004 - Your Lab Results Match… Your Heart Disease Doesn’t: The Gender Gap You Can’t See | ClearCardio

Welcome to Clear Cardio's Prevention is Power podcast, where we help you take control of your health and protect your future. I'm your host, J.D. Enright, and today we're diving into a topic that impacts everyone: heart disease. But here's the twist: it doesn't impact men and women the same way. When you think about heart disease, most people picture a middle-aged man clutching his chest. But did you know heart disease is the number one killer of both men and women? And the symptoms, risks, and even outcomes can look very different depending on your gender? Joining me to unpack this critical conversation is the brilliant Dr. John Osborne, a Harvard-trained cardiologist who has dedicated nearly 3 decades to preventing and treating heart disease. Dr. Osborne, welcome to the podcast.

Thank you so much, JD. It's such a pleasure.

Great to have you here. So really, men and women, the gender thing, it's really that different?

Yeah, it is and it's not. Okay. As you said, and it's absolutely true, as far as if you lump together things that plaque in our arteries causes, right? Heart attacks, but also strokes, right? Those 2 things, heart attacks and strokes, kill over a million US, people in the US every year. And it's basically pretty evenly split when you lump strokes and heart attacks together between men and women, right?

So like a 50/50 ratio? 50/50.

Now, as it turns out, a little bit more guys than girls, women, will die of a heart attack. A little bit more women than guys will die of a stroke. But if you lump those 2 things together, that's a million deaths a year, which by far is the leading cause of death in the US, which is roughly 40% of all deaths. Some, depending upon the estimates, go up to about 52% of all deaths. But needless to say, is greater than the next 7 causes of death combined.

Like cancer?

Yeah. Really? Yeah.

Infectious disease and—

HIV, motor vehicle accidents, COPD, diabetes. All those things lumped together, heart disease kills more people than the next 7 causes of death combined.

I'll bet you most, most people don't know that.

No.

Yeah. And so, so, okay, so men, more heart attacks?

Yeah. Overall, overall, a few more heart attacks, death, deadly heart attacks in men, a few more deadly heart attacks and strokes. But again, Plaque-derived diseases, atherosclerosis or plaque, again, is by far the largest preventable killer. And unlike that, right, you think about cancer. Well, how many cancers can we say, oh, we can detect it 20 to 30 years before you get the cancer and do X, Y, and Z and you won't get it?

You can't now, can you? No.

Not that I'm aware of, unfortunately.

Imagine that. That would be amazing.

Oh, I agree. But that's why I love being a preventative cardiologist, right? Because we already have all the tools in place, and they're only getting better and better, but all the tools are in place right now, today, to diagnose plaque years before you have symptoms, before you have a heart attack or die from a heart attack or stroke, or before you need stents or balloons or surgery. Or before you keel over dead. We have all of the tools available for early detection, and we have an incredible array of tools that I call anti-plaque tools, things that treat plaque, things that reverse plaque. And so ultimately, I think we really do have all the tools, and admittedly, they're only getting better and better, but I think we have all the tools available.

Yeah.

Particularly here at Clear Cardio.

Yeah.

To really completely change the face of heart disease.

So let's just stop there. That's fantastic. Knowing that there's such a difference between men and women, when I think of a heart attack, the first thing that pops in my head is, again, like when we opened up the podcast, would be an older gentleman clutching his heart, falling down dead. Things like that. I understand most men pass away from heart attacks in the morning, like after when you know before they wake up in their sleep or just after they wake up for a number of reasons which we can talk about in some other podcasts. But but you know I don't think about women necessarily dying of heart attacks and strokes for whatever reason. And and now we're talking about the fact that that it's about fifty fifty. Right? More men with heart attacks, a little bit more, and a lot of women with heart attacks and strokes. And so recently, I understand that you had both a husband and wife come into the Clear Cardio Clinic, and you, I guess it was, it really, it changed the way I understood the dynamics between gender, heart attacks, and strokes. Can you elaborate a little bit on what you found with that husband and wife when they came in?

Yeah, absolutely, JD. A fascinating story encapsulated in a couple, in 2 people. So, to set up the story, these individuals, one's 56, the other's 57, no prior history of symptoms, problems, issues, whatever.

Now, I'm 57. So, It hits home.

Getting close to home, right? Yes, very close to home. Exactly, right? So feeling a little nervous out there? Okay. This is you. So again, no symptoms, prior issues. And what was fascinating was, for me, now I have to admit it to everybody. So in my training and fellowship and all that stuff at Harvard, I spent 2 years in the Harvard medical school Department of Genetics, right? So I always had this tremendous appreciation and interest in the genetics of cardiology, right? So as it turns out, both of them had very high cholesterol.

So the husband and wife come in and they both have high cholesterol. Yeah, very, very high. Okay, so they come in looking similar from a blood work perspective.

Exactly.

Okay, got it.

Yeah, so their cholesterol levels, both high, right? Enough, you know, clearly both of them says, hey, we got an issue. And so what we did, of course, they came to Clear Cardio. And the first thing that we start out with, beyond a history and physical and all those things, genetics and family history, is we put them in our scanner, right? So we did their scanner, we did the AI. And this is where mind blown, right? Now I know this, but it was really fascinating to see this reflected in a couple. So appreciate, you've got a couple, they've been married a long time, same environment, neither smoke, they're eating the same, exercise is the same. Cholesterol levels, both very high, not that terribly different from one another, but both very high.

So from the outside looking in, you would expect them to have the same situation going on internally, right?

Exactly.

They've got high cholesterol, they're married, so that means their lifestyles are probably very similar.

Precisely.

Right? Their eating habits are very similar.

Age.

Yeah.

A year apart.

Yeah. And they're older, so they've probably been married quite a while. So they're into that whole thing, the similar exercise. So that's a really good baseline case study.

It is.

Right? That takes us to the next step is like, okay, what's the difference in gender here? So what's like— so yeah, keep going.

So we looked under the hood, as I like to call it, right? We did the scan and what was—

Okay. So what does that mean, looking under the hood? For those of us who don't— Sure.

Okay. So we looked under the hood, that is, we put him in our scanner, our first of this type of scanner installed in North America that I'm very proud about. A 640-slice scanner. I started out 20 years ago with a 64-slice scanner. We're now up to 640. Wow, okay, yeah.

Turbocharged.

Beautiful pictures, low radiation, all those things. We did the scan, but there's really 2 parts. We do the scan, so that gives us the data, the 3-dimensional high-resolution data. Then we feed that up to the cloud and do this incredibly phenomenal AI analysis of that data.

Of the imaging, right?

Exactly.

So it's this incredible AI-powered tool.

So with AI, literally it shows me things that I cannot see with my eye.

Got it.

And quantifies it. So I can tell you exactly how much plaque you have. In your whole heart, in each vessel, in each segment.

Got it.

Stuff that we could not do just until— up until just a few years ago.

Wow, fantastic. Okay, so now—

So that's looking under the hood.

Okay, so you've looked under the hood, right? For all intents and purposes, outside looking in, these people are husband and wife, been married for a long time, similar background, high cholesterol, everything looks similar. You've looked under the hood, now what?

Okay, so I'll start with the wife. So we put her in the scanner, we look under the hood, and a little background. Literally for years, they've been harping to her about her cholesterol, right? You got to get on a drug, your cholesterol's high.

These are other doctors?

Other doctors, right, before me. Harping on that and saying, gosh, your cholesterol's high, going to kill over die, whatever. Which, you know, high cholesterol definitely can do that. But here's where you got to listen closely, because this is a phenomenal example—

I'm all ears.

Of what happens all the time.

Yes, I'm listening.

But you got to get on a drug, right? She didn't want to be on a drug. I respect that. So what we did is we didn't push to say, hey, cholesterol's high. We knew that. We said, let's first of all not see what the cholesterol is. Let's see if you have the disease.

So you looked under the hood.

We looked under the hood, which no one had ever done.

Okay. Right. TailClear Cardio. Right. You.

Yeah.

Got it. Okay.

So we looked under the hood. We do the AI. She had an incredibly small— the AI did detect some plaque. Now, I will admit to you, over the last 25 years, I've done probably at least 20,000 cardiac CTs, so reasonably experienced. By eye, her vessels looked fine. I couldn't see anything.

Wow.

Now, the AI did detect a little bit of plaque.

Okay, so it's starting to emerge. It's like—

It's stuck, right?

Just starting to build up, right? Or the onset.

Exactly. My favorite analogy, cardiac CT is the cardiac colonoscopy. Let's find the polyps, take care of the polyps, you don't get the cancer, right?

Got it.

So, if you want to use that analogy, at the very limits of our being able to visualize it, we saw a little itty-bitty teeny tiny polyp in someone who'd had literally decades of high cholesterol that they had previously observed and had hammered her, you got to be on a drug.

Which she refused.

Which she didn't want to be on.

Okay.

So we did her scan, and here's the beautiful thing, right? She doesn't want to be on a drug. I get it. I don't want a drug unless it's going to benefit me. And I said, okay, the AI detected a very, very small amount of plaque. But remember, this is after she's 56.

Okay.

56 rotations around the sun, walking around with that genetically high cholesterol. The net manifestation as far as plaque, was very small.

So limited. So not— there's no risk of heart attack or stroke, really?

Not in the near term.

Okay, fair enough.

So I gave her a choice. I can lower your cholesterol by 70% cheaply, easily, highly effectively, highly quickly in 2 weeks. And I will admit to you, lower cholesterol always wins. Cholesterol is the fertilizer to plaque. Hers was genetically driven, had nothing to do with what goes in her mouth, exercise, etc. I like to say she chose the wrong ancestor.

Yeah, fair enough.

Ancestors, right?

And we talked extensively on another podcast about that genetic stuff and also what plaque is and where it builds up and all that.

So I encourage you, if this is your first one, look at our—

Yeah, go to one of the other podcasts because it's really mind-blowing to find out what actually causes heart disease.

Well, now I'll give you a few minutes to do the deep dive and then come back. Okay, so you've done that. Now you're all up to speed.

Okay.

So what was fascinating, and I've certainly seen this, right? is that if you looked at cholesterol, it says this is a high-risk person and, you know, get on a drug. I actually looked at her heart and looked at her plaque. Yeah, she has a little tiny bit of detectable plaque. Plaque is a slow glacial process, right?

Mm-hmm.

It takes decades to get to the point where we have symptoms, chest pain, angina, flunk a stress test. But by then, by the time you have symptoms or flunk a stress test, assuming you haven't already had sudden cardiac death.

As the first symptom.

Yeah.

Which we know is pretty 50% or something.

Which occurs in about 50% of people, right? But let's just say you didn't have sudden cardiac death.

That scares the hell out of me, by the way.

It should scare the hell out of everybody.

Yeah.

Right?

Like the first symptom is you just drop dead.

Yeah, thank you for backing me up on that feeling.

Yeah.

So it is a slow glacial process. So I gave her a choice. I said, yes, I can quickly, easily, safely lower the cholesterol. We have the tools, the drugs, whatever. We can do it in 2 weeks. That's great.

Okay.

That just turns off the faucet for plaque.

Okay.

The other option, and the outcome is going to be over the next few years exactly the same. Yeah, we did detect a little tiny bit of plaque, less than I can see with my eyes, but the AI did its magic. And the other option is eat right, exercise. I tell people, don't start smoking, right? Don't start doing bad habits. And let's put you back in the scanner 3 years from now. And see what you look like. And then we'll know. And one of the other tremendous attributes of AI is the ability to absolutely quantify plaque. We can measure it down to a 10th of a cubic millimeter, which by the way—

It's incredible, actually. I've seen my scan. I'm your patient. So for those of you who don't know, I'm also a Dr. Osborne patient. And so I've seen my scan.

Not only am I the president of the Air Club.

I'm also a member. Yeah. I've seen my year-over-year scan, and it's tremendous reduction for me. You saved my life. So, okay, so, all right, so that's her.

So the other option was kick the can down the road. It's not going to go to a 70% blockage, cause issues or problems in a fairly short period of time. We put you back in the scanner. If it's progressed, we have another discussion about maybe there's a bigger role for drugs.

But she has time.

Yeah. Or if we see it's stable or whatever, then We can keep kicking the can down the road. And so she was very happy about this. Okay, so that's her.

That's her. So that's the wife.

Yeah. Okay, so here's a case where you need drugs and we said, no, we can safely not do that. Right.

Okay.

With what AI told us. The husband, 57.

Basically the same age as her.

Same age. Cholesterol a smidgen higher, but we're talking very high and Very, very high.

Right. Okay.

But really a smidgen higher than her, but basically the same. Again, genetically high cholesterol, no symptoms, chest pain, angina. So we put him in the scanner. And so we now can stage plaque like we can stage cancer.

Through the AI analysis?

Through the AI.

Okay, fantastic.

You couldn't do it before AI with the absolute reproducible, validated, Very accurate plaque quantification.

So what was she? What was her stage?

Okay, so her number was— her plaque amount was 38 cubic millimeters, which doesn't mean anything, but that is stage 1. So stage 1 means anything from not 0, so 1, up to 250.

Okay, so she's at the very beginning of arteriosclerosis, which is, you know, heart disease, causes heart disease. It's plaque buildup, right? Very early, so stage 1. Yeah.

Or like a polyp. I saw a teeny tiny little polyp.

Okay, got it. Now you're looking at him.

We put him in the scanner. His total plaque volume was 658 cubic millimeters.

Wow, that sounds like a lot.

It is. And he had one vessel that was about a little over 70%.

Okay, so same lifestyle, same diet, same age.

Same cholesterol.

Same cholesterol levels, all of that stuff. Yet he is a stage what?

He is stage 3.

Stage 3.

Mild, moderate, severe. Stage 3.

Severe.

Severe.

Okay, so he has a lot of plaque.

This is a major red flag. Major interventions need to be undertaken. Fortunately on the medical side, not on the mechanical side.

So when you say mechanical, for those of us, that means intervention like stents and balloons?

Balloons, stents, bypass.

Bypass surgeries.

I mean, our goal is to, Identify this early, take care of it. Yeah, we don't want that. No. Right? So he needed a major intervention, not on the mechanical side, but on the medical side, right?

Wow.

So stage 3, severe, 658 cubic millimeters. And most all that plaque he had, because with AI we can differentiate it into what we call the hard plaque, that's the calcified plaque, that's old plaque, no longer really active, right? That's the extinct volcano. Or more worrisome, more concerning is the lava, right? All lava is the initiation of all volcanoes. The lava, the active stuff, the lipid plaque, the soft plaque. So the vast majority of his plaque, 1/3 of his was the extinct volcano, the cinder cone. Eh, don't sweat it too much. 2/3 was the lava.

Oh boy. So really high risk.

Really high risk.

So, so okay, Wow. And that's a gender thing from what you're thinking, right? That's what I'm hearing?

Well, partly gender, but I think the takeaway here is you just don't know until you look under the hood, right?

Yeah, I got it. And so are there risk factors that are more dangerous for men than women and vice versa? Are there risk factors that are more Like, that would indicate higher disease or plaque on women than men? Are there any differentiation in the risk factors?

Not really.

Like blood pressure and cholesterol?

No. They're all bad, but you still don't know. And this is something that confuses a lot of people, a lot of docs, a lot of my colleagues, and a lot of— just everybody. Yeah, I'm confused. Well, remember, There's a big difference between risk factors. Those are things that potentially, possibly could cause plaque and heart disease versus the actual disease. So they're a beautiful example. So imagine this, when we measure cholesterol, we're measuring how much cholesterol is floating around in the blood. Tells me nothing about is it sticking, right?

Mm-hmm.

So they both had high amounts of cholesterol floating around in the bloodstream. In him, it was sticking like crazy, and in her it wasn't. Okay? So there are other factors, there are genetic factors, et cetera, but you don't know unless you actually look to see and see if you have the disease.

Over time, has there been any— just for the audience who's watching, should women be looking at things, risk factors, in a different way than men?

Yeah. So let me tell you some very important differences in kind of risk factors that I think everybody should be aware of. Most people aren't. A couple things. One, with women, if you're a woman and you got pregnant, right, a lot of things about pregnancy give me an insight into what will happen or your risk 20 or 30 years down the road.

Really?

Yes. So if you develop gestational diabetes, diabetes during pregnancy, right? Which is not uncommon. Blood sugars get out of whack. There are genetic and environmental factors. Your blood sugars get out of whack and we take care of it. They deliver and then the diabetes go away.

I was just going to say, it usually goes away.

And they go, whew, close call. We're all good.

Yeah, exactly.

No. So those women that develop gestational diabetes, 20 to 30 years down the road, long after the pregnancy, by the time their kids are adults and Yeah. Out of the home, it is a higher risk, is a very high risk for both diabetes and heart disease.

No kidding.

The same thing too with high blood pressure. If you develop high blood pressure during pregnancy, or also called preeclampsia, or preeclampsia and toxemia, these are all things that can occur during pregnancy, all of which involve high blood pressure. Bad for her, for the woman who's pregnant, Really bad for the baby. Many times the baby has to be delivered early, right? Or C-section, et cetera. That then generally corrects the blood pressure. Blood pressure comes back down. They say, everything's good, move on. Guess what? Those women, 20, 30 years down the road, are at very high risk for high blood pressure and also heart disease too.

Got it. So with pregnancy—

These pregnancy changes tell you a lot.

And men don't get pregnant. So that's a very different thing, right? So that's an indicator.

Yeah.

And is there anything on the men's?

And another thing, one other thing with pregnancy, if you deliver early, premature delivery for whatever reason, again, that's a risk factor down the road for heart disease.

No kidding.

So this is important. When I talk to women, these are always things I ask about.

Interesting. You'd never think to think that. And so, wow.

A couple other things between the two. Remember I said they're basically the same age. So here's what happens with And when I say heart disease, I really mean plaque. That's strokes and heart attacks. Men are about 10 years earlier into the game. Okay?

So they, on average—

On average.

They start building up more and more plaque earlier.

I'm showing, yes, but also really I'm talking about events, right?

Okay.

Oh, heart attacks, strokes, 10 years earlier. Really starts hitting about mid-50s, right? But of course, the plaque has been there for decades, but we start Historically, how we define heart disease is we wait till you have an event.

Do we know why that is? Why men have heart attacks and strokes younger?

Well, we believe, I think it's a complicated story, but we believe that, yeah, I mean, men and women are different, right? Hormones and hormonal processes are obviously quite different. So we believe that probably because of the effects of estrogen and progesterone and maybe other factors too, but that's an easy thing for differentiate this, that those can be beneficial to women. But interestingly, so it really, the curves for heart disease really start going up in early to mid-50s for guys, right? For women, they catch up though, 10 years later.

Got it.

So after, so there's guys go up.

Curve, yeah.

And then women start, and then by 65, women are having just as many strokes and heart attacks as guys.

No kidding.

Right?

Wow. So, this is—

So, age is always a risk factor, right? It is a powerful risk factor. I can't fix age, though.

Got it.

I can fix all these other things. I can't fix age. But I think that's probably one of the differences between men and women. Hormonally different environment. But again, once women go through menopause, wait a few years, they rapidly catch up with men.

Fair enough. Okay. We started this podcast, you know, identifying or wanting to discuss the, the differences between gender, men and women, and heart disease, heart attack, stroke, plaque buildup, things like that. Um, and we've explored, you know, actual patients that you've seen who came in, husband and wife, married for many years, in their 50s, 56, 57 respectively, very similar diet, exercise background, things like that. Risk factors were very similar with respect to you know their cholesterol levels, things like that. Yet very different outcomes at the end of the day. And so that really goes to show you until you know you don't know. And that's why it's important to go out there and see that. And it's also for women who are watching this. You know if again if you've had any of those things that Dr. Osborne spoke about with respect to you know. Early delivery in pregnancies, pregnancy-induced gestational diabetes.

Diabetes during pregnancy.

Yeah, things like that.

Preeclampsia, premature delivery. Those are important factors, risk factors. Those are risk factors that are documented. Unfortunately, most providers don't know it. So you're clued in. You know now more than most providers.

And I'm sure we'll talk about this more in the future. But this has been eye-opening for me. I had no idea there was such a difference in genders and how the risk factors impact them and things like that. And if there was anything, in closing, if there was anything you would say to both men and women alike, from your position as Chief Medical Officer at Clear Cardio, as a preventive cardiologist, as a lipidologist, and all the other -ists and acronyms and things that you have, What would you tell them right now? If you've got a captivated audience, what would you tell them right now is the most important thing they need to do in order to take control of their heart health?

Well, let me start with this and say, with the ability now to do these high-resolution, 3-dimensional CT scans, now coupled with the power of AI, for me, it's very humbling, right? Because you'd think after 30 years, my Spidey sense is pretty good. Who has plaque and who doesn't?

Yeah.

I'm going to say, I never know until we look under the hood.

Yeah.

So for anyone out there that's worried, concerned, and frankly, you should be a little worried and concerned. Cardiovascular disease still, by far, is the number one killer. And you just don't know until you see if it's there.

Yeah.

Risk factors are risk factors. That's not disease. I can show you people who look perfect, who have gotten bypass surgery at age 33, and other people that I'd go, oh my gosh, I mean, this guy's gonna need bypass surgery, and have no plaque whatsoever. So just like colonoscopy, we don't gamble our lives saying, well, I think my colon's fine, I don't have polyps, right? No one would gamble that. No one will take that bet. I wouldn't, right?

Yeah, I didn't.

So exactly right.

Yeah.

And as I love to tell people, I'm not here to save your life from cardiovascular disease, by far the biggest causer of death in the US, only to have you die of a stupid preventable disease like colon cancer. Okay, so you got to do all that.

Yeah.

However, cardiovascular disease is still the leading cause. Yeah, still statistically the greatest likelihood of what will take you to your grave. And the great news is, and this is why I love being a preventive cardiologist, having the tools we have now today, Is it is almost completely eliminatable.

Yes. Well, that's a perfect segue into wrapping up this fantastic, insightful, um, podcast. Dr. Osborne, thank you for coming out again, um, and educating me and educating our audience. Um, I'd like to thank all of you, um, who've been hanging in there for this very insightful podcast for joining us today, uh, on another Clear Cardio podcast with Dr. John Osborne, myself, JD Enright, and please reach out, check us out, give us a call, and set up an appointment to come out and visit Dr. Osborne and the Clear Cardio team and take control of your heart health.