Interview with Dr. Barbara H. Roberts
Thursday, April 21, 2005, Women’s Cardiac Center, Providence, RI
Barbara H. Roberts, MD, FACC is the director of the Women's Cardiac Center at The Miriam Hospital in Providence, Rhode Island and is the first female cardiologist in the state. The Women's Cardiac Center offers complete diagnostic and clinical cardiology services, cardiovascular surgery and cardiac rehabilitation to women. In addition, the Center offers nutritional counseling, stress reduction sessions, and monthly educational seminars. Dr. Roberts is also an Associate Clinical Professor Medicine for the Brown University Program in Medicine. She is the author of How to Keep from Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease.
What are your duties and responsibilities as a cardiologist?
As a cardiologist or as a cardiologist in the position that I hold here? Well, I mean obviously, a cardiologist specializes in the study and treatment of heart disease. Cardiology really has gone through a tremendous evolution. Bypass surgery, which is now one of the most common surgeries performed, really wasn’t invented until the mid-1960s. And even when I was an intern, which was ‘68, ‘69, in a big hospital in Cleveland, University Hospitals in Cleveland, there was an open heart surgical program there, but exactly one of my patients all year had open heart surgery, and that was for an aortic valve replacement. And now most major medical centers do hundreds of bypass operations a year, valve replacements, some do cardiac transplants. So cardiology itself has undergone a tremendous evolution just over the course of my medical career. The specialty is subdivided into many different subspecialties.
When I was a cardiology fellow at Brigham back in ’73 until ’75, I decided to concentrate on what was called invasive cardiology which was heart catheterization; stents hadn’t been invented yet. The first angioplasty wasn’t done until 1977, and it was done by a doctor, Andreas Gruentzig, who was a Swiss physician. So when I was a fellow, angioplasty hadn’t been invented yet. Bypass operations were becoming more common. But I decided that I really liked doing cardiac catheterizations because that’s what I had concentrated on during my fellowship. For the two years after I finished my fellowship, I was a full-time faculty member at Princeton. And then I came to Providence in 1977 and went into private practice. I was the first female adult cardiologist in the state – and the only one for many years. I was in solo practice for fifteen years, and then another cardiologist and I joined our practices. It became a very large, multi-office practice, and I got extremely burnt out.
In 2000, I took a two-year sabbatical during which I wrote a book because I saw the need for teaching particularly women more about their risk of heart disease. I wrote this book, which was published last year, called How to Keep from Breaking Your Heart: What Every Woman Needs to Know About Cardiovascular Disease. About eight months into my sabbatical, Dr. Kathleen Hittner – Do you know who she is? She’s the President and CEO of The Miriam Hospital – and she’s a woman anesthesiologist that I had known since she came here in 1979. She called me and asked me to come in and talk to her. She said, “Barbara…” – and she hadn’t been CEO for very long – “…I lie awake at night thinking about how I can make Miriam Hospital a better place, and I realized that we really need a women’s cardiac center here.” She did open heart anesthesia, and she would see women come in for open heart surgery at a far later course of disease than the men. And people were starting to get interested in some gender differences in cardiovascular disease. And she said, “So I really want to start a women’s cardiac center. Would you like to direct it?” I said, “Would I like to direct it? That sounds like my dream job!”
So I had about fourteen months to plan this facility, and I was given free rein in designing… I mean, the architects decided where the walls would go, but I picked out all the furnishings. And I had fourteen months to decide what the women’s cardiac center was going to look like and be like, what we would really do. I decided that in addition to offering focused cardiologic care, we would also try and get out in the community and increase knowledge amongst not only our patients, but the general community about heart disease and specifically, heart disease in women. So, we see patients here – and a lot of my male patients from when I was in private practice followed me over here – so about 20-25% of our patients are men. They don’t seem to mind coming to a place where “women’s cardiac” is written on the door. And a lot of women we see want us to take care of their husbands, fathers, sons, brothers, so we don’t turn anybody away.
We see patients here four days a week and schedule them between eight in the morning and four-thirty in the afternoon with about an hour break for lunch. One evening a month, we hold a seminar which is advertised on the Lifespan internet and I think in the local papers, and we get members of both the practice… patients in the practice and people in the general community. We talk about topics like hormones and heart disease, or implantable defibrillators or pacemakers or stents, open heart surgery. We have some very, very well-attended diet seminars, particularly the Mediterranean diet. We do that eleven months in the year; we usually don’t have it in December. Also, about six times during the course of the year, we go out into the community and we hold a cardiovascular screening, and I give a talk. In fact, we had one last night at the Jewish Community Center – I think we had a close to a hundred people – where we screen blood pressure, cholesterol, blood sugar, and then I gave a thirty-five minute talk using the title of my book and a PowerPoint presentation. And we have other events coming up in the next few months in Pawtucket, Smithfield and Johnston, and then we also participate in a yearly event at Miriam called “Women’s Wellness Workshop” where women come in for screenings and sessions on all different aspects of diseases. We had a nationally-known speaker, Heloise of “Hints From Heloise”; she’s a newspaper columnist and commentator. So we’re very involved in community education.
I also, partially as a result of publishing this book, have been invited all over this country and a couple of foreign countries also to talk about gender-specific aspects of cardiovascular disease. As I got older, I was less and less enamored of the catheterization aspect of cardiology and more and more interested in prevention. And so now, I would consider myself sort of a general cardiologist, a preventive cardiologist with a special interest in gender differences.
I also have had a long interest in international issues. When I was a young doctor, I spent two years with the National Institutes of Health, and during that time, I was very active with the anti-Vietnam movement. And then when I was at the Brigham, one of my professors was Dr. Bernard Lown, who was an internationally-known cardiologist. He had revolutionized the treatment of myocardial infarctions, and he invented the cardiac defibrillator. In 1981, he founded something called the International Physicians for the Prevention for Nuclear War with a Russian cardiologist by the name of Evgeni Chazov. In 1985, IPPNW was given the Nobel Prize, which Dr. Lown and Dr. Chazov accepted on behalf of the organization. Dr. Lown and I became – even though I was not in his fellowship; we all rotated through all three services – so I got to know Dr. Lown, and we’ve stayed in touch over the years. In 1997, Dr. Lown founded something called ProCOR which is a web- and email-based organization that is combating the rising epidemic of cardiovascular disease in the Third World, and in 2003, he asked me to be an editor. That is pretty much how I spend my days: seeing patients, writing, and having speaking engagements.
How many women do you treat in a year?
I think our patient base now is probably around 1000.
And you said 20-25% of your patients are male?
What is your typical female patient?
We have a computerized database, but we don’t have all of the patients entered yet. So, at some point in time, I will be able to answer your question. But right now, I can’t really give you a hard answer. Our patients tend to either be older patients with established cardiac disease – some of those are recent, some of them we have taken care of for years and years and years – and we also see a fair number of young people who either have a lot of risk factors or have a family history of cardiovascular disease or have symptoms that they fear might be cardiovascular disease but in fact, aren’t. So, I can’t tell you what the typical patient is, but we see a whole range of patients. We don’t see anybody under the age of 18. We don’t have an upper limit; we’ve got patients in their 90s.
When a patient walks into your office, how do you decide he or she is a candidate for surgery?
There are some cardiologists who are very aggressive about recommending invasive therapy. I consider myself fairly conservative. There have been very well-designed studies that show people with chronic, stable angina can be managed just as well by intensive treatment of their risk factors as they can by invasive treatment with bypass surgery or stenting. That’s chronic, stable angina. Obviously, you’ll get patients with unstable angina that need to be treated more aggressively, admitted into the hospital, put on heparin. If that doesn’t work or you have reason to believe you might be dealing with a potentially very fatal lesion, then you must treat it appropriately.
So, the aggressiveness of the therapy really depends a lot on the clinical situation of the patient. If you have a patient who has chronic fibrillation and they can walk on a treadmill for twelve minutes and not have a frightening EKG, that patient’s going to do just as well treated medically or treated surgically. And we know that intensive lipid lowering, for example, will decrease the risk of progression to an unstable, acute kind of syndrome. So every patient is different. You really can’t look at a recipe and say, “This is what I’m going to do with the treatment.”
Do race and gender play a role in treatment?
Oh, there are a lot of studies that show that both race and gender can predict how aggressive doctors are in treating heart disease. It’s obvious to me, with respect to the fact that I see a lot of women who’ve seen other doctors, other cardiologists, and have been unhappy with the care they’ve gotten. They’ll say, “This doctor didn’t listen to me,” or “He just blew me off and told me not to worry.” The first article that really addressed how women were treated differently from a cardiac standpoint was published by a guy named Tobin in 1987, and he looked at 390 patients who had nuclear stress tests. Thirty-one percent of the women and sixty-four percent of the men had abnormal stress tests. And then when he looked at how many were referred to catheterization, forty percent of the men with abnormal stress tests were referred to catheterization; only four percent of the women were. So if you were a man, you were ten times more likely to get what was then considered a definitive study. And this difference was independent of age and not explained by differences in rates of coronary artery disease.
Then Leslee Shaw and her colleagues published this article in 1994 in the Annals of Internal Medicine where they looked at 840 patients. They were forty-five to sixty-five years of age, so they were in the prime coronary artery disease age years. Forty-seven percent of them were women. And there was no difference in the rate of test positivity, about twenty percent of the men and twenty percent of the women had positive nuclear stress tests. But then when she looked at follow-up testing, thirty-eight percent of the men did not have follow-up testing; sixty-two percent of the women didn’t, and that is a statistically significant difference. She then looked at what happened over the next two years, and over the next two years, 2.4 percent of the men either had cardiac death or an M.I. compared to 6.9 percent of the women. Again, that was statistically significant. And she looked at how aggressively they were treated: 4.9 percent of the men had either an angioplasty or a bypass operation compared to 2 percent of the women.
The next study was published by Amy Arnold in the American Journal of Cardiology in 2001. It looked at over 3500 people who came to ER visits with chest pain in the 1990s. Men were significantly more likely than women to have an EKG, and blacks were significantly more likely than whites to have an EKG despite the fact that the American Heart Association and the American College of Cardiology both recommend that anyone presenting with chest pain of any age have an electrocardiogram/ But again, that’s not the recommendation. And then Joan Lehman looked at over 300 patients who presented with nuanced chest pain to an ER at a university hospital in West Virginia and found again that a man was more likely to get an EKG – 94% of the men versus 81% of the women – and men were three times more likely to get a cardiology consultation. They were more likely to get nitroglycerin, aspirin, cardiology consultation, anticoagulants, and thrombolytics, and women were more likely to get narcotics and anti-anxiety medicines.
The study that looked specifically at race was Kevin Schulman’s study which was published in the New England Journal in 1999. It had 720 primary care physicians who were attending either the AAFP or the ACP meetings participate in a survey where they watched a standardized interview with actors playing the role of patients and the actors were said to be either 55 or 70, male or female, black or white. And after watching various interviews, the doctors were then given results of certain laboratory tests to do with either blood work or risk factors. They were then asked to make recommendations about additional care. They found that women were only 60% as likely as men to be referred for cath, and blacks were again less likely to be referred to cath. And black women had the lowest odds of getting a cath; a black woman had 40% of the chance of a white man of being referred to a heart catheterization despite the fact that a black woman under the age of 55 has twice the mortality rate of cardiovascular disease of a white woman of the same age and even higher mortality rates than black or white men under the age of 45. And remember, coronary artery disease presents ten years later in women, so you have to compare women who are ten years older than men to get equivalent data. So, his conclusion was that sex and race both independently influence the doctor’s decision as to whether to refer people for [can’t hear]. A cartoon I often show (shows cartoon): Give it to me straight, Doc. I can take it. What’s wrong with me? You’re not a white male.
How can we interpret all of this data?
I think we can interpret it by saying that doctors treat men and women differently, and part of that is the misconception about the risk. I mean, there are some doctors who still think that cardiovascular disease is primarily a disease of men. And yet, more women than men have died of cardiovascular disease in the last 21 years. And this year, 65,000 more women than men have cardiovascular disease.
Who is responsible?
I think it’s both on the part of the physician and the part of the patient. Women often don’t think they’re at risk for heart disease. And we know that women with chest pain present to emergency rooms later than men do. Now that doesn’t account for the fact that once they get to the emergency room, they wait later for the treatment or therapy. But it is certainly true they present later because they themselves don’t think they’re at risk.
I’ve read that there are actual biologic differences between men and women: the heart for example.
Oh yes, absolutely, there are biologic differences. Women’s hearts are smaller. On average, their coronary arteries are smaller. There are certain aspects of the EKG that are different. A woman’s QT is longer than a man’s QT interval on the EKG, and that may explain part of the increased sensitivity of women to an abnormal heart rhythm called “Torsade des pointes”. It’s what’s called a pro-arrhythmia that you can see in response to various drugs. It appears that we’re just learning about some of the gender differences in atherosclerosis. For a long time, there was something called Syndrome X, and that is anginal abnormal coronary arteries, “normal” coronary arteries. People had known for a long time that that seemed to occur much more often in women. They usually just sort of patted women on the back and told them, “Nothing’s wrong with you dear; it’s all in your head” and sent them on their way.
Starting about ten years ago, a man by the name of Steven Nissen, who is now at the Cleveland Clinic, started doing intravascular ultrasound in the course of coronary angiograms. You’ve probably all heard of ultrasounds of the heart. Well they have little tiny ultrasound transducers on special coronary catheters, and they can put it down the coronary artery and get an ultrasound right inside the vessel. And what they found was, you can have a perfectly normal-looking coronary artery on the angiogram (remember, the angiogram just shows you a lumen, it’s a lumenogram). But if you do an intravascular ultrasound, you can find large amounts of plaque in the wall of the artery. And a lot of these women, when they did intravascular ultrasounds, had significant plaque bursts. Men, however, seemed to get more peaks and valleys, whereas women have a higher plaque burden. [points to slide on computer]
This is a schematic drawing that speaks to this. The yellow would be the plaque that you would see on an intravascular ultrasound. The red would be the lumenogram. This is from a man up here. And right here, it looks like this: a real pinch there, right? And this is the pressure drop across the vascular bed. And you can see that there is a significant pressure drop. This is a schematic of a woman’s coronary angiogram. You can see that if you look at the plaque burden, there is actually more plaque in the woman than in the man. But there is less intrusion on the lumen.
So, you know, someone would do an angiogram on this woman and say, “Insignificant coronary disease.” I try to teach the fellows, “That’s like saying, ‘a little pregnant.’” There’s no such thing. If you have any coronary disease, it’s significant. We know now from many studies that it’s precisely these plaques that don’t significantly narrow the lumen that are more likely to rupture and cause myocardial infarction. And if you look at the pressure drop across this vascular bed, it’s the same as that across the bed that looks a lot worse angiographically. What Dr. Nissen has found is that women undergoing coronary angiography have more diffuse atherosclerosis measured by intravascular ultrasound adjusted for body surface area compared to men. But they have fewer episodic changes, fewer peaks and valleys.
We’re still really in the process of learning what the biologic differences are between men and women. My pet peeve is that we’re all told to practice evidence-based medicine, and yet, we don’t have the evidence on women on which to base because so few women have been included in most clinical trials: not only of medicines like statin, but even medicines like aspirin. I don’t know if you all heard a few weeks ago about the study that was presented at the American College of Cardiology meetings in Orlando last month that finally looked at aspirin for primary prevention in women.
It wasn’t until 1993 that the NIH mandated that women be included in clinical trials of any disease.
Has the situation improved as a result of that mandate?
Not really. For example, the aspirin study, the women’s health study, aspirin used as primary prevention for women came out, and it showed diametrically-opposed results from what a similar study showed in men which came out a couple decades ago. The physician’s health study showed that aspirin (this is in a group of physicians without diagnosed vascular disease and I think they were 50, maybe 40 and above), works for primary prevention of myocardial infarctions in men. You give men low-dose aspirin, and you lower their risk of myocardial infarction. You don’t lower their risk of stroke. Just the opposite occurred when they finally got around to studying women. You lower a woman’s risk of stroke but not her risk of myocardial infarction. And you do it at the cost of 40% increased risk of GI hemorrhage severe enough to require transfusion. But there was an age difference. The women’s health study that looked at this enrolled women who were 45 and above. Only ten percent of the women in that study were 65 or above. But in that group, when they looked at age-specific results, aspirin significantly reduced both the risk of myocardial infarction and the risk of stroke. So, it was not helpful as far as myocardial infarctions in younger women, but it was helpful as myocardial infarctions and stroke in older women. There was a decrease in the overall risk of stroke in younger women at a slight increase in risk of hemorrhagic stroke. But overall, the risk of stroke was significantly decreased.
So, diametrically-opposed findings from what we found in men. Do you all know the difference between a primary prevention trial and a secondary prevention trial? A primary prevention trial is when you gather a group of subjects who, at best you can tell, don’t have the disease you’re testing. You treat half with a placebo and half with an active medicine, and neither you nor the subject knows what they’re getting. And then you follow them over time for predetermined hard-end points. In most cardiac trials, those hard-end points are fatal or nonfatal myocardial infarction, cardiovascular disease death, overall mortality, and some have included things like revascularization and stroke. So, in primary prevention, you’re trying to prevent the first event. Secondary prevention trials, you gather a group of subjects who already have the disease, and you treat half with a placebo and half with a medicine that you hope will prevent secondary or recurrent events.
I looked into this question of primary prevention and the use of statin medications. There have been only three primary prevention trials of statins: West of Scotland trial, AFCAPS/TexCAPS trial, and the ASCOT-Lipid Lowering Arm. Overall, there were over 23,000 patients in these trials. Now, WOSCOP, West of Scotland, had no women at all. It was done in 1990 or the late 1980s. The total percentage of women in the three primary prevention trials was 12.5%. The WOSCOP trial had a positive effect: it showed if you take men without cardiovascular disease but who are at high risk, and treat half with statins and half with placebo, you’d lower their risk of a composite primary end point (myocardial infarction and death).
The AFCAPS/TexCAPS trial had 15% women. That trial, again, didn’t have vascular disease, they had average cholesterol levels, but they had low levels of HDL which is the good cholesterol. They treated half with statins and half with placebos. The trial was stopped prematurely because they got a 36% reduction in the composite primary end point. When they looked specifically at women, while there were 13 events in the placebo versus 7 events in women on statin, that’s not a statistically significant difference.
ASCOT-Lipid Lowering Arm came out a few years ago. This was a big trial in England and Scandinavia of people with hypertension and at least three other risk factors but no diagnosed vascular disease. They did a little better. They also stopped that trial prematurely because they had almost identical 37% reduction in the risk of composite primary end point. In secondary prevention, we have better data. There have been five big secondary prevention trials. That’s shown here. [points to computer screen] And these included over 43,000 subjects, and 25% of them were women. Three out of those five, when we do gender-specific analysis, showed a significant benefit of statin use in women with established vascular disease, but two didn’t. However, all five of those studies, five out of the five, showed a significant benefit in men.
There’s another class of medicines used to treat high cholesterol, mainly high triglycerides, and those are called fibrates. [points to computer screen] This is a meta-analysis that we published in the Journal of the American College of Cardiology just a few months ago. There were 8 fibrate trials that looked at clinical end points; 2.6% of the subjects were women. And the only 2 that showed a significant benefit of fibrates in lowering the risk of a cardiac event had no women at all. So even though the current guidelines suggest treating women with fibrates, we have zero evidence that it’s effective in either primary or secondary prevention.
In your opinion, what is the future of the gender gap? What should physicians be doing?
Someone asked me that at the Cleveland Clinic last weekend. Should we mandate a percentage of women in clinical trial? I don’t think that’s the way to go. I think that we should continue to encourage all investigators to not only recruit more women to their trials but in any study that is published, I think we should keep asking editors to please give us gender-specific analysis. It can be very difficult to tease this data out. I’ve been emailing to the offices of some of these studies when they haven’t included gender-specific analysis, and it can be very difficult. But I think if enough people keep insisting… Look, we want to know. Because now we have very good evidence from the aspirin trial that men and women respond differently to medications. If they don’t present the data in a gender-specific way, I think we have stronger ammunition to take them to task and say, “This is not enough information. We want to know how the women did, not just the composite.”
Where do we go from here?
I think an educated population is the best defense against it. I think the more every individual takes responsibility for learning as much as they can about their own health, then that will push the doctors to do what they need to do. Doctors are under tremendous stress right now, particularly primary care doctors. They’re asked to do too much in too little time.
Overall, what is your advice to women regarding cardiovascular disease?
First of all, 80% of it is preventable, and it is very easy… or very difficult, depending on how you look at it. If you smoke, stop. If your blood sugar, blood cholesterol, blood pressure or weight are high, get them down. Do aerobic exercise for thirty minutes a day. Eat a heart-healthy diet, and pick your parents wisely. That’s all it takes.