Why Women’s Heart Disease Gets Missed with Dr. Ambreen Mohamed

Heart disease has long been framed as a “man’s disease” – but women are being missed, misdiagnosed, and overlooked in ways that can be life-threatening, especially within South Asian communities where cardiovascular risk often develops earlier and more aggressively.

In this episode, Dr. Komal Patil-Sisodia sits down with advanced imaging and preventative cardiologist, Dr. Ambreen Mohamed, to unpack the evolving science of women’s cardiovascular health, the hormonal shifts that impact risk throughout midlife, and why prevention needs to start far earlier than most people realize.
Together, they explore the subtle symptoms women experience that are too often dismissed, the intersection of menopause, PCOS, pregnancy complications, insulin resistance, and heart disease, and why traditional risk calculators frequently fail to capture the realities of South Asian patients. Most importantly, this conversation reframes prevention not as fear-based medicine, but as empowerment: understanding your risk factors early enough to change the trajectory of your health before disease develops.

Connect with Dr. Mohamed: 

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Website

Connect with me: 

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TikTok 

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Eastside Menopause & Metabolism 

Audio Stamps :
00:00 – Dr. Komal introduces Dr. Ambreen Mohamed and sets up the conversation around women’s cardiovascular health, prevention, and South Asian risk

00:00 Podcast Mission Setup

01:05 Meet Dr Ambreen Mohamed

04:38 Why Women Get Missed

07:10 Women’s Heart Attack Symptoms

11:18 Hormones Menopause PCOS Risk

15:06 Pregnancy As Stress Test

18:36 Menopause Hormone Therapy Debate

25:59 South Asian Heart Risk Factors

28:02 Advanced Lipids Lp(a) ApoB

33:07 MASALA Study And Risk Tools

36:27 Perimenopause Lp(a) Spike

37:18 Estrogen and Lp(a) Research

38:11 Who Counts as High Risk

39:55 Doctors Still Learning

42:12 Labs to Ask For

43:31 Insulin Resistance Markers

46:15 Beyond Labs and Blood Pressure

47:52 Sleep Apnea and Heart Risk

48:41 CAC Score When It Helps

50:12 CT Angiogram and AI

54:32 Lifestyle Changes to Start Now

58:48 Advocating at the Doctor

01:02:31 Wrap Up and Where to Find Her

01:04:25 Final Takeaways and Call to Action

Thanks for listening. Find more info about Clearly Hormonal on the website or Instagram.

Transcript

Dr. Komal Patil-Sisodia 0:01

Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies. I'm Dr. Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society Certified Practitioner, which is really just a whole lot of words to say hormones are my jam. I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it. This podcast is my answer to that gap. We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm. A quick disclaimer: I'm a physician, but this is education, not personalized medical advice. Take what resonates and discuss it with your own healthcare team. Now, let's get into it and talk about what's clearly hormonal and what's not. All right. Hi, everyone. Welcome to Clearly Hormonal. I am your host, Dr. Komal Patil-Sisodia, and I'm very excited to introduce Dr. Ambreen Mohamed. She is a pre- preventative and advanced imaging cardiologist based in Southern California in San Diego, and she completed her undergrad training at UC Irvine. She went to Ross University School of Medicine, then went on to do her internal medicine residency at the University of Connecticut, and her cardiology fellowship at Drexel University College of Medicine. She was the chief fellow there, and then went on to do additional subspecialty training in cardiac MRI and structural cardiac imaging at Scripps Clinic in San Diego. So welcome to the podcast. I'm so excited to have you here.

Dr. Ambreen Mohamed 1:45

Thank you so much. When you initially reached out, I was like, "Oh my God, this is so cool." I'm so happy to do this, so happy to connect with you, and I'm excited about our conversation.

Dr. Komal Patil-Sisodia 1:54

Thank you. I saw all of your stuff on TikTok, and I just thought, "My God, she's putting such amazing information out there about cardiovascular health." We're both South Asian, and I was hearing what you were talking about, and so much of it was resonating with me because like I shared with you before, my mom developed heart disease at a pretty young age when I was in high school, and then my husband had a heart attack about 10 years ago, and this is just a very common thing in the South Asian population. And heart disease is the number one killer of women, right? So for my platform, I've felt very passionate about this. I'm not a cardiologist. I'm an endocrinologist, but I see a lot of that precursor disease that goes into the development of heart disease. So I was just very excited that you agreed to come on and chat with us today and share your expertise.

Dr. Ambreen Mohamed 2:42

Yeah, absolutely. And I love that, endocrinology and cardiology are meeting, right? Because I feel like the union is so needed, especially in this space, right? Not only is heart disease the number one killer of women, however, women are also developing heart disease earlier and earlier, right? And especially in our community. And, listen, I never thought I would be on TikTok and Instagram's front news- but here we are. Here we are in our, prime, doing the TikTok thing, and it's great because, we're able to reach bigger communities, and the response that I've gotten from a lot of South Asians has been so positive and people have just said all around "Hey," "we-" We didn't know about this. We are gonna go get our cholesterol checked. We're gonna go get our lab work. I'm gonna put this in the family group chat. Let me tell you, one of the biggest compliments that anyone can give you is spreading this news to other people that they love and care about, because truly, this information is needed. And just how you shared, like you've had family members your husband, your mom, who've had, heart disease at really young ages. And when you don't have that information and that this is happening, it can be a really scary thing. So to empower people with information is one of the biggest blessings, I think, that, I can have. And if I can share and, be able to save lives, like what other purpose is there, yeah, so I'm happy to do this, and I think we're gonna have a really good conversation today.

Dr. Komal Patil-Sisodia 4:08

And so today I wanted to focus more on the intersection of women's health. Talk a little bit about the South Asian diaspora, and then just talk about prevention in general. There's also new cholesterol guidelines that just came out. And I think caused a bit of a frenzy, like for the endocrinologists,. I can't even remember what the first set of guidelines were. Those were pretty clear. The last ones were a little nebulous. These ones, I think, are leaning towards getting more clear on exactly what to do and what targets to treat towards, so I'm excited to talk about all of that.

Dr. Ambreen Mohamed 4:36

Yeah. I'd

Dr. Komal Patil-Sisodia 4:38

like to just focus a little bit on, reframing heart disease in women. For so many years, especially in my training, it was mainly put out as this is a male disease, right? This happens in men. But we now know that heart disease is the number one killer in women. So I'd love to hear your thoughts on the shift of looking at that and what the data shows around that.

Dr. Ambreen Mohamed 4:59

Historically, heart disease in men has been at the forefront, and so we see this because if you look at research studies dating back decades and decades, unfortunately, most of those research studies primarily looked at men. Women were excluded for a lot of different reasons, women were excluded because of hormonal changes, because they were too complex to understand, because of, pregnancy and all of that surrounding that. So it's just easier to be able to just exclude women, put them on the side, and then primarily study men. So if you're gonna do that over and over again, you're gonna see that the data is really just reflecting what happened. And then on top of that, when you look at the presentation of how heart disease presents in men and women, it can actually be quite different, right? So you know, there's this classic, symptomology that we see of like the elephant sitting on the chest, and crushing chest pain, and- Nausea and diaphoresis, and yes, that can happen in both populations, but that classic presentation can happen more often in men. And unless people have that kind of presentation, and a lot of times women don't, their symptoms can be ignored, and so that's something to really look at as well. And why is the presentation different? Because women's pathophysiology can be a little bit different. Like that classic coronia- cor- coronary disease that occurs in men doesn't necessarily occur in women. Women can have more, microvascular disease. Women can have endothelial dysfunction that doesn't necessarily happen, in men. Women can have plaque erosion, and so the presentations of how they present can just be different. Look at the cultural narrative, right? Like that Hollywood drama how it's being presented, that typically, was highlighted in men. If you're gonna, if you're gonna be exposed to that over and over again, it's not easy to see that it can actually be, different in women. Fortunately we have a huge movement in our, specialty now, especially over the past few years, where we have a lot of, powerhouse women in our field, and even our societies like the ACC, AHA really recognizing that, women are dying from heart disease more than anything else, and they can present differently. And so we really have to recognize them, recognize how they present, recognize what the pathophysiology is behind that, and really highlight that and understand that.

Dr. Komal Patil-Sisodia 7:10

And how do you see... like we talked a bit about the symptomatology in men, right? It's that classic what in the Hollywood movie, the grabbing at the chest, the grabbing of the arm. They fall over. What are the symptoms in women that you typically see, and, what are things that if women are starting to feel these things they need to get themselves to an ER?

Dr. Ambreen Mohamed 7:28

Yeah. Again, women can classically present like men. Okay? So it's not that they don't have those symptoms. However, women can also have different kinds of symptoms, and so this is where it gets a little bit dicey. So again, the classic symptoms of a heart attack would be intense chest pressure, maybe radiating to the back or the neck or the jaw or the arm, the left arm, and associated with, trouble breathing, diaphoresis, nausea. But, in women it could actually sometimes be different. Just feeling a lot more fatigue than usual, and that's really different from them. Maybe they're starting to get really dizzy and lightheaded, and they don't understand why. Maybe they're just getting more short of breath, especially with activity or even at rest. Maybe they are having chest discomfort, but it feels more like an indigestion or just like some kind of uneasiness that they have that they can't describe that they weren't experienced before. Maybe they're, having like indigestion, but along with that comes like a little bit of nausea, but then they'll just say "Oh, maybe I just ate something," or whatever, so it definitely can present, we call these like constitutional type of symptoms. Yeah. We really don't have a box that we can put it in. And I also talked about like the referred pain, so sometimes it could maybe just be isolated pain that they have theirs. Maybe their jaw is like starting to really hurt, and they don't know why, or maybe their left arm is really hurting, but they don't have that classic chest pain. All of these things need to be taken into consideration. And I will say I've seen a lot of women over the years and, I've just recognized more and more that women themselves can downplay their symptoms. And then they don't really know what to ask or what we're supposed to be looking for. But fortunately, because I've seen this so much, I tend to take these things very seriously. So if by the time you're coming to me, if are complaining of something, it would be really easy for me to just pass it off as "You're anxious. Not a big deal," yeah. Or, "It's just a little indigestion. Take some Tums. You'll be fine." I'm like, "No," by the time they're seeing a cardiologist, they feel like something is wrong, or they're getting a second opinion, and I'd much rather be conservative and, get the extra testing because had I not done that, we could have missed something, and potentially something that could have been devastating for them.

Dr. Komal Patil-Sisodia 9:39

Yeah. And I, it's so true. I watched my mom navigate this when I was in high school, and she was starting to get a little more short of breath, right? Our driveway had just a little bit of an incline, and she was having difficulty going up the driveway. Yeah. And it wasn't really anything else. It was like such a subtle presentation. It took her almost two years to get to a cardiologist because people just couldn't figure it out. It was, "Oh, maybe she's anxious. Maybe it's her lungs. Maybe it's asthma. And we went down like every rabbit hole except the right one. And by the time they found it, she was very lucky she didn't have a heart attack before that, because it was- an 80% blockage. It's a big deal in the left anterior descending, which is one of the main arteries of the heart. And so I feel very lucky that my mom is still here, but I saw how long it took her to get there.

Dr. Ambreen Mohamed 10:24

Wow.

Dr. Komal Patil-Sisodia 10:25

I think that I'm just so happy to hear that there are cardiologists out there like you who are taking these complaints more seriously, and other primary care doctors as well. I went in to see my primary care doctor because I was lifting at the gym and I tweaked my left shoulder, and it was like radiating up to my neck. And I'm sitting there in her office just very calmly telling her how I injured my shoulder and it's been hurting for a few days, and she just looked at me, she goes, "Why are you here?" And I said- "I tweaked my shoulder." And she's "Repeat your history with your family history back to yourself, and then tell me whether you should be in my office." And I was like, "Oh my God, I'm so sorry." But I really- You're the doctor, and you're the-

Dr. Ambreen Mohamed 11:03

I'm the

Dr. Komal Patil-Sisodia 11:03

But I had really truly just tweaked my shoulder, but it bought me a cardiology workup, and I'm so grateful she did it because of my mom's history. But yeah you have these moments where you're like, "Oh my gosh," it doesn't register for yourself sometimes.

Dr. Ambreen Mohamed 11:17

Yeah.

Dr. Komal Patil-Sisodia 11:18

One of the other things that I wanted to talk to you about is this hormone connection that we see in women, right? We know that women who go through premature ovarian insufficiency, if we don't get them on hormones right away, they will develop cardiovascular disease at very high rates. I think our biggest question is what happens to women in midlife, right? And what are these hormone connections that are there? And then I see a lot of women who have PCOS who are at high risk for metabolic syndrome, right? Hormones, I think, play a bigger part in female heart disease than we give them credit for, and I'd love to hear your thoughts on that.

Dr. Ambreen Mohamed 11:50

Before menopause... heart disease is traditionally diagnosed, and you can even see this in terms of what's considered premature heart disease- premature heart disease is actually earlier in men, earlier onset in men than it is in women. And really why is that is because our hor- hormones are protecting us before menopause, fortunately. And so why is that? So estrogen is a huge player in the field here, right? Estrogen is a huge player in our vascular system. It can improve vasodilation, it can impru- improve endothelial function it can, lead to healthier lipid profiles, healthier inflammatory profiles. And so we know that with all of that, and if we see that as protective or heart protective, then when you start to hit perimenopause and menopause, you start to see shifts. You start to see shifts in your body where your fat distribution starts to change, and more of that, centripetal obesity which we know is very metabolically active. We start to see more insulin resistance. We start to see our blood pressure increase. We start to see changes in our cholesterol profile, increase in inflammation sometimes. And so what is all of that mean? It means that all of these different things are all risk factors for heart disease. So it doesn't necessarily mean that, hey, you hit menopause and you're absolutely going to, develop something. But it means that because all of these other things are going on, compounded can actually have a significant effect and, lead to an event if we're not really aggressive about care. And then, you talk about PCOS. So PCOS I think traditionally has been seen as this reproductive thing, right? You know- Correct, yeah you have some difficult issues with fertility, and it's just a reproductive diagnosis. Maybe when they're young, they have, a ton of acne, and they have facial hair, and so you just gotta combat that and put them on some metformin, and they're gonna be fine. This is also a huge cardiometabolic, risk signal. It's like a bat signal. And if somebody is diagnosed with PCOS young, now they're gonna be battling that for, a very long time. Why? It's because of a lot of the risk factors I already talked about. You can see changes in lipid profile, changes in fat distribution. You can see changes in blood pressure. You can see changes in insulin resistance. And again what does all of that mean? That means that, you're increasing your risk of heart disease. PCOS isn't you get to the fact that you're gonna be pregnant, and hopefully you get pregnant, and then everything is fine. Correct. No, you're now dealing with these risk factors as well, and so we have to be much more aggressive with tackling like the blood levels and all of that, but then looking at the lifestyle factors too, because other things can change. Your sleep patterns can change. Like I said, your weight distribution can change. And so we really have to package this as not only just looking at it from a reproductive perspective, but also from a cardiometabolic perspective and being much, much more aggressive, I would say, in terms of risk factor reduction earlier on.

Dr. Komal Patil-Sisodia 14:37

I see so many young women, and I think one of the hardest things about PCOS is that women will present in their teens, right? Late teens they'll start having symptoms, but we are so hesitant to give them a label- because it has such a long impact on their life over time. But I think we almost do women a disservice by not telling them sooner, right? It is scary to hear in your teens or early 20s that this is going to be a lifelong issue for you, but I think we have to be more transparent and find better ways of communicating that information. Pregnancy itself can be A risk as well, right? We see gestational diabetes, we see high blood pressure in pregnancy. Can you talk a little bit about how that affects cardiometabolic health long term?

Dr. Ambreen Mohamed 15:18

Yeah, so you have to think of pregnancy as a stress test. Your body's having a stress test- for nine months, right? You're increasing your blood volume, you're increasing your cardiac output, and your hemodynamic changes to your body significantly increase. So if you're healthy otherwise, you're a young girl, you're healthy and you're pregnant, most people can withstand pregnancy during that whole entire time and they're fine. They don't really have any complications, they deliver okay, and then you just continue to monitor and they're doing okay. However, in a lot of women, they have something that kind of is unmasked during their pregnancy, so they can develop gestational hypertension they can develop gestational diabetes, they can develop a pre-eclampsia, eclampsia, have preterm delivery, and then we go into the postpartum. They can have postpartum complications. And all of these things have to be taken in consideration 'cause it's not just a pregnancy issue. This can actually mean that if you develop high blood pressure even within the realm of pregnancy, that puts you at an elevated risk of heart disease later on. If you develop diabetes within pregnancy, that puts you at an elevated risk later on. So not only do you have to be really focused on making sure that they're well controlled during the pregnancy, of course, for the health of you and your baby, but then even after you deliver, you have to make sure that you're staying on top of all of your lab work, your blood work and your lifestyle changes because you don't know the type of risk that you could have accumulated and continue to accumulate later on.

Dr. Komal Patil-Sisodia 16:41

And I think that's one of the things that we see fall off pretty quickly in medicine, right? You now have a new little human you're in charge of, right? And you have all these responsibilities and you may not be sleeping well, you may n- you just don't have the time for self-care that you may have had prior to a pregnancy, and then I think with each next child, that responsibility compounds. And so what I frequently see is women who've had gestational diabetes or gestational hypertension, sometimes they don't come to their follow-up, right? And we skip out on the postpartum testing and that, if you are a young woman who happens to be listening to this and you had these complications during pregnancy please go back to your doctor. Yeah. We want to help you. We want to make sure that your gestational diabetes resolves or the high blood pressure resolves. I think they're a bit better about the high blood pressure. The diabetes piece, people are like, "Eh, it's fine now," right? "I'm not pregnant anymore."

Dr. Ambreen Mohamed 17:32

I think it's like, "Oh, I delivered." Yeah. That was such a tough thing in and of itself. Yeah. I don't wanna have to deal with anything else. I know. I don't wanna take more medication. I don't wanna have more follow-ups, right? Exactly. But I think, again, if we look at this as more of a long game- even if you're thinking of getting pregnant again, you're just putting yourself at a higher risk. And so it doesn't... I feel like we talk about all of this stuff, and it's just people get so scared, right? 'Cause they're so inundated with the information. We're giving them all the facts and this and that, but I think it's really just to empower women to say "Hey, you know that this is what has happened, and now you know that this is what has happened. You know it can come with an increased risk, and you wanna live a long, healthy life, not only for you, but your children as well."

Dr. Komal Patil-Sisodia 18:15

Yes.

Dr. Ambreen Mohamed 18:15

So if you think about it that way, what are the things that you can do to try to help yourself as much as possible? It doesn't mean getting checkups every week, but it means at least doing your annuals and keeping up, with your blood work to make sure that if something is a little bit off, that's looked after a little bit more, because that potentially could save your life down the line.

Dr. Komal Patil-Sisodia 18:33

Yeah, absolutely. I couldn't have said it better. Now I'm gonna ask the controversial question,

Dr. Ambreen Mohamed 18:38

which

Dr. Komal Patil-Sisodia 18:38

is hormone therapy menopause hormone therapy, do you feel like it's protective or risky? And I know where I stand on it, but I think your answer will probably be similar to mine.

Dr. Ambreen Mohamed 18:48

Honestly, I think it's really dependent. I think it's dependent on why you're giving it, I think it's dependent on when you're giving it, and I think it's dependent on who you're giving it to, right? So we know that if you're giving hormone replacement therapy within 10 years of onset of menopause or less than age 60, then this potentially could have either neutral or potentially even positive cardiovascular, benefits, right? But if you're giving hormone replacement therapy later on in life or very far off from menopause, it potentially can have an adverse effect. So yes, can it be good? Sure, but it has to be given to the right person, especially to the person who is having those vasomotor symptoms, absolutely it should be tailored to them, and then also, again, in women that are younger and are closer to onset of, menopause. It also shouldn't be looked at as a preventative tool for cardiovascular disease, because it's not, and we've seen this over and over again. I think, if you looked at hormone replacement therapy honestly, not even too long ago there were studies that were done years ago that have paved the way and said, "Absolutely not. This is bad. This has adverse cardiovascular effects." We're seeing that's not really the case anymore, but again, you have to really individualize treatment. So I would prioritize the age of the patient, If they're having symptoms or not, how far they are out from menopause, and again, individualizing treatment, and then also understanding their inherent risk. If they have a history of vascular disease and things like that, you have to take that stuff into consideration because you wanna make sure that these hormones, even though they're hormones at the end of the day, it can still have, a negative effect. There's no safe, 100% safe medication out there. So you wanna go to a specialist like yourself who understands the nuances of the medication, what you need, what may not be beneficial for you, continue to have talks, continue to have adjustments. It's not a one-size-fits-all, but I think if it's done in a safe way, it potentially could be beneficial. I hope I gave you the right answer, Komal.

Dr. Komal Patil-Sisodia 20:41

No. That's exactly how I feel about it. I might wait. I'm gonna wait to see what she says. No. I don't. That was the test. No. But when I was in my fellowship, my program director pointed out something so interesting to me, right? Which was, as our hormone levels start to decline, all the protective effects start going away, and it's almost like our genetics get unmasked.

Dr. Ambreen Mohamed 21:00

Yeah. So

Dr. Komal Patil-Sisodia 21:01

if you have a family history of heart disease, if you have a family history of high blood pressure, if you have a family history of high cholesterol or diabetes, all of those things start to come out, right? I will have women who have stone-cold normal blood sugars and cholesterol, and all of a sudden they hit perimenopause. They have not changed anything. They're doing the same workouts. They're eating the same foods. And all of a sudden the cholesterol's double what it used to be, right? And it's fascinating to me to watch that. Now, how that looks in everybody in terms of how they respond to hormone therapy is widely different, right? I have one person that, you know... And I track these things. I look at cholesterol levels before and after. I look at glucose levels before and after. For some people, it actually helps drop the levels close to what the baseline was. Not exactly there, but closer to what the baseline is. For other people, it makes no difference at all, right? Yeah. And these are the things that we don't understand, but if we're not tracking, we'll never know. Yeah. And you can never, to your point, just blindly give somebody something and be like, "Oh, that's it for you. You're good now," right? That's not gonna work out well for people. So I love the approach of making sure that, you know- how far out somebody is from menopause or if they're in that perimenopausal window. I feel like we still need to do so much more research on perimenopausal women. And the impact of this, because I think we may potentially see benefit. At least that's what my gut tells me. I don't have evidence for that. So hopefully that's the case. I think encouraging women that like getting this information about their health is going to be a way for them to take control over what their future is, right? Because at the end of the day, like if you fall in that group of people who can't have hormones because you have a contraindication like a series of unprovoked blood clots or, a recent heart attack or stroke, or an estrogen fueled cancer of some sort, breast or gynecologic, a lot of women come into my office and they feel so hopeless. They're like, "Oh my gosh- It's like- I'm just gonna die now because I have nothing else." And I tell them, I'm like, it's a series of pillars." Hormones are one piece of everything, and the reason we have medicine and we have research and we have innovation is that if you can't take option A, right? You can take option B. But if option A is something you can take but it's not working well for you, you still have option B, right? Like we're trying to make sure that we're giving you all of the things that are getting your health back to a baseline where you're not increasing your risk for heart disease long term. And that's a hard thing for people to swallow because I feel like they think that it's their fault or that they are failing or it's a moral failure on their end, when it's really your genetics are the hand of cards you were dealt in life. It is what it is, right?

Dr. Ambreen Mohamed 23:35

Yeah. And I explain this to patients all the time, from, perimenopause and menopause aside, or even just women aside, women in general. I really try to explain to patients that heart disease is not a one-size-fits-all. Yeah. And this goes back to just even foundational things "Doctor I have a great diet and I exercise. My cholesterol shouldn't be like this," or, "I don't have to take medication because, I do all of these things. Why do I have to do this? Why is it still this way?" And I'm like, "Because it's not just your diet and exercise. There's other things that come into play." And I think that, when we have patients that are coming into offices like yours or mine- a lot of times they're really in a vulnerable position, and they're just looking for any kind of help. They're seeking any kind of answer. And again, a lot of times they don't know- what they're looking for. They just want you to help them. And so when you tell them that, the thing that they think they need may not be the best option, it can be really frustrating for them, and so to then to explain like, "Hey," you have to be really gentle. "Hey there's different options here. We have, option A, option B, option C. It doesn't mean that we can't help you. We just have to tailor treatment individually for you, and it's also not gonna change overnight." I've seen a lot of female patients that are on hormone therapy, and they're like, my doctor started it, and I'm still not feeling better. I don't understand," and all of this stuff. And it's just "Hey it's not going to just shift overnight. Sometimes it takes a little bit of trial and error to see what works for you."

Dr. Komal Patil-Sisodia 24:57

Yeah. And your silver bullet may not be somebody else's silver bullet, right? Hormones may work well for patient A, but not work well for patient B, right? Because the hormones may not be the actual problem, right? That's the other thing, is if you don't see an improvement after a period of time, you have to be open to changing your approach. You can't keep forcing the same thing and hoping for a different outcome. It doesn't work that way, right? But that's where that personalized, individualized care comes into play, and I think your patients are so lucky to have a cardiologist who looks at it that way, right? I remember going with my mom to some of her early cardiology appointments, and there was one in particular that left me very rattled and very angry, because he just was not willing to listen to or work with my mom in any capacity. Yeah. And that's really hard to watch, right? Especially when women in general don't tend to ask for help, and then you put them in a position where they feel like they have no options because nothing they're doing is right? It actually just creates this environment where they don't wanna ask for help. Yeah. I think in general that's harder for women, but I think in South Asian women particularly, it tends to be hard, and we're both South Asian by background. So

Dr. Ambreen Mohamed 26:07

I'd

Dr. Komal Patil-Sisodia 26:07

love to switch gears a little bit and talk about heart disease in South Asian women, because that tends to be a very high risk group, and that is really where you've put a lot of your efforts into education and putting good information out there, not just for South Asian women, but for South Asians in general. So I'd like to chat with And I'll hand it over to you.

Dr. Ambreen Mohamed 26:27

Yeah. This has become like a passion project of mine. And I will tell you, back in my day when I was doing fellowship- Yeah we didn't really learn about the nuances of this, we understood that, certain ethnicities had maybe a little bit of a higher risk, and so I knew a little bit, but I wasn't really- I don't know if I wasn't, if it was like I wasn't really taught, or we just weren't really exposed or, or whatever the case might be. But it wasn't this whole thing of like we really have to be vigilant about, this particular type of ethnicity. And it was only until recently when I started really, deep diving into the research and really, even just listening to family, listening to friends, listening to colleagues, listening to my community and their concerns, and really seeing patterns and really alarming rates of heart disease at younger ages which I was just like, what is happening here?" Yeah. And why is this not being brought to more people's attention? And then you talk to them and they don't even understand really what's going on because, it's everybody has diabetes. Like- Yeah everybody has diabetes, right? Or, one in two, three, four people have some type of heart issue. It's so common- that people are just, they just live with it. And they're just like, "Whatever. It's just a part of how it is. And so I'm just gonna continue doing what I'm doing. It's not gonna make a difference. It's still there." And so I think when we talk about why South Asians are at high risk, I put them into a couple of buckets. I think there's the genetic bucket, where we have genetic, factors that cause us to have an increased risk of heart disease, and then there's the lifestyle bucket. And now you put these things together and they start to compound on each other, and now you're left with some really, big consequences for our ethnicity. And so when we talk about the genetic bucket, there's a few things. We have a very complex lipid profile. So it's not just the general cholesterol panel that hopefully all of us are getting screened once a year. But a lot of times, our LDL, which is a quote unquote bad cholesterol, that's the type of cholesterol that can lead to plaque formation, so a lot of times, a lot of South Asians will have borderline LDL or sometimes even normal LDL. But then you take a peek behind the curtain and you look at other, what we call advanced lipid markers. So they can have higher rates of lipoprotein A. So what is that? Lipoprotein A is basically a cholesterol marker that makes the LDL stickier. So what happens with that? You have accelerated plaque progression a lot of times at earlier ages. And many a times, your primary care doctor, not because they're bad or anything, they're just not checking for it because they don't know. A lot of cardiologists, were not screening their patients for- protein A. And this is a genetic marker that if it's high. If it's low. It doesn't really change over your lifetime. Sometimes, diet and lifestyle can alter it a little bit, but we don't even have any medications right now specifically tailored to lower that. There's some in development though, right? There's some in development, and that's really exciting for us because we've never had a medication that could directly lower that. And so hopefully within the next, year or two, we can start to see some of these medications on market. But right now, like we have PCSK9 inhibitors like Repatha and that might lower it maybe like 20-ish percent, but there's not a clear indication there, right? Like it's not guideline based that we can give that. It's like a off-label thing. Other than that, we put you on a statin, it's really because we're trying to reduce your future risk of heart disease, because it's gonna lower that. So usually about one in four South Asians have an elevated LPA level, right? And then we also have apolipoprotein B or ApoB. So that actually has really come on the up and has really been seen as, this indicator of plaque formation in the future, increased risk of heart disease, in the future. And why? Because it's a surrogate for, atherogenic particles that are swimming around or a surrogate for LDL particle numbers. So when you're looking at the general cholesterol profile and you look at that LDL, that's actually reflective of how heavy the LDL is, the mass. And so then again, when you take a peek behind the curtain and you start looking at LDL particle numbers, you start looking at the size of the LDL, small versus big. We know the smaller particles are the not so good ones 'cause they have a easier way of causing plaque formation. There's one ApoB that's attached to every LDL particle. So the higher the ApoB, the more of a predisposition you would have- of a potentially developing plaque. That has also been shown to be significantly more elevated in South Asians as well. And so again, increasing your risk. We also have more insulin resistance. Diabetes runs rampant. And it's not just diabetes. This is even just pre-diabetes- and just having elevated fasting blood glucose. Maybe you weren't diagnosed with diabetes yet, but you have a family history of it, so it's coming. Reducing that- You're watching the train out of the corner of your eye. And diabetes is one of the biggest risk factors for heart disease. And then also just our genetic predisposition of our fat distribution. So we tend to have more visceral fat. That's that not so good fat that can be surrounded, on, around our organs. And so We might look okay on the outside, but we might have something really bad going on the inside, and that visceral fat is actually metabolically active. And so that means that it can lead to more insulin resistance, and it can potentially change your lipid profile. It can potentially lead to increased inflammatory markers. So again, all of this can increase your risk of heart disease, and most of us are very unaware. And then you have the lifestyle bucket. So we tend to not have the greatest diet. Our food tastes amazing, but it's not always- good for us, right? Yeah. We tend to have more sedentary lifestyles. Like physical activity in our community is not something that is celebrated or I would say is considered normal. We don't tend to deal with our stress very well. And that could be for a lot of reasons. There's a lot of immigrants in this country coming from South Asia that have to deal with a lot of stress of, like adjusting to a new country. There's a lot of family dynamic issues. Chronic stress is just something that we all, deal with. And then I think, also just, looking at sleep patterns and all of those things. So I think, taking everything together, again, it's not just we eat bad food. You take the genetics plus the bad food, the genetics plus the chronic stress, the genetics plus the sedentary lifestyle, and you start to compound this stuff, you're starting to see higher rates of heart disease much earlier.

Dr. Komal Patil-Sisodia 32:23

And it's interesting because when I look at my family history, my grandfather, my paternal grandfather, he had diabetes. It was totally diet controlled, but he was a civil engineer. And he owned farmland. So back in India, he was walking all his civil engineering projects. He was walking his farmland every day. And he lived well into his 80s and had a stroke then, but was never on any diabetes medications, right? We moved to the States, where it's higher stress, more sedentary, all of these things, and my dad had a much harder time controlling his diabetes just because of the change in the environment, right? And the change of the stressors. So it's very interesting to see that difference generationally. And then I think, to your point, all of that compounded, we see that increased risk of heart disease as well. I know you had mentioned the MASALA Study when we were talking earlier. Can you talk a little bit about that? Because I don't think I've read that one. I'd love to hear it.

Dr. Ambreen Mohamed 33:15

Yeah. So the MASALA Study, and don't ask me what it stands for. I already forgot. But it basically is like the first of its kind, where it was studying South Asian population within the United States. So it basically started in San Francisco and Chicago at two big academic centers, and they were studying basically South Asians and why, South Asians were getting heart disease- at earlier ages or why their risk was elevated. So they were looking basically at all of these parameters looking at lipid profiles, looking at, coronary CTAs and calcium scores to see, do they have, an increased amount of plaque? Do they have increased, calcification in their arteries? They were looking at fat distribution and found that, there was more of that centripetal obesity and visceral fat. And the way that they were able to find that out is that they actually did CAT scans and saw that there was more of a visceral fat distribution in this patient population. Chronic stress and then dietary patterns, and then looking at all of these things and seeing what the heart disease rates were. MASALA was just I think an initial project, and then the sub-studies that have come from it- Yeah there are multiple studies that have come from it. Even until this day, they're still doing more and more studies on this- patient population, to really understand the demographics. It's... I feel like prior to MASALA really the I feel like the research within our, community- It was,

Dr. Komal Patil-Sisodia 34:34

like, nonexistent.

Dr. Ambreen Mohamed 34:35

So this was actually pretty revolutionary for us, especially in the United States for it to be understood. And now if you actually look at guidelines, back in 2019, the ACCHA came out with the prevention guidelines, and being of South Asian ancestry is considered a high risk-enhancing factor. That is with no other ethnicity. These people are paving the way for us to be able to be understood on a greater scale. And you and I talked offline a little bit about this before, about, how the general, risk calculators that are out there, ACCHA just came out with the PREVENT calculator. It used to be something a little bit different before. But it's still not taking different ethnicities, especially our ethnicity, into consideration and our factors into consideration. For example, if I had an elevated LPA and I had a larger waist circumference but my BMI was normal, my cholesterol profile looked normal, I had a normal blood pressure, I don't smoke, no diabetes, my risk score, 10-year risk score for developing heart disease would be very low. But that's actually not the case. But it won't be picked up by that. And if that could potentially cause a huge issue down the line, I have a problem with that, and so I just, I feel like we just need to continue to have open conversations about this. I'm so proud of the people that started this research and continue to do this research. Now there have been more, research studies that have come up. There's been the INTERHEART study. That's more of a global study. There's been the LALE study that recently came out. There's a lot of South Asian cardiologists have now, big academic centers have been studying this as well. And so I really think that there's more and more of an effort to Get more of this information out there and study our patient population at a grander scale to be able to make more of an impact.

Dr. Komal Patil-Sisodia 36:17

I think that's fantastic, right? And I have so many questions too. My sisters and I, we've been getting screened for heart disease since our mid-30s, since our mom was, like, 42 when she had hers. And it was interesting for me that I, after I had my son, I struggled a bit with my weight, and so I really... But at that point, my lipoprotein little a was normal, and I did all of the lifestyle things, lost weight on my own, I work out several times a week, I cook at home, and I hit perimenopause, and it doubled, and it went to 98, right? Yeah. And all of my lifestyle stuff was dialed in. I was healthier in perimenopause than I was five years prior. And so for me, it's always been like what the heck? I can't really do anything else," right? Yeah. And so I think we- I have so many questions around what does happen, right? For people who have these high-risk features i- especially in our South Asian communities, right? What is the effect of estrogen on those women, right? Because it, the, right now, the current guideline says you check lipoprotein little a once in your life. Yes. But what if you check it when you're 30 and not when you're 45? And it's important to- So it's a really,

Dr. Ambreen Mohamed 37:23

it's a really good point that you brought up that I forgot to mention before- Yeah when it came to lipoprotein, but there actually has been, some research has been done that shows that estrogen estrogen and hormone replacement therapy can actually decrease lipoproteinlevels. Again, should not be used as a sole treatment. Correct. Yeah. It just goes to show that, it can potentially be beneficial, and it is something that needs to be studied more. Yeah. Because if it can be given in a way where women are at significantly higher risk- Yeah and it can be given safely and potentially help them, I think that would be a huge game changer as well, right? Totally. Because this is killing people, worldwide. Yeah. And so what are different ways that we can be able to, treat it? So I think that there's, a lot of more interesting things to learn- and so much more research to be done to be able to help people.

Dr. Komal Patil-Sisodia 38:10

Yeah. And it's interesting, like I had somebody ask me, they're like what does South Asian mean? What countries are those," right? And I was like I'm pretty sure it's like India, Pakistan, Nepal, Afghanistan." But the rest of Asia has pretty low cardiovascular risk except for when you get out to the Philippines. I think their heart disease is also like ours for whatever reason, right? Or similarly in that way. But I think just for understanding, like if you are from a country that is not South Asia, and I had to Google this to figure out which ones were in there because my patient asked

Dr. Ambreen Mohamed 38:42

I know. It's seven or eight countries that are within that South Asian continent. But it doesn't necessarily mean that if you're not within that specific continent- you do not have an elevated risk at all. This can go into, Middle Eastern ancestry. This can go into- the Southeast Asian, you know- Asia area. And so I just think like looking at, even African Americans, like the black population- actually has elevated LPA levels, across- the board as well. So it doesn't just mean that, oh, we're the highest risk and we shouldn't pay attention to anybody else. But Yeah unfortunately, just with everything like we talked about compounding, we are, at a very elevated risk and it shouldn't be ignored.

Dr. Komal Patil-Sisodia 39:16

Yeah. And it's interesting because I read all those lipoprotein little A studies that you were talking about with the estrogen. As soon as I realized mine had doubled and I like freaked out, but you're right, like there's no data showing that even lowering those lipoprotein little A levels will prevent heart disease in the future. So what does that mean? Yeah. We don't really actually know, right? No. Yeah. But I think just the act of being aware sets people up on such a better trajectory than being like- "Meh, doesn't matter," right? So- yeah. It's it's definitely fascinating. I feel like I could talk about this stuff all day. I have so many questions both selfishly and for our listeners- Yeah who are there. Absolutely.

Dr. Ambreen Mohamed 39:55

It's hard to fit all this information in just an hour, that's why this podcast is wonderful and it's gonna educate a lot of people. But I also think putting the information out there day to day and, having people follow along- for a long period of time, you'll be able to learn a lot, as we're learning too. It's not like we know everything. We're learning this stuff, too. Yeah.

Dr. Komal Patil-Sisodia 40:13

Exactly. And I think, that's the thing that people have to realize is doctors don't have all the answers, right? And what we tell you today could be different in five years, because there's- gonna be research that happens in those five years, right? So it's important to- If

Dr. Ambreen Mohamed 40:26

doctors could just be given... if we could just be cut some slack.

Dr. Komal Patil-Sisodia 40:29

Just a tiny bit. Tiny bit, right? But we don't know, right? God, our creator, whoever you believe, created the system, created our bodies, right? Mother Nature, whatever you wanna call it, we know a fraction of what our creator intended. And it's... I will say that being a doctor is probably one of the most humbling professions. It really is. Because the more you learn, the more you realize you don't actually know a whole lot, right?

Dr. Ambreen Mohamed 40:50

And we have to be very honest about it, right? There is so much to say about, what a privilege it is to be a physician, to be able to be knowledgeable in your field, all of this stuff, but then at the same time to also understand that there is a lot of unknown. And to be able to show that to your patients "Hey, sometimes I'm not going to have all of the answers." And sometimes it is gonna take a little bit of trial and error, or sometimes we have to learn a little bit more about this, and that's okay, right? I am not an encyclopedia. I still have to study and learn. Everybody has to study and learn. And so pe- you know, I feel like people should be giving us a little bit of grace, but then we also shouldn't put out there that we know everything, because we don't. That's right. And there are people- Yes that are in our profession that do put out there that they know everything, and they are overly confident, and, I don't know if that's the best way to be. I think it's good to be confident. Of course, be confident- Yeah about the stuff you know, but then also- Yeah be confident in saying "Hey, there, there are some things that I don't know, and I'm still learning, and I'm still growing, and if it's not in my field-" Exactly I'm definitely going to leave it to somebody who knows better.

Dr. Komal Patil-Sisodia 41:53

Yeah, and I think that's a shift away from patriarchal medicine and the Socratic method of how we u- used to get taught, right? You had to be confident and, I'll say 50 years ago there was less stuff to know because there was less research. Yeah. You didn't know everything- Absolutely that there was to know at that time. Yeah. But that doesn't mean that's always gonna be the case. So I love that, and I think that, If more doctors are embracing that mindset, we can actually help people more so with prevention as opposed to treating the end stage of disease, and I think, we can very nicely segue our conversation to there, because I did wanna talk to you about, when you are coming in to see a cardiologist or you know you have a high-risk family history, what are the tests that one, women should ask for, and two, if you have, strong family history or South Asian profile or you're in some other high-risk group what are the things you should be asking for?

Dr. Ambreen Mohamed 42:46

Yeah. So it's not just the annual, Unfortunately, it's not just the annual checkup. Yeah. One of the main things that I'm really try- trying to push our community, and it really should be pushed in women as well, is you need to ask for more. And so what is that? We talked about some of this stuff before, but it's not only just the complete lipid panel, but it's also getting additional markers like ApoB and lipoprotein A, especially if you haven't gotten screened before. You absolutely should get that checked at least by the time that you're 30. If you have a strong family history of heart disease, I would advocate getting the lipoprotein A checked maybe a little bit earlier in your 20s. But, at least by the time you're 30, you need to start really working on, prevention and getting some of this stuff screened. So the lipoprotein A, getting a full lipid panel, getting an A1C, getting a fasting blood glucose. I kinda wanna know your thoughts on fasting insulin level, because I see a lot of that and I know fasting insulin levels can be elevated in patients that don't necessarily have diabetes. Yeah. But I don't really strongly advocate for it because I feel like it should only be done, in certain like-

Dr. Komal Patil-Sisodia 43:50

yeah. I would agree with that, right? I think we can- look at the pattern of tests sometimes and just know somebody is insulin resistant, right? Like for example, if in your 20s your fasting glucose is around 70, right? And then every year you're gaining a few pounds here and there, and then by the time you hit 30 your fasting glucose is like in the 80s, right? That's a 10-point jump. You've developed some insulin resistance there because your beta cells, in my opinion, are like factory assembly line, right? And when you get more visceral fat, it's like the factory assembly line has to run faster. You have to make more insulin to cover the same number of carbs when you gain more visceral fat.

Dr. Ambreen Mohamed 44:28

And

Dr. Komal Patil-Sisodia 44:28

so you see this creep in blood sugar slowly that goes up over time, right? So if your fasting blood sugar goes from 70s to 80s to 90s and it's hovering you have developed insulin resistance. I don't necessarily need an insulin level to tell you that. But sometimes in women who have PCOS and we're doing that initial thing and they're having a hard time understanding or believing it, sometimes as from a demonstrative perspective for people who want to see that insulin level, it can be a helpful tool, right? Do we need it? No. Can it be helpful to help people understand their disease? Yes. It's not recommended in any of the guidelines, and usually by the time people have an elevated A1C they... That's why we have two things that we look for prediabetes now, right? We look at either an elevated fasting blood glucose between 100 and 125 for a diagnosis of prediabetes, or an A1C of 5.7 or to 6.4, right? Yeah. You only need one to be abnormal to, for it to be true, and the number of people who I have who have normal glucose but a slightly elevated A1C, those, there's insulin resistance there. So I feel like I can talk patients through it where we don't necessarily need those levels, but then, some people are like, "I really just want to see the numbers so I feel better about it and I understand how it's impacting." I have one of my partners, she is a PCOS expert, she advocates for insulin levels in everybody, right? And when she sees her patients, she will check them again and- You know, if they're struggling with overweight or obesity, she's also an obesity medicine specialist- and she puts them on a GLP-1-

Dr. Ambreen Mohamed 46:03

it's

Dr. Komal Patil-Sisodia 46:03

really nice to see that insulin resistance come down. So I think from that perspective, it can be a very helpful teaching tool. Do I need it to make a diagnosis? Probably not.

Dr. Ambreen Mohamed 46:12

Some of the other, things should be checked. We talked about lipid profile, ApoB, lipoprotein A, fasting glucose, A1C, and then also other things outside of your blood work. So if you have a normal BMI, you would also at least once would wanna get your waist circumference checked as well, right? Because we know that there can be a difference where your BMI could be normal and you could be considered normal weight, but you could still be at an increased risk. So also getting your waist circumference checked, looking at your blood pressure, and not only just getting it checked once, but also making sure that you're looking at trends, right? Especially if you have a history, like a family history of high blood pressure. And then also not just saying "Oh, my blood pressure looks normal and I don't ever have to care," or the top number is normal. Even the bottom, the diastolic number matters. And we've, had many updates to our blood pressure guidelines over the years where we can see that it's just getting stricter and stricter. And so even when you're in a pre-hypertension stage-

Dr. Komal Patil-Sisodia 47:09

Yeah

Dr. Ambreen Mohamed 47:10

it still can increase your risk, right? And then also looking at, your history and your family history. So do you have a family history of heart disease? Do you have a family history of premature heart disease? Do you have a, if you're, if you've been pregnant before, do you have a history of gestational hypertension? Do you have a history of gestational diabetes? Do you have a history of having any pregnancy complications? Did you have postpartum complications? Did you have preterm, delivery? All of these things matter because this can increase your risk in the future as well. What is your physical activity like? Are you sedentary? Are you moving? What kind of foods are you eating? What are your dietary patterns like? And then what are your sleeping habits like? Because we also know that patients that don't sleep well and don't sleep consistent- that can in and of itself, increase your risk for heart disease.

Dr. Komal Patil-Sisodia 47:52

Yeah. And there is an association between sleep apnea and heart disease as well, correct? Yes. Yeah. Absolutely. And I think it's underdiagnosed,

Dr. Ambreen Mohamed 48:01

It's very significantly underdiagnosed because I think it used to be, it used to just be seen as like a diagnosis in- overweight or obese people, but that's not really the case anymore. And so we know that, and like for us, like we see a lot of patients with high blood pressure, and one of the things that we'll do, or even just arrhythmias, and we know that sleep apnea can trigger arrhythmias. We also know sleep apnea is a Huge cause for high blood pressure, and a lot of patients have no idea that they have sleep apnea. And so once we get them screened, all of a sudden they get diagnosed with it, they start, wearing a CPAP and, their numbers get better and it's "Whoa, like I, I didn't even know that this was like an issue." So absolutely it's a huge risk factor. And I would say the other thing, like the only diagnostic test I would consider would be a coronary artery calcium score. Now- Okay. That's fair yeah, there's a lot of nuance to this, and I think, again, I have a love-hate relationship with coronary artery calcium scores. It's a huge thing. But, if you are borderline or intermediate risk we talk about that like prevent like we, there's, we're, talking about a lot.

Dr. Komal Patil-Sisodia 49:03

We've been all over the place today.

Dr. Ambreen Mohamed 49:04

Yeah, so but that prevent risk calculator, and you can find it on ACC website, there's different like risk categories. So if you're at like the borderline or intermediate risk where you're not really sure if a patient should be started on statin therapy or they'll benefit from it or maybe they're a little bit hesitant, then you can get a coronary artery calcium score. Now the guidelines are saying in men that are greater than 40, women that are greater than 45. It doesn't mean across the board everybody gets it. It doesn't mean that if you're already on cholesterol lowering therapy, you get it. You do not get it. That's one of my biggest pet peeves. People are just getting serial, coronary artery calcium scores. They're not getting any utility from it. Their score's going up. They're on, statins. They have no idea why. I'm like, this is not- Yeah a detector for plaque." That's not what it's used for. But it can be used in certain scenarios where you're unsure about whether to start lipid lowering therapies or not, and sometimes if even if it's a little bit elevated, then we'll say "Hey, you're already starting to develop calcified plaque. It may be a good idea for us, to start this." So that's like the one thing that's like a little bit nuanced. I don't like to say like absolutely get it, but as long as it's done in the appropriate cases, I think it could be useful.

Dr. Komal Patil-Sisodia 50:11

Yeah. So I'm starting to hear a lot online about CT coronary angiogram. You knew I was gonna ask. I'm just curious, what is the utility there, right? Yeah. So

Dr. Ambreen Mohamed 50:21

It's so funny that you mention that. So in my practice, I actually work a lot with AI analysis, even with coronary CTAs and, just all of the advancements is- significantly different than what we used to do before. Even when I was in fellowship, we barely were using coronary CTAs, and now we're, using them so often. I use them a lot more than I just do, stress tests. Now, I think the thing that people have to understand is even, guidelines now do not support coronary CTAs for the general public. So just because you want one doesn't mean you can have one, which is gonna be covered by insurance. You have to have an indication for it. Do I think it's an amazing test? Yeah. It's a non-invasive angiogram, and it's, like the quality's become so good, and now with these like AI analysis platforms, with HeartFlow, we have Clearly, these startup companies that are doing amazing. I think, we can actually see really r- really good resolution, on this plaque, and it's saved a lot of lives. It's helped a lot of people understand what's actually going on. I wish it was available to more people, but if the general public wants to get it, they have to pay money. So do I think it's indicated? No, unless you're having symptoms, you have an abnormal stress test, you speak with your cardiologist, but do I think it's something that could be really beneficial? Yeah I've actually changed my attitude a little bit. I used to think- Yeah "Why are people doing this?" And now I really think it can be beneficial because I feel like once you see that you have plaque in your arteries, if you were not taking your health seriously before- 100%, yeah I believe you are gonna be taking it seriously now. And I'll, I'll I'll kinda give a little side stories. We recently had the American College of Cardiology National Conference a couple weeks ago, and my company was doing... They paired with HeartFlow to do screening CCTAs for- conference participants, and that has never been done at a conference before. Bringing in a mobile CTA- to the conference- to do this. And so I was lucky enough to get one 'cause I was like, "Hey, I'm just gonna put myself on the wait list and see- if I'm lucky enough to get one." And it was like the coolest, craziest experience. Amazing. I know. But then to think "Oh, my God. Now, if I have something, I'm a cardiologist." This doesn't feel good. I was so scared. I was like, "If I have something what am I going to do?" But fortunately, everything was fine, but it really was an eye-opening experience for me. Yeah. And then just hearing stories of other participants, and the fact that people were having things diagnosed that they didn't know about before, and these are all cardiologists that are getting screened, it's just a wild thing to think about. But I really think we're gonna start to see a shift in how coronary artery disease is screened and treated in the future, in the very near future, with the advent of all of these different types of technologies. So I feel like if you're able to get one, and you're able to afford it if you don't have a clear indication for it, it might be something worthwhile considering. But do I absolutely recommend it? I don't, know. As long as your cholesterol is very well controlled, and it's treated, and it's at goal as you discuss with your doctor, you don't need it, but it is like a nice to have if you're able- to get it.

Dr. Komal Patil-Sisodia 53:18

Yeah. We have a company here locally that does them. I send them all of my CT coronary artery calcium scores- Yeah for the people that I'm trying to convince they should probably go on a statin when they have- Yeah high lipids. But I was curious because it seems like it would be helpful to know, right? But without all of the stress that comes with having a, an actual coronary.

Dr. Ambreen Mohamed 53:39

Yeah.

Dr. Komal Patil-Sisodia 53:40

Okay. Thank you. That's really helpful. And, for me it's similar in the diabetes space when I put somebody on a continuous glucose monitor. When- they see their pattern of blood sugars- it's "Oh, I'm not gonna touch that food again," right? I did that to my dad. My dad I'm gonna call him out a little bit here, but he- he was telling me how he felt like he could feel his blood sugars, and I was like, "Daddy, you're an engineer. You can't feel your blood sugars," right? Yeah. So we put him on the Dexcom Stilo, and sure enough, like he saw how what he was eating was shifting his blood sugars in a way that didn't look great, and he changed his eating habits and it's like back down to target goal-

Dr. Ambreen Mohamed 54:18

That's amazing

Dr. Komal Patil-Sisodia 54:19

Just from seeing the data, right? And that was helpful for him. So I'm really excited to see how technology can help people make these health decisions for themselves. And you're right, it does create behavioral change that we need. It does.

Dr. Ambreen Mohamed 54:31

Does.

Dr. Komal Patil-Sisodia 54:32

All right. If you were talking to somebody who is listening, like one of our listeners, what would you want them to know that they could start doing now to start decreasing their risk overall?

Dr. Ambreen Mohamed 54:45

So I would say that if there are things that you could start like today, one would be movement, right? So get in your movement. We all say that we don't have enough time in the day to really, do anything, but it's really are you gonna prioritize that time or not? And it could be something as simple as taking a walk after meals. We know that decreases glucose levels, especially like- Post-meal walks. So maybe if you don't wanna do it alone, do it with your family, do it with your partner, do it with your kids. Make it a group activity. It doesn't necessarily mean that you have to get your steps in. I know that- Yeah that's always the thing that everybody's hyped about is "We have to get 10K steps." But you don't necessarily need to do that. It's more so just focusing on being consistent with your activities. So we have, different ways that we categorize activity. Moderate intensity, something like walking. 30 minutes a day, five days a week. So on the low end, that's 150 minutes a week up to 300 minutes a week, so that's 60 minutes a day, five days a week. You can break that down however you want to. But just to be able to build up to that and start being consistent. We know the significant cardiovascular benefits of even just something as low impact as walking. And then of course, if you're into more high-intensity stuff I'm a runner running, jogging, swimming, dancing, biking, whatever is your cup of tea, 75 to 150 minutes a week. So either moderate or high intensity, and then also incorporating some resistance training. So especially as women, we know that as we age, our bone health start to deteriorate. We start to lose lean muscle mass, and so we wanna be able to protect that. And what is the way that we protect that? We have to make sure that we maintain our muscle and we, improve our bone health or at least maintain our bone health. And what is one good way that we can do that is start with strength training. Let me tell you, as somebody who is a cardio junkie, like- Yeah hate lifting weights. I will say it on record, I hate it. It's so hard for me to be consistent, but... And I'm like, "I'm not seeing a difference. My body just hurts. This is stupid." I, all of this stuff goes through my head, but I'm like, "No, I cannot be the person that preaches all of this stuff- Yeah and then doesn't practice it." I have- It's the

Dr. Komal Patil-Sisodia 56:41

I hate running with a passion. Really? I wish I loved running No, but I actually really enjoy lifting weights, so it's like- Oh my God a struggle just for me for cardio.

Dr. Ambreen Mohamed 56:51

Both of our minds together, we'd be like the perfect specimen.

Dr. Komal Patil-Sisodia 56:54

It's funny but to your point walking is so underrated, right? So I told my doctor- Yeah I'm just not gonna be a runner, but I'm gonna walk. So I'm- gonna walk and I'll lift her and it's fine, right?

Dr. Ambreen Mohamed 57:04

Yeah, any kind of movement or activity, and then just doing two or three days, a week of some resistance training, whatever your cup of tea is, I think could be really beneficial. And then also the other thing that you can start working on right away is your meals. So looking at your dietary habits, what are some small changes that you can make? You can maybe increase your protein intake. Maybe you can increase your fiber intake. Maybe you can eat, more whole fruits and vegetables. Maybe you can, decrease the amount of refined carbs that you're eating, decrease the amount of, sweets that you're having, and start to, change your plate, a little bit. And you don't have to make an overnight change. It's really hard to go from eating, a certain way to eating completely healthy, and we're human at the end of the day. We wanna enjoy our food. But, I tell people, "If you start to make these small shifts and you do it every day, it's gonna start to stick with you, and it'll become a habit." So I think, making dietary changes, starting to move your body, and then it's really easy to pick up the phone and call your doctor and schedule your lab work. It's the easiest thing to do. I, as a good old doctor, hate needles. Same. I hate needles. I'm the worst patient. They're always like, "Are you gonna faint?" "What's wrong?" I'm just like, "Just do it. Don't tell me. Put the needle in." But then, I was hesitating for two years. I'm being honest. For two years I didn't get my labs done because I was just like, "I don't wanna go. I don't wanna go." And then I was like, "Again, what the hell? I can't say all of this stuff and not..." So I did it, and then I was like, "Why didn't I do it before? It wasn't that bad." So it's so easy to just... Once you make the appointment, it's just easy to go. It potentially, again, could save your life. If there's something that you find on there that it doesn't look great, then you have to work with your doctor to start to make changes, and it's better to find that stuff out sooner than later.

Dr. Komal Patil-Sisodia 58:48

And then just as we close out, a lot of women feel like they get dismissed when they go in to see a doctor, right? What are your tips for women to have themselves be heard when they walk into a doctor's office, right? Because that I think is the hardest part of the experience.

Dr. Ambreen Mohamed 59:07

Yeah, and even us as physicians, like we're women- Yeah but, we're physicians, but we're also women, and I think that I even, will go into the doctor's office and I sometimes am just like, "It's, it's fine. I don't really-" Downplay it, right? But that's what we do as women Yeah We don't I think a lot of times the big issue with this is that we downplay our own symptoms. We're constantly prioritizing our families. We're prioritizing our children. We're pri- prioritizing our partners. We're prioritizing our parents, our family, our community, our patients, for doc- whatever, and we're downplaying what's going on with us, and a lot of times that's gonna lead to delay in care. It's gonna lead to you not being able to advocate for yourself, and, then if something happens, what do you do? Now you're dealing with the aftermath of it, and you can't take care of the people that you need to take care of. So you know what's that whole thing of when you're sitting in the plane and they're giving you the instructions, put your oxygen mask on first before you, put it on your kid. It's, the same theory here is that you really need to advocate for yourself, and I think, women's intuition I think is something not to be messed with. And so if you feel like something is wrong with your body, you need to advocate for yourself absolutely. If you feel like when you're going to somebody and they're not taking you seriously, you go and get a second opinion, right? And so now you're going to this expert and, you're telling them like, "Hey, I don't feel good." You need to tell them what is actually going on. Try to verbalize okay, it started at this time. This is the thing that triggers it. This is what makes it worse. This is what makes it sometimes better. I used to feel this way, and now I feel this way now. What do you think could be going on? Does this fit into a certain category? Hey, my mom had, a heart attack in her 40s, and she didn't really know what was going on until it just happened. She wasn't even able to describe it." Ugh. "And so I'm scared that's gonna happen- Yeah to me. So these are the symptoms that I'm having. Is there anything that I can do about it? Are there any tests that I can get? I feel like I'm not able to have the same quality of life. I was able to run around with my kids, and I was able to walk up a flight of stairs and do the laundry, or I was able to clean the whole house, and I can't even do half of that stuff anymore. Stuff is piling up at work. I just feel really like foggy and tired, and I don't know-" This is a shift in how I feel. And then, say "Hey," again, bring up your family history. Bring up the fact that you're South Asian. A lot of doctors don't even know that your ethnicity is a high risk. "I'm South Asian, I know I'm high risk. I've seen it everywhere and I'm just nervous that this could be something that, is heart disease related." Or, "Hey," "I'm in that perimenopause era. Is there something that's that could be going on?" Or, "Hey, I actually had gestational diabetes when I was pregnant, and I just want to make sure that my symptoms along with that, and I have a couple other risk factors." Try to just say as much as you can say, and ask the expert "Hey you know these things. Here is the story that I'm telling you. Do you feel like it fits into a certain category?" And if you feel like despite that you're still not being heard, absolutely get a second opinion. Yeah. Or you can just ask for a referral- to say "Hey, you know what? I've been feeling like this for a long time, and I would just really appreciate if you would just refer me to a cardiologist. I'd really like to speak to somebody."

Dr. Komal Patil-Sisodia 1:02:14

Thank you for saying that, because I think people are so afraid of offending doctors if they go out and seek a second opinion. You are the most important person in that visit. It's not my ego. It's not the ego of any other doctor that's there. If you're not getting what you need out of that visit, go find somebody that you feel is hearing you. So thank you for saying that. I think that is such a great way to close out our episode on heart health- especially in women. And thank you so much for taking the time today, Dr. Mohamed. I really appreciate it. Oh, yeah, of course.

Dr. Ambreen Mohamed 1:02:42

And I

Dr. Komal Patil-Sisodia 1:02:43

I'd love to have you back in the future as a guest if you're game. I'd love it. Yeah. I feel like there's many more things we can talk about.

Dr. Ambreen Mohamed 1:02:48

Yeah. I love talking about this stuff, and I also love talking to people that are outside of my field. I feel like there's so much, in the endocrine space, I feel like there's so much that I don't know and I love to learn. And I just feel when we all collaborate together, we can really make huge impact and have really great conversations that can actually really, help people. And so it was a privilege to be able to be here. This is my first podcast appearance.

Dr. Komal Patil-Sisodia 1:03:12

Is it really? You're a natural. You did so well. Thank you. You did fabulous, and I'm sure that I will get all of that feedback from people who are listening, so- thank you. Can you tell people where we can find you on social media? 'Cause I love your TikTok channel. That's how I first-

Dr. Ambreen Mohamed 1:03:28

Thank you

Dr. Komal Patil-Sisodia 1:03:29

came across you, and I was like, "Oh, she's amazing." need to talk to her."

Dr. Ambreen Mohamed 1:03:33

I'm on TikTok @ambreenmd, and then I'm also on Instagram @drambreenMohamed. I'm on LinkedIn, Ambreen Mohamed. I have a website, ambreenmohammad.com, so you can contact me and email me from there. And then I also have a Linktree that's linked to both my Instagram and my TikTok. I have a YouTube channel that I kinda cross-post everything. Maybe thinking of doing some longer form content. The people that are dedicating their lives to social media, let me tell you, it is tough. Oh my God. It's not easy. It's not easy for someone who's working full time. I'm like, "How? When? What's happening?" Yeah. I don't know. Is the camera angle okay? I look funny here. I just, whatever.

Dr. Komal Patil-Sisodia 1:04:11

No.

Dr. Ambreen Mohamed 1:04:11

Anyways yeah. But I will

Dr. Komal Patil-Sisodia 1:04:12

say, your colleagues and then the people who are out there listening who are potential patients everybody is so appreciative. Of course thank you again for being here. You're welcome. And to the listeners, thank you for tuning in, and I will see you on the next episode.

Dr. Ambreen Mohamed 1:04:24

Woo-hoo.

Dr. Komal Patil-Sisodia 1:04:26

And that's a wrap on today's conversation with Dr. Ambreen Mohamed. And I have to say, I don't think I've ever had a guest on this show who I connected with so immediately, so personally, and on so many levels. We're two South Asian womens, both carrying our family's history into work every single day, both of us watching women we love navigate a system that wasn't built to hear them. If you heard me share the story about my mom today, the shortness of breath going up our driveway, the two years it took to finally get the right doctor, and the 80% blockage they found in one of her coronary arteries, and something in that story felt familiar, I need you to sit with that feeling. Don't file it away, because the theme of this entire conversation was that women's symptoms get explained away, minimized, and missed, and the cost of that is devastating. The best thing Dr. Mohamed said today, and she said a lot of great things, was that you need to put your oxygen mask on first. You cannot keep going to the back of the line of your own life. So here's what I'm asking you to do right now. Save this episode. Text it to your mom, your sister, your friend who's been feeling off and can't get anyone to take her seriously. That's who we made this for. And if you haven't yet, please leave a rating and review wherever you listen. It's what helps other women find Clearly Hormonal when they're searching for answers at midnight, and we both know they are. Now, if today's conversation made you want to understand your own cardiovascular and hormonal picture more clearly, your lipids, your lipoprotein little A, your metabolic risk, how your hormones are interacting with all of it, this is exactly why I designed the Midlife Health Compass. It's a free tool I've been developing for women in perimenopause and menopause that looks at all of these systems together, the way they connect in your body, and it gives you something real and specific to bring to your next appointment. I'm going to release it in the next few weeks. You can find it at the midlifehealthcompass.com. It's free for anyone to use because my mission is to make sure no woman has to navigate this alone, dismissed, or without the language for what's happening in her own body. I'll see you next week.