Advance with MUSC Health

Heart Disease in Women with Arasi Maran, M.D.

December 05, 2023
Arasi Maran, M..D.

Heart disease is the number one cause of death in men and women. Yet, recent data shows the majority of American women don't realize that heart disease is the biggest threat to their health. In this episode, Arasi Maran, M.D., an MUSC Health interventional cardiologist, dispels some myths about women and heart disease and shares ways women can take charge of their heart health.

“(Women) may not necessarily have exertional symptoms. They may have symptoms at rest. sometimes even in their sleep. So, it differs in that way. And women tend to have more silent heart attacks because the symptoms are not super dramatic.”
— Arasi Maran, MD

Topics covered in this show:

  • Dr. Maran says there is a historical misconception that heart disease is primarily a man's disease. One reason is because in pre-menopausal women, estrogen offers extra protection from heart attacks. But new evidence shows that adult women of all ages can be at risk, and one in every five female deaths is due to heart disease.
  • Women can present with atypical symptoms of a heart attack such as nausea, vomiting, fatigue and shortness of breath, which can lead to late diagnosis.
  • Silent heart attacks are also common in women with symptoms that can be subtle and overlooked by both care providers and the women experiencing the symptoms. She says women should not dismiss new discomfort during everyday activities, such as walking or suddenly feeling exhausted and should seek a second opinion if they feel their concerns are not being addressed by a doctor.
  • Common risk factors for heart attacks in women include uncontrolled diabetes, obesity, smoking, physical inactivity and uncontrolled blood pressure. In particular, Dr. Maran says smoking can be very damaging to heart health in women.
  • While coronary artery disease is the traditional form of heart attack, heart attacks can also happen in the absence of severe blockages in the blood vessels.
  • Managing stress, exercise and eating healthy are all essential to good heart health, but Dr. Maran says you shouldn’t overhaul your lifestyle overnight. Incorporating small changes can add up over time to a heart-healthy lifestyle.

Read the show transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Heart disease is the number one cause of death in men. and women. Yet recent data shows the majority of American women don't realize that heart disease is the biggest threat to their health. Today's guest, Dr. Aarsi Maran, is going to help dispel some myths about women and heart disease and share ways women can take charge of their heart health. She is an interventional cardiologist at MUSC Health and this topic is near and dear to heart. Thank you so much for joining us today.

[00:00:50] Arasi Maran, MD: You're very welcome. And I'm really happy to be here and talk about this topic.

[00:00:53] Erin Spain, MS: Tell me about heart disease and women, and why has it been historically and wrongly thought of as a man's disease?

[00:01:01] Arasi Maran, MD: So heart disease is extremely common in women too. One in every five female deaths happen because of heart disease. So it's very common in women. When you have heart attacks because of blockages to the blood vessels of the heart. It is seen more in men, and women until their menopause have some protection from the estrogen, and therefore it was thought to never to happen in women. But times have changed and heart disease has evolved where you get heart attacks because of blockages, and sometimes not necessarily because of blockages too. And as we have been growing and learning and educating ourselves, we realize it is not a man's disease. It's a disease of all human beings who are living in this ultra-processed world.

[00:01:47] Erin Spain, MS: Tell me, what are the most common preventable causes of heart attacks in women?

[00:01:53] Arasi Maran, MD: It is still blockages to the blood vessels of the heart or coronary artery disease, and women usually have the same symptoms of chest discomfort. Just please realize I'm using discomfort, not chest pain, chest discomfort, chest tightness, pain in the neck, radiating, etc. Apart from that, women are also more likely to have atypical symptoms such as nausea, vomiting, fatigue, difficulty breathing or shortness of breath. And they may not necessarily have exertional symptoms. They may have symptoms at rest. sometimes even in their sleep. So it differs in that way. And women tend to have more silent heart attacks because the symptoms are not super dramatic.

[00:02:35] Erin Spain, MS: Tell me a little more about the silent heart attack.

[00:02:39] Arasi Maran, MD: Let me just kind of narrate a story. Like, let's say a woman normally walks a block in 20 minutes or something like that. And suddenly, she notices it's taking a longer time, and she's taking frequent breaks, but she's going to still finish the block. She will find reasons. I'm just tired. I didn't sleep well. I'm exhausted, but I still should be able to do that. So they kind of don't think that when they can't complete a task because of discomfort that there's something physically wrong with them, and they don't tend to take care of their health. They're usually the primary caregivers, and they don't prioritize their own health.

[00:03:16] Erin Spain, MS: So what are the risk factors for heart attacks in women?

[00:03:20] Arasi Maran, MD: The usual risk factors are uncontrolled diabetes mellitus, obesity, smoking is a forest fire in a woman's body compared to the men, physical inactivity, drinking, uncontrolled blood pressure. Women think just because they're on the move all the time, that they are actually being extremely physically active, but they are on the move taking frequent breaks and they may not be actually reaching a target heart rate or actually doing meaningful exercise. So physical inactivity adds a big component to them. Diabetes is, you know, another silent killer.

Diabetes itself gives to silent heart attacks. Women who are diabetics, it's like a double whammy kind of a situation. So having excellent blood sugar control and fixing your diet, most women are busy taking care of families, working, and fast foods have become the way of living. And, you know, and that just leads to extremely ultra-processed food intake, which causes an inflammatory response in the body. Smoking. Somehow the nicotine affects the endothelium, the cells which line the blood vessels, very differently for women than men who are exposed to nicotine. It causes endothelial dysfunction, it causes microvascular dysfunction.

So, it basically leads to heart attacks in the absence of severe blockages, and the blood vessels also shrink up. And women already tend to have slightly smaller blood vessels compared to men. And when they shrink up, the blood vessels are not even big enough for us to put stents if we want to. So it kind of puts us in a rock and hard place situation, and ultimately, we end up only giving the medications. Medications are effective. But sometimes it's not enough and we are not able to give them more because of the way the blood vessels have just pretty much pruned up because of the exposure to nicotine. So, please stop smoking. Please stop vaping. It's just a fancy smoking. Please do not. If you haven't started, don't start. If you are, please stop.

[00:05:22] Erin Spain, MS: You know, you mentioned before that there's some protection that takes place maybe before menopause in women, but there are certain points when they are at more risk of a heart attack. Walk me through those points in life.

[00:05:34] Arasi Maran, MD: So while coronary artery disease is the traditional forms of heart attacks, but heart attacks can also happen in the absence of severe blockages in the blood vessels. It's actually called minoca myocardial infarction with non obstructive coronaries. In layman's language, your blood vessels look great, but you're still having a heart attack. It is more common and frequently seen in women, and it accounts for 43 percent of all the heart attacks in women. And some physical groups, such as pregnant women, can get spontaneous coronary artery dissection, which can lead to heart attacks in them.

And then there are some women less than 50, the middle-aged women who can also get coronary vasospasm, where the blood vessel contracts for whatever reason, and you can get microvascular dysfunction where the meeting point of the teeny tiny arterioles and venules and the capillaries, you can get dysfunction there, and you get pain and heart attacks because of that. And these are all way more common in women than in men. It's just not blockages which can cause heart attacks. And then we have the broken heart syndrome or the Takotsubo cardiomyopathy, where a sudden physiological response can kind of stun your heart and cause a heart attack and also weaken the heart muscle.

[00:06:55] Erin Spain, MS: Can you give me some examples of those types of stressors that you know of and you have seen?

[00:07:01] Arasi Maran, MD: I've had bad news coming on a phone call to someone switching their diet all of a sudden to an extreme low-calorie diet and things like that. So it can happen anytime, you know, it's not like "a" stressor is connected to the heart disease. It's just the body's response to it. And most of the time we may not even be able to identify the stressor itself.

[00:07:23] Erin Spain, MS: I just want to talk a little bit more about stress. And you mentioned before, so many women are so busy doing so many things, wearing lots of hats and taking time to exercise and eat right is important, but controlling stress is really important too for heart health. Isn't that right?

[00:07:39] Arasi Maran, MD: Absolutely. One of the most common risk factors for heart disease is being a type A personality. And what do type A personalities have? Extreme amount of stress. So, managing stress is crucial, and I think now we are more aware of it and the mindfulness movement has come in, and it's taken away religion and meditation away and mindfulness is independent of all religion. I think it speaks to more people than meditation or something like that.

[00:08:07] Erin Spain, MS: So your specialty is an interventional cardiology. Explain that to the listeners. What is it exactly, and why did you choose to go into this field?

[00:08:16] Arasi Maran, MD: Well, to put it in simple terms, I'm a glorified plumber. So when there is a blockage in one of the blood vessels of your heart, I get into the blood vessel and I pass a wire and use a balloon to kind of expel the blood. Banned the blockage and to put a stent in so that the blood vessel stays expanded. I specialize in blockages, which have been there for a long, long time, more than three months. It's called chronic total occlusions, where the blood vessel is completely shut down. But it happens over time, and because it happens so slowly, the patients don't realize, and the symptoms are way more subtle, so I focus on blockages which have been there for a long time.

[00:08:56] Erin Spain, MS: Tell me about some of the women you treat. What are their demographics?

[00:09:00] Arasi Maran, MD: It's a wide range. Sometimes I have a lot of young women coming to me, and they feel they're not taken seriously, and, uh, they seek out a female interventional cardiologist, and the example I can give you, which is near and dear to my heart, is a 36-year-old mother of a teenager who had open heart surgery at 36 years of age because of severe blockages and kept having chest pain and kept having chest pain and was discounted whenever she went to the emergency room or even when she was hospitalized.
Literally, Google searched me and found me, and I took her to the cath lab, and all her bypass grafts had failed, and we had to put stents in her and to make her feel better and... She has a 13-year-old daughter, and she was holding my hand and crying how her life has changed because she couldn't work. She has to go to work, and she couldn't work because of chest pain. And that was quite dramatic. And then I also have elderly women, like 60-year-olds, whose only symptom will be "I'm not the person I used to be, and I'm having profound fatigue. Is it in my head, or is it really there?" And, uh, you go investigate, and they do have significant blockages or you just need to change the medications because patients who don't have blockages but who still have heart attacks are a different population. They need a different set of management.

[00:10:20] Erin Spain, MS: What would you encourage a patient to do who might be experiencing some of these symptoms?

[00:10:24] Arasi Maran, MD: Advocate for yourself. Whether it is me or some other physician, just don't take what they say without doing your own background research. And if something is not right, something is not right, and you have to find a good reason why it's not right. And usually, there is a workable, manageable solution. It will not be a magical wand all the symptoms will not go away. But there should be a workable solution. And if the solution is not working for you, don't give up and accept life the way it is, but instead, get a second opinion, get a third opinion, talk to your other counterparts, and don't suffer in silence.

[00:11:00] Erin Spain, MS: Do you think if there were more women cardiologists that there would be more awareness about heart disease in women?

[00:11:08] Arasi Maran, MD: We don't need women doctors to increase the awareness. We need good doctors to increase the awareness about heart disease in women. Women's heart health is not a women's problem. It's a problem per se. So I think it's the responsibility of everyone in the medical field to provide equal care and know the pathophysiology of the diseases you're treating. And it's a knowledge gap more than a gender gap.

[00:11:35] Erin Spain, MS: MUSC Health offers a lot of treatment options for folks in cardiology. Tell me about some of the invasive and non-invasive treatments offered.

[00:11:44] Arasi Maran, MD: So we have a very robust group of cardiologists who are all committed to the heart health in women. All our cardiologists are committed to the cause. So we have excellent support system. We have, from the non invasive side, we have excellent cardiac imaging. Our cardiac imaging department, we work very closely with them. We also have our very robust cardiac catheterization labs where we do our angiograms, that is, take pictures of the blood vessels of the heart. We do intravascular ultrasound to measure the thickness of plaque, et cetera.

Spontaneous coronary artery dissection, sometimes you can diagnose them only under intravascular ultrasound. We have that. We have excellent, all the latest technology for management of calcium within the blood vessels of the heart too. We have all the best tents available nationally and internationally. So all the tools and the tricks and, you know, we all have it. We have a very strong structural program for valvular heart disease. And we also have the Hypertrophic Cardiomyopathy Program, which is internationally renowned. So we truly have the best folks and MUSC Heart taking care of our community here.

[00:12:56] Erin Spain, MS: What are some really specific things that someone listening could do starting today to make just a little improvement in their heart health?

[00:13:04] Arasi Maran, MD: I would say don't try to change everything today. Just try to change one thing today. Maybe eat a better breakfast or eat a better lunch or skip a drink tonight. Just start with one thing. And once you have mastered that particular task, take on the next one. So for example, if you have cereal, sugary cereal with milk and that's your breakfast, maybe switch that up for a couple of eggs and avocado for breakfast and just do that. Just fix your breakfast for one to two weeks. Then maybe you focus on your lunch and then your dinner. And if you are a soda drinker, just stop drinking soda. Let's start there. Drink water.

[00:13:45] Erin Spain, MS: You care so much about your patients, and it comes across in many different ways. In fact, you published a poem in a recent medical journal about some of the experiences of your patients. Tell me about that.

[00:13:58] Arasi Maran, MD: What made you want to write a poem? Patients who have those chronic total occlusions or CTOs, they are really very difficult blockages to treat. And when sometimes, when you're treating them, you end up with a tear and bleeding around the heart, and it can be a very traumatic and devastating complication. The poem I wrote after, thankfully, we saved the patient from the complication, and when I went to speak to the family, it was a wife all alone, and you know, she was so scared, and she was trying to reach her family, and she couldn't reach them, the daughter was in a different state, driving her kids around, so it was just extremely traumatic and I take all of that in. I'm honored to be able to do that, put a wire in a patient's heart, but I'm also humbled, and it was, uh, it was a learning experience, and every time something great happens or something not so great happens, I try to learn from it, and I tell patients, this is not a Botox injection. You are coming with a support system, so you have to be prepared, and I want patients to be prepared for anything and everything.

[00:15:05] Erin Spain, MS: Do you have that poem handy by chance?

[00:15:08] Arasi Maran, MD: So my poem, "It's Just a Heart Cath They Said," and I will just read the last paragraph in it. "Is he fine? Will he be okay? The man I married, will our father come back to us? The way he used to be, it's just a heart cath, they said. Time will tell. We were fast. We were efficient. There was no delay in treatment. The rest is up to nature. It's just a heart cath, they said."

[00:15:35] Erin Spain, MS: Thank you for sharing that. It's a good reminder to folks to take their heart health seriously. Is that right?

[00:15:41] Arasi Maran, MD: Absolutely. Like the most of the times when female patients come to us with heart attacks and we ask them, "Oh, when did you start feeling bad?" And they'll be like, "Yeah, it was a few weeks." And we're like, "Why? Why didn't you seek care? Why didn't you give us a call?" So, sometimes, I think this is a good point to make, they think they just have to come to a cardiologist, and only then the treatment starts. But most of the treatment can be initiated by the primary care physician too. And so they don't need to wait for a cardiologist appointment to talk about their concerns. So just find any primary care provider, whoever you go to, and tell them you're experiencing difficulty breathing. You used to be able to do that, but the past few weeks, you're not able to complete a task, or you're taking frequent breaks, or you're waking up uncomfortable in the middle of the night, and something just does not feel right. If you talk about it, they will listen, but if you don't talk about it, it never gets heard.

[00:16:36] Erin Spain, MS: Before we leave today, I want you to share what you do to optimize your health and live well.

[00:16:41] Arasi Maran, MD: I wasn't good when I started. When I was in my fellowship, I used to walk into the hospital with a six-pack of soda and finish that six-pack by the end of the day just to survive. But when I got into practice, I realized I have to practice what I preach or I'm going to end up in the cath table too. So I stopped. I quit drinking soda altogether. That was my step one.

Step two was snacking in between, so just having three meals and then no, nothing in between. I'm extremely strict about that. Then I do have a very strong family history of diabetes, so I'm very paranoid about blood sugar levels. So I cut processed sugars, ultra-processed sugars, and that's the best thing, right? The cookies and the candies and the cakes, everything. I'm not going to say I'm 100 percent off sugar, but 85 percent of the time, I try to stay off sugar and I balance it.

And from the physical standpoint, if you want to be in the cath lab, because we wear a lead skirt, which is about 25 pounds heavy, and we are standing with that. Your core has to be extremely good. So I have given birth to three children. My core is not great, so I had to work on that. So I had to prioritize myself, which means waking up early so that I get that 30 minutes for myself to work on, my exercises or go to sleep or sleep late just so I get it in between or run between cases to the MUSC gym to get things done. So you know, you just, it's like where there is a will, there is a way. And if you don't want to do a thing, you'll just find excuses. So we need to get past our excuses. We need to be better than our excuses.

[00:18:22] Erin Spain, MS: Well, thank you so much for coming on the show today. This was a lovely discussion. I really appreciate it.

[00:18:27] Arasi Maran, MD: Thank you so much for having me.

[00:18:34] Erin Spain, MS: For more information on this podcast, check out