brain function. You'll have more energy. Like everything, it does everything. It'll sleep better, gets rid of sleep apnea.

Decreases blood pressure, decreases cholesterol, all of it. So zone two is the way to go. So all this high intensity berries, bootcamp, that kind of stuff.

Kind of leave that to the side every now and then. Well, listen, I mean, high-intensity intervals do increase VO2 max. It's not your day-to-day activity.

it's your two- to-one ratio activity, you know, five minutes in zone 2, two and a half in high intesity, but that's super high intensity. You just don't do that as much or when you do it, it is for 30 seconds a minute and bring it back.

bring it back. All right, well good. Well, I gotta say, it's been a spirited discussion. We've covered exercise, physiology, sexual health, lab testing, pretty much everything under the sun.

But what I would always like to do whenever we come to the end of the session is ask my guests two questions. So here we go, all right? Number one, you are a preventative cardiologist.

That's kind of taking cardiology one step further in the right direction, What is some of your advice for anybody who's a healthcare practitioner, maybe a cardiologist that can see the value of preventative medicine being actually interjected into whatever endocrinologist, pulmonologist whatever it could be.

Could you kind of give some your tips and tricks as to what you've learned over the years on how prevention has actually helped you as a Cardiologist?

My gosh, I'm so lucky because I get to see people's lives change. I love, yes, very true. And I think it is the coolest thing to empower people to learn how to best take care of themselves.

How we do it, is through data. This is not a criticism of anyone in any way. I thing coaching is so important to help people become empowered. But what drives the understanding of how do do comes down to the science and comes to medicine and data and that includes those blood test results and the cholesterol, the inflammatory marker, sugar, all of it.

And to be able to implement medical science, data, and research and apply it to a human being to tell them how to become the healthiest they can, That is by far the most empowering way to impact these lives.

Prevention, Precision Medicine, and Finding Care

And I'm going to tell you, I've been doing this long enough and this is the only thing I love about getting older and having experience. It's that I get to get, to be a little bit more arrogant and confident.

Well, I love that. That's what you should be. Hell, that's very good. I'm saying no, no. It works. Trust. Proof is in the pudding. All right. Question number two.

For patients now who are looking to kind of steer away from the solely traditional factory pill, pill pill push, push push and who're looking into the wellness space and be like, maybe I want a physician who's going to look beyond just lab tests or whatever it could be, what's some good advice for patients who were looking at getting into wellness industry and find a practitioner who is actually going take care of their health as a whole?

Can I say, like, come find me. I'll tell you where to go and what to do. Even better. That's a good answer. Haven't had that one yet, so that's even better!

I mean, I've helped people all over the world actually, really figure out the best roadmap. You know, it's almost knowing what questions to ask your doctor.

Love that. And I really help people figure what they need the most. Again, there are so many ways to this. And it comes down to the individual. There is not an algorithm, one size fits all.

I believe in personalized precision prevention. So, you know, I'm around, You know? I have, come on social, have a website. Even better. Now comes the point where, tell us how patients can find you, get a hold of you.

Where's your book at, your social media handles. Tell us everything about you please. Dr. Suzanne Steinbaum's on my website. I'm on social on Dr Steinbombe, you know, and all the places.

Instagram, I actually just started TikTok. Yeah. But you know, on all of these things, and I kind of say this joking around, but I've gotten to this point in my career where, wow, this sounds great.

I'm a little ahead of where everyone else is right now. And so I am really in this position of saying, help, I got a question. It's getting to the point, hey, we'll do Q&A.

We'll figure it out. Because I think that patience, if you're listening, You're consumers now. You got the message. And especially the women out there.

This has been the year of women saying, we don't like it anymore. and it's time that we have that same conversation regarding heart health. I'm all for it.

All for taking women in total to that next place of let's demand having personalized precision prevention the way we deserve it I'm a fan of that for sure.

I gotta say it's been an absolute delight today, cardiology. It's obviously the root of everything health-wise. So I mean, I am so happy to have somebody such as yourself on the show, so thank you for stopping by.

And again, maybe we have to do a part two because I sure there's a lot more information we could have got into. I mean, there's definitely other things besides the main things that we talked about.

What we talk about was fun. I got I'm not going to deny that one. But again, guys, it's the lifestyle medicine podcast for power by access labs. If your doctors not checking your labs, they're not your doctor.

Check us out on Apple, Spotify, YouTube, anywhere that this is, you know, and anywhere they show podcasts as you'll find us. Dr Steinbaum, thank you so, so so much.

It's been an absolute pleasure having you today. Thank you. Thanks for joining us today on the Lifestyle Medicine Podcast. At Access Labs, every innovation we pursue is driven by one bold purpose, making personalized medicine more practical and accessible for patients and providers.

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Suzanne Steinbaum, MD

Matters of the Heart: Women’s Cardiovascular Health and Longevity