This week, Expertscape had the opportunity to speak with Dr. Erin Michos, who happens to be an Expertscape World Expert across an impressive array of cardiology and health topics. Dr. Michos is the Director of Women’s Cardiovascular Health and Associate Professor of Medicine at the Johns Hopkins University School of Medicine.

In this “Ask The Expert” session, we discuss preventive cardiology and specific challenges and advancements in women’s health.

Expertscape: How did you get involved in the study of Preventive Cardiology?

Dr. Erin Michos: I am excited about being a Preventive Cardiologist, because approximately 80% of cardiovascular disease is thought to be due to modifiable or preventable risk factors. Cardiovascular mortality has declined substantially from several decades ago, so it is largely a success story, but there is still a lot more we can do.

The best way to prevent cardiovascular disease is to follow a healthy lifestyle throughout the lifespan, and I am certainly an exercise enthusiast myself. Physical activity is one of the best “prescriptions” we can give our patients. However, it is important that all adults be screened for the known traditional risk factors of cardiovascular disease – such as blood pressure, lipids, diabetes risk, and use of tobacco products – and treated appropriately. There should be particular consideration of “risk enhancers,” which are clinical conditions that elevate cardiovascular risk beyond the traditional factors I mentioned. These risk enhancers include factors related to early menopause, history of pre-eclampsia, having a family history of premature cardiovascular disease, autoimmune disease, HIV disease, chronic kidney disease, South Asian ethnicity, and certain lipid abnormalities including elevated triglycerides, apolipoprotein B, or lipoprotein (a) that would favor more intensive preventive therapies such as with statins.

For adults age 40 and above, if cardiovascular risk is uncertain, a non-contrast cardiac computed tomography (CT) scan can help refine one’s cardiovascular risk estimate upwards or downwards depending on whether or not plaque is detected in the coronary arteries. This information can help guide the shared decision conversations we have with our patients about the benefit of preventive pharmacotherapies for them.

At the Johns Hopkins Ciccarone Center, we have specialized clinics in Preventive Cardiology for a comprehensive “ABCDE” approach to cardiovascular risk assessment and management. As the Associate Director of Preventive Cardiology, I am proud to be part of our program, which also includes active research, education, and advocacy efforts, in addition to excellence in clinical care.

Expertscape: What do you consider to be the most significant advancement in the field of Preventive Cardiology, and what has that impact been?

Dr. Erin Michos: We know that low-density lipoprotein cholesterol (LDL-C) is directly related to atherosclerotic cardiovascular disease (ASCVD), although it is not the only risk factor. Studies have shown that a lower cumulative exposure to LDL-C delays the onset of cardiovascular events and slows plaque progression. Thus, high-risk patients, such as those with clinical ASCVD or multiple ASCVD risk factors with residual burden of atherogenic lipid particles, benefit from more intensive lipid-lowering therapy. Patients maintaining intensive LDL-C reduction for longer periods of time gain greater cardiovascular risk reduction.

The exciting news is that we are now in a new era of lipid lowering management. Beyond statins and ezetimibe, we now have new agents such as PCSK9 inhibitors, which can dramatically lower LDL-C to help our highest risk patients, such as those with ASCVD or familial hypercholesterolemia (FH). Additionally there are other new LDL-C lowering drugs such as bempedoic acid and inclisiran that are currently being studied in large cardiovascular outcome trials, as well as a new drug being studied that targets lipoprotein (a). We await to see if these are also proven to have cardiovascular benefit. However, it is exciting that we will have more options for patients for their lipid management than ever before.

In addition, we have renewed understanding of the impact of elevated triglycerides on cardiovascular risk. In patients with ASCVD or diabetes who are treated with a statin but have moderately elevated triglycerides, the addition of icosapent ethyl (a highly purified fish oil of EPA at 4 grams a day) can confer large cardiovascular benefits.

Insulin resistance is an important driver of risk too. Again, lifestyle changes such as heart healthy diet, regular physical activity, and weight management are paramount. Additionally, among individuals with diabetes, there have been exciting new developments in recent years with diabetes medications called SGLT2 inhibitors and GLP1-receptor agonists, which have been shown to confer cardiovascular benefits beyond just glucose control. SGLT2 inhibitors also have benefits in heart failure and kidney disease prevention. It is a new era for cardio-renal diseases, and patients benefit form a multi-disciplinary collaboration between endocrinology, cardiology, and nephrology.

I am still a huge enthusiast for the promotion of lifestyle changes, but it is an exciting era now that we have all these new drugs – new tools in the toolbox – that can prevent cardiovascular events.

Expertscape: You also specialize in Women’s Cardiovascular Health. Should the public be encouraged by the progress being made in this field as well?

Dr. Erin Michos: Yes, overall, we have made great strides in the reducing cardiovascular mortality in women over the decades, but recent data have showed a stagnation in this progress, and worse, heart attacks appear to be on the rise in middle age women. Heart disease kills more women at all ages than breast cancer. Some risk factors like diabetes and smoking confer greater cardiovascular risk in women compared to men. Furthermore, women have unique risk factors that men do not experience related to pregnancy, hormones, and menopause. A history of early menopause or a history of adverse pregnancy outcomes such as pre-eclampsia or pre-term delivery are “red flags” that enhance a woman’s risk for developing later cardiovascular disease. Autoimmune diseases like lupus and rheumatoid arthritis are also more common in women and confer increased cardiovascular risk. It is important that women undergo a comprehensive cardiovascular risk assessment with special attention to these “risk enhancers” that may warrant more intensified prevention.

Expertscape: What makes your work in Women’s Health so challenging, and also rewarding?

Dr. Erin Michos: Women are not smaller men, and prevention and treatment of cardiovascular disease needs to be through a sex- and gender- specific lens. There are demonstrated gaps that affect the care of women like the disparity in the number of women who are prescribed optimal medical therapy, so they are more likely to be readmitted back to hospital after a heart attack than men. Women are less likely to be enrolled in cardiovascular clinical trials so we have less evidence to understand efficacy and safety of certain cardiovascular drugs in women to guide clinical practice.

Additionally, women can have unique presentations of cardiovascular disease. Women have smaller sized coronary (heart) arteries than men. Women with angina are more likely to have coronary microvascular dysfunction or ischemia without obstruction (stenosis) in their coronary arteries, while men with angina are more likely to have obstructive coronary artery disease. Thus, heart disease sometimes can be missed in women. Women might have discomfort in their backs, their jaws, suffer from severe fatigue or nausea – but not chest pain and thus women and their doctors may attribute their symptoms to other causes than the heart. Then these women do not receive an accurate diagnosis or get treated as promptly, compared to men who may exhibit symptoms that are more characteristic.

Furthermore, even heart attacks can be from different causes in women. Women are more likely to have myocardial infarction with non-obstructive coronary arteries (MINOCA) which can be due to spontaneous coronary artery dissection (SCAD), coronary vasospasm, coronary thromboembolism, or microvascular disease. A comprehensive workup and follow-up care for these women is important.

Given the overlap of SCAD with Fibromuscular Dysplasia (FMD), I work closely with our vascular medicine specialist, as well as our genetic counselors. I am also particularly interested in comprehensive cardiovascular risk assessment for women after menopause especially for women considering menopausal hormone therapy for vasomotor symptoms, and individuals using transgender hormone therapy. We also have experts in Cardio-Obstetrics for the care of women in the setting of high-risk pregnancies due to cardiovascular disease, or after delivery, to evaluate their cardiovascular risk in the setting of having had a hypertensive disorder of pregnancy.

At the Johns Hopkins Women’s Cardiovascular Health Center, we have special clinics for SCAD, microvascular angina, cardio-oncology (breast cancer), Cardio-Obstetrics, and preventive cardiology for a comprehensive evaluation of women’s cardiovascular risk throughout the lifespan.

Expertscape: Thank you for your time, Dr. Michos. The progress being made is encouraging, and we look forward to learning about new discoveries in preventive cardiology. We wish you continued success!

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