Matters of the Heart: What Women Need to Know with Dr. Natalie Bello
about the episode
In this episode, Sharon is joined by Dr. Natalie Bello, Director of Hypertension Research, Staff Physician and Associate Professor of Cardiology at Cedars-Sinai Medical Center.
After learning that 80% of heart disease is preventable in medical school, Dr. Bello decided that focusing her career on helping people stay healthy, optimize their risk factors, and live long lives was an easy choice to make.
Hypertension, also known as “The Silent Killer,” is a leading global contributor to heart disease. A common myth is that heart disease disproportionately affects men when, in fact, it is the number one killer of both men and women. This misinformation has major consequences, namely that women experiencing chest pain wait 29% longer in the emergency room to be seen by a doctor than their male counterparts.
Dr. Bello shares that just because a woman doesn’t present their pain the same way as a man doesn’t mean that they aren’t experiencing the same pain. Being your biggest health advocate is the best way to regain your agency in heart health. Sometimes, for a woman, that may look like firmly declaring that your chest pain has brought you to the emergency room, stating your risk factors and that you must be treated for potentially having a heart attack.
Dr. Bello recommends the tests for anyone with chest pain or interested in improving their heart health, like an EKG, troponin, stress test, or angiogram. In order to assess personal risk factors, the Pooled Cohort Equations to Prevent Heart Failure (PCP-HF) or PREVENT are most used. Dr. Bello then discusses the mechanics of hereditarily passing down heart conditions between genders and the importance of increasing the number of studies on pregnancy’s impact on the body.
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“As women, we need to retrain ourselves from societal norms that tell us to ignore our symptoms. We need to listen to our bodies, advocate for ourselves, and if your doctor isn’t talking to you about heart disease, you should feel empowered to bring it up or get a new doctor.”
About Dr. Natalie Bello
Dr. Natalie Bello is Associate Professor of Cardiology at Cedars-Sinai Medical Center, where she is Director of Hypertension Research. Dr. Bello is Staff Physician at the Smidt Heart Institute. Previously, she was an Assistant Professor of Medicine at Columbia University Medical Center, and before that she was a Postdoctoral Research Fellow at Harvard’s Brigham and Women’s Hospital. She is board certified in internal medicine, cardiovascular disease, echocardiography, nuclear cardiology and has advanced training in cardiovascular MRI. Dr. Bello’s research focuses on better understanding the relationship between hypertensive disorders of pregnancy and cardiovascular risk, as well as ties between preeclampsia and peripartum cardiomyopathy.
Episode Outline
(00:55) Meet Dr. Bello
(01:35) 80% of Heart Disease Is Preventable
(05:14) PSA: Women Wait Longer in the ER With Chest Pain
(12:46) Knowledge Is Power: Know Your Hereditary and Gender-Specific Risk Factors
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Sharon Kedar (00:02)
Behind every pioneering idea, method and device is a fellow human or humans, a trailblazer who is daring enough to ask the questions that push the boundaries and make the impossible possible. I'm Sharon Kedar, co-founder of Northpond Ventures, a multi-billion dollar science-driven venture capital firm, and the host of, "Innovate and Elevate." In each episode, we'll have candid, in-depth conversations with top doctors, scientists and innovators about leading-edge discoveries, and how they impact our lives. Season one focuses on women's health with the aim of helping women lead our healthiest lives. You'll hear from leading experts such as Dr. Kathryn Rexrode, Division Chief Women's Health at Harvard's Brigham Hospital. It's time for all of us to innovate and elevate.
Sharon Kedar (00:53)
Hello everybody. We are here today with Dr. Natalie Bello. Dr. Bello is Associate Professor of Cardiology at Cedars-Sinai Medical Center, where she is Director of Hypertension Research. Dr. Bello is Staff Physician at the Smidt Heart Institute. Previously, she was an Assistant Professor of Medicine at Columbia University Medical Center, and before that she was a Postdoctoral Research Fellow at Harvard's Brigham and Women's Hospital. Dr. Bello, welcome to the podcast.
Dr. Natalie Bello (01:26)
Thank you. It's so great to be here, Sharon.
Sharon Kedar (01:34)
I would love to hear a little bit about how did you decide on cardiology?
Dr. Natalie Bello (01:39)
Unfortunately, I lost both of my grandfathers to heart disease when I was really young. And both of these were before I was five years old, and I loved science, and ended up going the route of going to medical school after my undergrad. And when I got to medical school, I realized, or I learned that 80% of heart disease is preventable, and to me it just seemed like, well, this is a no-brainer. If I can do something where I can focus my career on helping people stay healthy, optimize their risk factors, and live long lives so that they can see their children and their grandchildren grow up, why wouldn't I want to do that? And so it just kind of was a nice fit for me.
Sharon Kedar (02:21)
You just said something that kind of blows my mind. In a lot of medicine, we don't have a lot of agency, but in some areas of medicine, like what you're talking about, so, for the viewers and listeners, Dr. Bello will correct me if this is inaccurate, but I'm pretty sure that heart disease is the number one killer of women and men. Most people historically have thought about it more as a male disease, which we will unpack, but hearing you say that 80% of heart disease is preventable, can you talk a little bit more about that? That's a very high number.
Dr. Natalie Bello (03:00)
Absolutely, and so little of what we do in life has such odds. You know, I think, many things are still stochastic and random, or we feel predestined. It's in our genetics. We have a family history of this or that, and so even for folks like myself with a family history of heart disease, there're so many things that go into developing heart disease that we can, in some ways, control or manage. Something like hypertension is the leading global contributor. So, hypertension or high blood pressure, biggest risk factor for heart disease, stroke, heart attack, dementia, and we have so many therapies, drugs and new devices that are coming out and interventions we can do to help manage blood pressure.
Dr. Natalie Bello (03:49)
To me, it's really just almost criminal that we don't do a better job as a society treating that risk factor, because we can keep people healthy. And it's hard, nobody realizes they have high blood pressure because you don't feel it. We call it "The Silent Killer" for a reason. And so, that's a lot of what I do when I see patients, when I'm working on my research, is thinking about how can we get that message across? How can we empower people to understand their risk factors so that they can make positive change and lead a healthier life?
Sharon Kedar (04:21)
If the doctor determines that you have high blood pressure, what's the typical sort of first-line of treatment?
Dr. Natalie Bello (04:27)
So, for everybody with high blood pressure, the first-line is always going to be lifestyle changes, focusing on things like eating a healthy diet, moderating our sodium intake. But for other people who do have a high enough blood pressure that's, you know, what we call stage 2 hypertension when your blood pressure is above 160/90, some of those people we know that even with the best of intentions and the most rigorous lifestyle changes, we're going to need medicine, at least in the short-term. Sometimes we can peel it back later, but everybody should get lifestyle optimization and then medications are the next line.
Sharon Kedar (05:13)
Taking a step back, why is heart disease traditionally known in this country as a male disease when it is the number one killer of men and women?
Dr. Natalie Bello (05:24)
It's a great question, and you know, I think we're unfortunately just fighting the stereotypes that came from some of the earliest papers about heart attacks. One was written back in the 1920s, and it was really described as angina, this chest pain sensation that we know is caused from the heart not getting enough oxygen, was described as being predominantly a disease of men. What people don't realize is there was actually a follow-up paper written a couple of years later speaking about how women had the exact same experiences, but for some reason, it just didn't get into the literature, into the dogma, and we've been fighting this ever since.
So, we need to really, you know, I think, podcasts like this, getting out the word to people about what are your risk factors, what is heart disease? And if your doctor isn't talking to you about heart disease, you should feel empowered to bring it up. Ask them, "What are my numbers? What is my risk?" And if they still don't want to talk to you, get a new doctor.
Sharon Kedar (06:26)
Wow, that is such an interesting and powerful statement. I think most people assume that their doctors would know best, especially about what is the number one killer of basically everybody, right? Men and women. Dr. Bello can you talk about how heart disease presents differently in women versus men? Do women and men present the same symptom profile when they're having a heart attack?
Dr. Natalie Bello (06:58)
I think if you ask the right questions, both women and men will report chest pain, and there have been papers to prove that. The dogma is that women don't always have chest pain, that they're more likely to say they have fatigue, or just feel unwell, or nauseous, but if you actually dig in, there is chest pain as well. But yes, you're correct that sometimes the presenting symptom when someone comes to the emergency room when they're a woman may be nausea, or just generally feeling unwell, whereas men are typically coming in and describing that pain more acutely.
Sharon Kedar (07:35)
Well, that's what's so fascinating is the subtleties of how a woman presents, how we're socialized maybe not to go in and say you have chest pain because that could seem alarmist, but of course with, you know, with a man it's sort of the first thing they check. So, I'm a little baffled by how we address this and what women need to know about this disease so that they can have some agency here.
Dr. Natalie Bello (08:04)
Yeah, I think that's a great point, and I think women do need to sort of re-train ourselves from what you're saying. Societally, we are all often told, you know, just you can get through this, this is just one more thing to add to your to-do list, just ignore it, it'll go away, or it's not that big of a deal, you can work around it, but I think we need to listen to our bodies. We need to advocate for ourselves. And if you're having chest pain, you need to talk to your doctor, or call 911 honestly. If you know something's not right, listen to your body.
Sharon Kedar (08:37)
So, if someone is showing up at the hospital with chest pain, or other symptoms and suspect that there might be a potential issue related to heart health, what are the tests that someone would want to get?
Dr. Natalie Bello (08:49)
Certainly when someone's in the emergency room and looks unwell or is telling me they feel unwell, our first-line is almost always an EKG, very easy to do, non-invasive, just some stickers on the chest. A piece of paper prints out, it takes a few minutes to set up and can show us very acutely is somebody having a heart attack that we need to intervene on where time is muscle, time is heart, and we have metrics where if you present, and some ambulances can actually do this, if you call 911, out in the field they can get an EKG and call us so that we're ready for that person. The second they hit the door, they go straight into our catheterization lab and get that artery opened up if it's blocked. But for other people, it's not that acute of a setting, and the EKG may be a little abnormal, and so we may keep them and do other tests, like troponin.
Dr. Natalie Bello (09:45)
Troponin is a wonderful biomarker that has evolved over the course of my career from something that was a little bit crude into something that we have a lot of precision now. It can tell us, it's a protein that is given off by the heart when there's damage to it, and damage can occur when a blood vessel is blocked and the heart's not getting enough oxygen. There are other conditions as well, which is why we would still get a full history. But, that can help us understand, again, who is at higher risk, who might need more invasive testing, like looking directly at the arteries themselves, to see if there's a blockage that needs to get opened.
Sharon Kedar (10:24)
That's really helpful to know. I think one of the things that the viewers and listeners would appreciate your perspective on is the Journal of American Heart Association recently reported that women who visit emergency departments with chest pain wait 29% longer than men to be evaluated and are less likely to be admitted. So, in the reality of needing to self-advocate, if someone shows up suspecting that this could be an issue, do you have like one, two, three things that, you know, they should ask for?
Dr. Natalie Bello (10:59)
You know, if they present to the emergency department, and if you say, “chest pain," to the person who, I think, lead with, "chest pain," would be my tip. If that's what's bringing you in, even if it's heaviness, even if it's a feeling of nausea or unwell in your chest, call it "chest pain." Call it what it is to raise the red flag so that you do get evaluated faster. I do think, you know, "chest pain," "should I get an EKG?" "I know people who have had symptoms like this,” or “I know that this could be heart disease, here are my risk factors: I have high blood pressure and diabetes," that's also very helpful. Because you may look healthy
Dr. Natalie Bello (11:42)
But if you don't give that history of your risk factors then it, you know, comes back a little bit to how much of heart disease is preventable and what goes into our risk for heart disease. Things like high blood pressure, high cholesterol, diabetes, pregnancy complications. It may not be apparent just from looking at somebody that they have three, four or five risk factors for heart disease when they're a woman in their late 40s. And if you actually, again, if you take the time to take that history, you get there, but we don't have time in the emergency department. We need to be able to triage people faster, and so, I think, you know, that would be another important piece of information when you're coming into the emergency department to help make sure you get seen faster.
Sharon Kedar (12:33)
Okay, and in terms of risk factors, we just did a series about breast health, and there are several online tests to figure out your breast cancer lifetime risk level, which is really important, just to your point of how constrained the system can be and sort of knowledge being power. Is there a similar sort of recommendation when it comes to knowing your heart health and your risk level?
Dr. Natalie Bello (12:59)
So, there absolutely are. There's one sort of tried and true risk calculator that we use, and there's a new one that's just come out. So, we, most of us use and our guidelines still recommend, what's called The Pooled Cohort Equations. So when you come to my office, there are lots of things that go into it, like your actual blood pressure levels, your cholesterol numbers, whether or not you have diabetes, if you're a smoker, certain actual data points. And there's a newer, I call it a risk calculator, called PREVENT that's just come out in the last few months. We still haven't incorporated it into our guidelines. It is a similar sort of plug-and-play. We put in these data points and we get out a, "What is your short-term risk, what is your long-term risk of heart disease?" Which is helpful for life course risk stratification, not so much in the emergency room, because if someone comes in and sounds like they're having a heart attack, I don't care what your lifetime risk is. Your risk right now could be a 100%.
Sharon Kedar (14:03)
Yeah, the reason I ask is, to your exact point, by the time you're in an urgent situation, it's a lot more challenging, but one of the things the viewer and listener can do now is just understand their risk profile. Super helpful, Dr. Bello. A question for you as a follow-up, how hereditary is heart disease, and does it differentiate by gender?
Dr. Natalie Bello (14:28)
When we think about traditional heart disease and blockages and myocardial infarction, that's where we get into less of that is heritable. There's probably many, many small gene changes that contribute, but not so much the traditional Mendelian genetics: You have this, or you don't have this. You're going to get it, you're not.
Sharon Kedar (14:48)
So, if one of your parents had clogged arteries, that doesn't mean you have a higher propensity?
Dr. Natalie Bello (14:53)
You probably have a higher risk than somebody whose mother lived to be 110 and had no blockages, but how much of that is genetics, and how much of that is living in the same environment, eating the same foods, having the same habits? It's a little hard to tease out, but again, we say 80% is modifiable, preventable, so that leaves about 20% to be genetic for many people.
Sharon Kedar (15:20)
Okay, and like if someone's parent has, I don't know, AFib, atrial fibrillation, the genetic component might, I guess, we might not even know the answer. I wonder if it would pass equally to a son versus a daughter?
Dr. Natalie Bello (15:34)
So, AFib has some different risk factors by sex. Men, I believe, are more likely to have AFib. Women are more likely to have strokes as a result of AFib. So, there are some sex differences. There's also interestingly more risk of AFib with increased height. So, there's lots of things that go into it, you know, and whether it's just the way that the heart beats and has to pump blood higher over time, we don't know, but there are those correlations that have been seen. And there are other risk factors that are very specific for females and women, in general. So, there are certain conditions like peripartum cardiomyopathy is a form of heart failure that only happens to women.
Sharon Kedar (16:19)
And one factor that's not something we'll solve on the podcast today, but when we think about some of the things that fatigue or nausea, or chest pain, I mean, a lot of times, heart issues present when women are going through peri or menopause where, you know, Oprah talked about her heart palpitations finally being addressed through hormone therapy, and so there's such a confluence of factors that are so understudied that I think it just compounds the complexity of what really shouldn't be complicated, but it becomes more complicated for a woman.
Dr. Natalie Bello (16:57)
Right. And I think, you know, again, we need more women in science, in medicine to ask these questions so we can drive the fields forward and understand hormones and not just say, "Oh, it's messy, we can't study this." Okay, well let's figure out how can we study it? I do a lot of research with pregnant women, and I find they are some of the most willing and happy participants in medical research, because they feel so drawn to helping other people, and wanting their experience to be meaningful, and improve other people's outcomes. Even if they know it may not change their pregnancy or their baby, they want to help other people.
Dr. Natalie Bello (17:36)
And so, I think, you know, in the past, women have been considered a vulnerable population, especially pregnant women. We don't study them, we don't involve them in trials, and thankfully, we're really trying to change that tide and, you know, we call for our studies to include enough women so we can understand is this really helping women, or is this harming women? Women aren't just small men. We need to understand the differences. And so digging into some of those hormonal changes and impacts is super important.
Sharon Kedar (18:07)
Yeah, data is power. Well, Dr. Natalie Bello, it has been a pleasure. Thank you for everything you're doing in the world. We appreciate you and we appreciate your time on the podcast today.
Dr. Natalie Bello (18:17)
Thank you so much for having me, this was really fun.
Sharon Kedar (18:32)
Thank you for tuning in. Please connect with me Sharon Kedar on LinkedIn for additional innovative content. If you enjoyed this episode, please take a moment to like it. And don't forget to subscribe to the channel by clicking the button below this video. The views and opinions of the hosts and podcast guests are their own professional opinions and may not represent the views of North pond ventures.
About Your Host
Sharon Kedar, CFA, is Co-Founder of Northpond Ventures. Northpond is a multi-billion-dollar science-driven venture capital firm with a portfolio of 60+ companies, along with key academic partnerships at Harvard’s Wyss Institute, MIT’s School of Engineering, and Stanford School of Medicine. Prior to Northpond, Sharon spent 15 years at Sands Capital, where she became their first Chief Financial Officer. Assets under management grew from $1.5 billion to $50 billion over her tenure, achieving more than 30x growth. Sharon is the co-author of two personal finance books for women. Sharon has an MBA from Harvard Business School, a B.A. in Economics from Rice University, and is a CFA charterholder. She lives in the Washington, DC area with her husband, Greg, and their three kids.
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