Think you're too young to have a heart attack? Not according to this cardiologist. Watch why.

0:01 Thanks for watching episode #134 of the Doctor Podcast Show and I'm your host as usual, Doctor Robert Sikers, please subscribe to and follow Doctor podcasts and like and repost this and other episodes that you watch. It will get us more great guests and make you smarter when it comes to health and medical matters. Today's show is on a subject on everyone's mind, and that's your heart, very important organ in the body. Specifically, we're going to discuss the subject of heart attacks, which is one of the leading causes of death in the USA, and how to prevent them.

0:36 There's been an alarming increase of heart attacks in younger people and today's excellent guest has researched this issue extensively and has recently published an important article about it in a major peer reviewed medical journal and we'll get into that in in more detail. Our excellent guest today is Doctor Mohan Satish. Dr. Satish is a clinical cardiovascular disease fellow and a postdoctoral fellow at the Division of Cardiology at New York Presbyterian Weill Cornell Medical Center here in New York City.

1:10 He completed his MD degree at Creighton University School of Medicine followed by an internal medicine residency at Mount Sinai here in New York City. And currently he's a three-year fellow. That adds up to about 10 years of training, which is incredible, a long time. As a rising cardiologist and researcher, Dr. Satish focuses on cardiovascular epidemiology, heart attack trends, sex based disparities in heart disease outcomes, which we'll discuss in in detail, and the evolving role of traditional and non traditional risk factors in younger populations.

1:46 He's the lead author of a recent study published in the prestigious Journal of the American Heart Association on February 26th, just a couple of weeks ago, titled Sex Differences and outcomes of Young adults Hospitalized with first myocardial Infarction, which is the medical term for a heart attack from 2011 to 2022. So it encompasses an 11 year study. The article highlights concerning rises in hospital mortality for first heart attack cases in adults under 55. I was surprised to hear that there's a a large number of people under 55 that are getting heart attacks, and particularly among women.

2:28 His work emphasizes improving early risk identification and addressing health inequities in cardiovascular care for young adults, contributing to broader efforts in preventive cardiology and outcomes research. So, Doctor Satish, thanks for taking the time from your busy clinical and research schedule to share your important findings with us. We really appreciate it. I just want to 1st thank you for this opportunity. Thank you for your interest. Your podcast definitely serves as a wonderful resource to the community and likewise for the broader public.

3:02 So it's wonderful to to be able to use this platform to discuss this very important topic. So thank you again. Thank you. Thanks for taking the time. So first, can you provide us with an overview of the current prevalence of heart attacks in the USA including how many annual cases are there and the and the proportion that are first time versus recurrent heart attacks and are there any shifts in these numbers recently? Absolutely. And I think we're, I'm fortunate that we are all be able to, we're all able to be served by more recent data that was published within the within the last year.

3:34 But we're seeing that the annual case case rates are roughly around 800,000 cases per year of acute monocortic abortion. So just under 1,000,000 cases. And then when we look at case fatality, case fatality is just under about 100,000 cases. So if you, you know, look at the relative proportion, that's about just under 10% of those cases or just just about 10% of those cases, of which about 75% of those cases are first time MI cases and about 25% or 1/4 are recurrent cases. And you asked about sort of the trends and over time in terms of those two subtypes, what we're seeing more and more is that obviously we're we're getting better at treating those recurrent MI cases and as a result the relative proportion of first MI cases are increasing.

4:14 So, and obviously that's concerning because you know, the, the true or the inherent or intrinsic understanding of the first MI is that these folks had no sense of their, of their underlying risk. And they're presenting obviously before establishing much of their, their risk factors or even their coronary artery disease, which is obviously the precursor to their to their event. Right. When you say MI, that stands for myocardial infarction, which is the medical term for a heart attack, right? That is correct.

4:40 Yeah. So how has the incidence of heart attacks among young adults under 55 changed in recent years? And what data highlights that rising burden in this demographic group and especially women? Absolutely. I think the thing that was concerning for us is the most recent data which is hospitalization based data, which gives us the the the best sense of what's going on in terms of the incidence of disease is actually increasing in younger folks less than the age of 55. When we look at Myer cardio infarction trends, this was data that was published as recent and with trends leading all the way up until 2019.

5:17 And then subsequent data that we presented that this is actually very much the case both before, during and likewise after the the pandemic with relative plateaus when we compare any of these trends relative to older adults 55 years and older. So that is very much what we're seeing in terms of incidents. And then obviously, you know the mortality from an acute myocardial infarction is a different set of trends and data, so OK. Now could you discuss the key risk factors for heart attacks which traditionally are hypertension or high blood pressure, diabetes, smoking versus emerging new non traditional trends such as socioeconomic factors, drug or substance abuse and also chronic kidney disease?

6:00 Absolutely. And I think there's it's sort of A2 pronged discussion. One first, what's been going on with traditional risk factors, right. So traditional risk factors for the most part we've done excellent. We've done excellent things to help control certain risk factors like with the widespread use of lipid lowering therapies or cholesterol lowering therapies like the widespread use of statins. And we've also made quite a bit of a gain in terms of smoking cessation and trying to improve the public awareness of the importance of smoking cessation.

6:27 But where we're sort of missing it from the traditional risk factor senses. What we're seeing now is the rising rates of obesity and likewise the greater prevalence within the younger population in that sense to explain some of the event data that we're seeing. Event data in this sense in terms of myocardial infarction, So what we call sort of this metabolic sort of sequelae that are leading into myocardial infarction. So obesity, diabetes, all predisposing. Likewise hypertension, even though we've done a great job in terms of screening for for hypertension, the obesity is sort of your precursor for hypertensive disease in many cases.

7:00 And we're starting to see that the prevalence of hypertension is very much not really mitigated over the last 2020 odd years in the in the most recent estimates that we have. And then in terms of the non traditional and emerging risk factors that prong of the of the discussion, yes, you're absolutely correct. We're we're starting to see that, you know, we're seeing non traditional risk factors like non tobacco drug use, socioeconomic status, chronic kidney disease, which obviously has a lot of time with traditional risk, but can have a lot of time with non traditional risk elements.

7:27 And then factors such as psychiatric disorders really finding their way into the discourse and more so again, within this younger population. And some of that discussion as far as where the mechanisms stand is, you know, very much an interest in sort of the biological mechanisms. But as inherently as some of these risk factors might suggest there, there are sort of other impact or or mechanisms that are at play that seem to maybe make it difficult to because of those non traditional risk elements to control traditional risk.

7:56 I mean, if somebody has, for example, psychiatric risk, that very much would complicate somebody with overlapping traditional risk. So starting to understand those relationships are becoming also critical as we see these risk factors start to emerge. Now, what do the national data show about sex or gender differences in heart attack occurrence, the severity of the heart attack and outcomes across all different age groups, and how these patterns differ in the younger versus the older adults? Absolutely great question.

8:26 The first way to take this is the sex based differences, which I will say for the most part are actually not quite different in the older population, as we see in the younger population. When we look at the differences between young men, young women and older men, older women, we published a study in just at the end of August in 2025 last year in Jack advance is where we actually wanted to answer this very question, which was sort of the initial inspiration for the analysis that we we otherwise discussed with with our with our discussion for today.

8:54 And what we saw actually is that women have a greater burden of these non traditional risk elements that I described. And again, very much the case whether you look at it in the older population or the younger population. Now in terms of the actual types of subtypes of MI, we looked at all first MI cases in that in that paper, but in that study. But what we also noticed is that some of the more severe forms as it's called or STEMI or St. elevation myocardial infarction were higher in proportion in males as compared to females.

9:23 And likewise, we actually found that that was also higher in proportion in younger adults overall as compared to older adults. So the fact that they're having this more severe form of myocardial infarction was quite surprising. And obviously it sets the stage to ask 2 questions. 1, Is this a factor? Is this a product of risk factor control that's just not being addressed? So obviously as risk factors progress, you have more delayed disease presentations and that, you know, can be the that can set the stage for a more severe form of heart attack or two.

9:50 You know, why are we also seeing these sex based differences? Is there something about sort of the traditional risk elements or the non traditional risk elements within men specifically that we saw that they have a higher proportion of, of this more severe form of heart attack proportionally? But, but obviously when we start to look at outcomes, you know, different stories, you know, takes, takes, takes flight. So and I'm sure we'll we'll talk about that. Right now, you mentioned socioeconomic factors.

10:15 To me that implies it, that certain patients just don't have access to doctors and medical knowledge and information and so they're ignoring or not aware of the risk factors. Is is that how the socioeconomic component fits in? It's an access problem. Absolutely. That there was an excellent piece of work that was published in the European Heart Journal in 2025 that was looking at first MI events and actually looking at the percentage of folks that had no documented risk factors. And found particularly in the younger cohort that there was a high prevalence of folks with no documented risk factors and interestingly enough had a high burden of low search economic status.

10:52 So it is that of course observation of the nature of that data, but it would seem to suggest that that is one of the things that seems to be suggesting that this this group of and this population seems to be impacted by low socio economics such that we don't know what their risk is. And unfortunately their presentation is very much at the time of their event and not at the time of when their risk factor is being identified, right. So. Instead of coming in for checkups and exams they they come into the emergency room with with chest pain and and a heart attack.

11:21 Unfortunately correct, correct. Now what are tell us what silent heart attacks are and what role do silent or unrecognized heart attacks play in under diagnosis of of MIS or heart attacks and and what are the estimated statistics on their prevalence and is is that higher in diabetic patients? Great, great series of questions. The first thing to understand is that a silent MI is one that is actually based on an ECG and electrocardiogram based diagnosis. So most of the time this is happening unfortunately retrospectively or retroactively when we're seeing somebody's ECG in any sort of clinical setting.

11:58 They could have been hospitalized for heart failure, they could be in the in a clinic visit and that's when we're picking this up. So for that reason, most of the data that we have is based on like cohort data that have looked at looking at ECG or electrocardiogram data, which you know, large administrative databases such as the national inflation sample do not, do not have. So when we look at that prospective cohort data, what we're finding is that these folks actually tend to, they make up of all MI cases roughly between 30 to 50% of all MI cases.

12:26 So that's huge. That's huge. Absolutely. So it makes you question naturally when you look at these large population studies, the true incidents because you would you would you would be under the impression that if we're not capturing these these cases, these silent MI cases, that the true incidence of MI is probably a little bit, not a little bit, but maybe substantially higher than probably some of the estimates that are being presented. So that's number one. Number two, what we've recognized from the same cohort studies is actually that the risk and likewise the outcomes from those who have silent MI tend to be almost three times higher in terms of the ventilates compared to somebody with an incident MI or at least what we call a clinical MI, an MI that's presented sort of traditionally and classically.

13:04 And a lot of that obviously has to do with the fact that, you know, silent MI obviously are probably products of unrecognized and, and sort of progressed risk. And one of the major risk factors is the one that you brought up, which is diabetes. And at least our understanding in the in the context of silent MI is that they don't have sort of the classic symptoms that obviously present traditionally with a with a myocardial infarcum. And as a result, we're seeing sort of an higher burden within the diabetic population.

13:30 But also another population is women. Women have a higher burden as as in within the same cohort studies of silent M is as well. And I think I think for those for those two reasons, I think that's that's speaking towards some of the both the sex based differences and likewise some of the issues that we're seeing from the the rising rates of cardio metabolic risk as I was mentioned earlier, particularly in the younger population when we talked about obesity and diabetes etcetera. So that's critically important, especially for women to get checkups earlier, especially if they have obesity or diabetes or high blood pressure because they may have a heart attack, not have the typical chest pain, shortness of breath symptoms, and they progress with their heart disease and then wind up in in serious problems like heart failure, which is difficult to treat.

14:19 Absolutely, absolutely. And I think, I think that's a community from the physician standpoint and from a research standpoint, it's actually trying to understand what are the different diverse symptoms that silent and mice could present with. So that is that's sort of the the, the next, the next frontier in a way. Do we know why diabetics have silent eyes? Is it that their nerve supply to the heart is is adversely affected by the diabetes so they don't get the typical pain symptoms? That's actually one of the leading thoughts behind this, because it's the same neuropathic compromise that otherwise explains some of their peripheral neuropathy.

14:51 That seems to explain the the differences in pain perception as well. Now what about trends since COVID start in 2020, it's about 6 years now is have we seen an increased trend, increased heart attacks or is it about the same? And is there also a sex difference since COVID start? Yeah. So I think you know, when if we look at this in terms of all, all types of mortality, which we can derive mostly from death certificate data, which is one of the data sets that's often used, which is called the CDC wonder.

15:22 A lot of the trends that we saw in terms of the reductions in mortality from heart attacks from myocardial infarction continued just before the the pandemic in 2018-2019. And then we saw a little bit of a blip in 2020-2021 in, in terms of those mortality trends. But then the same folks that wanted to look at those data sets that are published work from their data sets now start to see a decline in mortality across age subgroups after about 2022. But some of that data obviously doesn't extend beyond 2024.

15:53 The in hospital course, we also saw similar reductions and maybe a little bit of a blue, but during the pandemic that has the question is what's going on now sort of after the 2022 feast. And that's where our paper has an interesting spin on things because we looked at in the context of first MI in young adults, first myocardial infarction in young adults. We're actually seeing that mortality was actually increasing before the pandemic, during the pandemic, very much after the pandemic. So a lot of a lot of how we look at trends, and I know this is maybe a little bit different from the question you asked is specific to the what population you're looking at and what type of subtype of MI that you're looking at.

16:26 And specifically where we're seeing that increases with the most severe form, which is the SD elevation myocardial infarction. So it's a little bit of a puzzle. I was thinking that maybe the first two years of pandemic, people stopped seeing their doctors. They were afraid to go to hospitals and physicians offices and so that accounts for it. But you're saying it it's still continued afterwards, is that right? It it did very much so, at least in the context again, of in hospital mortality from St. elevation my in young folks, which the argument to be made from that is because if you if you see reductions in death certificate data and you're trying to superimpose those two pieces of data together.

17:05 The thing you need to ask yourself is that that's very much treated risk once somebody leaves the hospital, right? So your mortality is informed by the fact that you're treating that risk now, whereas the mortality within the hospital that continues to climb. That's very much what's happening in the hospital and some of the prevention aspects that are of interest well before we can start to talk about treating somebody that now has had myocardial infarction event. So that's why, you know, the data is still concerning even if we see declines from that certificate data.

17:30 So trying to superimpose that is important for the community to understand. All right, Now I want to go a little deeper into the article that you published in the journal American Heart Association, February 26th. Just a a few weeks ago, you used National Inpatient Sample data from 2011 to 2/20/22. What inspired you to focus on this with regard to 1st myocardial infarction, specifically in young adults from age 18 to 54? I was shocked by that age. And why did you stratify the STEMI versus non STEMI type of heart attack and also stratify by sex?

18:09 Why? Why did you want to do that? Absolutely. So I'll take these in series and I appreciate all these questions because they're they're critical. I mean all of them are critical. One, as I mentioned, we had published in, in Jack Advances in the journal American Cardiology Advances Journal in late September, an article that showed that within those young folks ages 18 to 54 and I'll explain why that age subgroup we saw, we looked at risk factors with the first heart attack event and all first heart attack events.

18:35 And we saw that risk factors, both traditional risk factors as we've discussed and non traditional risk factors as we've also discussed are increasing quite a bit in in the young adult population as and likewise much so as compared to older adults. We compared it to older adults in that analysis. So that served as a critical point of inspiration to say, OK, well, the risk factors are increasing. What's actually happening with these hospitalizations? So quick aside, why did we look at, why are we calling young folks 18 to 54?

19:00 Because if you look at the literature of young folks can have a very, very definition. And I, my special place in cardiology, in my heart in cardiology is very much in the prevention space. And the way our risk tools are designed are when we look at long term risk estimates with like 30 year risk estimates, those 30 year risk estimates are validated for folks that are between the ages of 30 to 59 years. So if I'm looking at this from a prevention bent, I'm very interested in the risk factors that are potentially at play for those who are less than 60 years old.

19:29 And if I, you know, if I match this up with census based restrictions with the data set, that gets me an age subgroup between 18 to 54 years. So that's the rationale for that subgroup and very applicable, because anytime we're talking about long term risk estimates is very much going to be for a young individual than it is going to be for an older individual. And then why in terms of looking at this in terms of sex based differences, I'm going to cite that same paper again, because again, we saw that these non traditional risk elements were much higher in young women as compared to young men.

19:55 So we said to ourselves, you know, if if we're going to tackle the question as to what are the risk factor impacts with outcomes in the hospital after a heart attack or myocardial infarction, the best way to do this would be to look at it in a, in a, in a sex based difference and look for sex based differences as well. And maybe they won't exist, but at least let's let's look into that and make sure that we're not missing that right? And then why we also looked at different types of heart attacks is because when most of the studies that we've looked at prior to our analysis that in prior analysis of ours in August and likewise prior to that is that we've grouped together these subtypes of both SD elevation MI and non SD elevation MI together.

20:29 And we've not been able to tease apart the differences in terms of risk factors and likewise the true outcomes between the two. And why pooling together might muddy the waters a bit is because obviously SD elevation of mine is a more severe form of, of a heart attack. And in many ways. But in addition to that, with the advent of high sensitivity troponin and when we see the greater detection of non SD elevation MI, it might be that we're just going to sort of dilute differences if we, if we pulled it.

20:57 So we thought to ourselves, let's, let's take this a little bit more grinder and let's dig a little bit deeper and compare this by MI subtypes as well. And I think that's actually one of the reasons why we saw the outcomes that we saw particularly with St. elevation MI. And because that is a pure trend that is associated with STEMI relative to and STEMI where we saw that, you know, mortality had not declined, it had rather was relatively unchanged relative to the increases that we saw in St. elevation MI.

21:20 So that was more of a rationale, but there's just to talk about it in three different ways, I guess. Right now the STEMI you're referring to is a finding you see on the EKG or ECG, the electrocardiogram that the patient has. And from what you're saying, I think the these ones who were STEMI had more severe heart attacks. That is correct. I think you know, severe and not and less severe perhaps in many ways seems to be sort of a bifurcation that the community and likewise the literature seems to utilize that.

21:53 I don't know how I feel as strongly about it. I feel more like it's a matter of emergent versus urgent. And yes, it is very much an electrocardiogram based understanding by which we are, we make that decision. But the thought is that you're dealing with a complete blockage versus maybe potentially A partial blockage in one of the vessels supplying blood to the heart. Right, that's what caused the heart attack is a reduction in in blood supply. So the STEMI probably has a a worse type of obstruction.

22:19 So less blood and oxygen is getting to the heart muscle, correct right now. Another thing I I found peculiar in the study is that young women had higher in hospital mortality than men for both the STEMI type and other types of heart attacks. What are the possible explanations for that? Since they're they're both in the hospital, that care you would think would be the same? And is it biological differences, hormonal differences? Are there diagnostic delays or treatment biases? What did you find about that?

22:55 Absolutely. I I think, you know, it doesn't form also our understanding of mortality between the two populations, young men versus young women that when we look at the complications, particularly if we take it in the context of first first elevation, first SD elevation in my, my apologies. We saw that even though those overall complication rates were similar, the specific types of complications in young women that were higher were things like cardiogenic shock and likewise cardiac arrest. So those are more likely than major bleeding events or for example, acute renal failure or kidney failure to portend a higher risk of mortality.

23:33 So that's 1/2. I want to go back to the risk factor sort of discussion that we had that with the presence of a higher prevalence of non traditional risk elements in women and the fact that we saw that these non traditional risk elements seem to for more so than the traditional risk elements impart a higher degree of association with mortality within the hospital. The fact that we saw that more so within young women is a second reason. So the fact that they have a higher prevalence of these non traditional risk elements.

24:00 The third element is the fact that like you mentioned, some of it is what's going on in the hospital. So the fact that we saw that there's less cardiovascular procedures being performed in younger women is a product of perhaps you know, the fact that we are not recognizing that risk and imagine if that. Let me just ask, when you say the procedures are, are you referring to angiograms or are you referring to stents or what specifically are the procedures? Absolutely. SO33 procedures, an angiogram for sure to look for a potential blockage, A stent if it needs to be placed, which obviously can be done with a potential angiogram.

24:33 And then the third thing is actually surgery to open up a blockage as well. So these were the three sort of types of cardiovascular procedures. All bypass. Bypass exactly correct. So, you know, what's interesting is that one, it's the recognition aspect that you brought up, which is absolutely which obviously we cannot identify from this data set, but we can infer that that is possibly one of the reasons why, particularly with the higher burden of non traditional risk. The second element is the fact that when we see these procedures, a lot of these procedures are for what we say, true blockages or atherosclerotic causes of heart attacks.

25:06 But what's interesting is that there are non atherosclerotic or not, you know, not really those true blockages in vessels to explain causes to explain heart attacks in myocardial infarction. And what we're realizing in the literature is that those other causes of heart attacks are very diverse and much more prevalent within within women, particularly young women. So in that setting, these procedures, not only is it that they're not receiving those procedures, but even those procedures might not necessarily be a benefit for them if they have one of these other ideologies or causes for.

25:35 And I think that's an important point that we're realizing with women, particularly young women. And that might explain why we see higher complication rates if we're not really treating what we think we're treating right or, or what we're not identifying what we're truly trying to identify. And likewise explains the the mortality rates that we saw, the differences in mortality between young men and young women. Can you name just a few non atherosclerotic causes for heart attacks and relatively young women?

26:03 What? What could cause it if it's not a build up of plaque in the coronary arteries that supply blood to the heart? Correct. So the actual, the actual blood vessel, the coronary artery itself can dissect or tear as it's called. And that's called the spontaneous coronary artery dissection, which happens much more so in in women than in men. And that can be a cause of a heart attack. And, you know, there's certain, you know, genetic and what we say, collagen vascular disorders that seem to cause it.

26:30 But in addition to that, there's obviously some of the more traditional elements like hypertension and hypertensive disease that also seem to be a 'cause as well. Another cause, and that kind of comes up quite a bit is actually something that's called plaque erosion, which brings up another interesting sort of discussion, which is that plaque erosion is not necessarily a true blockage, but it can be based off of inflammation within the vessel that's causing the vessel to later block off. And this is not necessarily because of traditional risk factors, but because of just underlying inflammatory processes that seem to be targeted within the the coronary arteries themselves.

27:04 And this has brought up an interesting sort of discussion in the community about using ways to image the coronary vessel itself in the, in the cases of these heart attacks and monocardial infarction to get a better sense if what the underlying causes of the heart attack. Because sometimes if we do use those imaging techniques in, in during an angiogram, for example, we might find that there is not a blockage. But obviously time is, is very much money in those situations. And you know, and the advent of using coronary imaging and imaging those blood, blood supply vessels is, is complicated, but it's become a, a topic of discussion, especially when we consider these different ideologies in young women, right?

27:41 So women watching this program, even if they're young, are probably going to get a little frightened about this topic that we're discussing. So what should a woman do to make sure she doesn't have these underlying risk factors? Should she have an annual ECG and then what age should that start? Or check her cholesterol and blood pressure? What? What do you recommend for women to do to avoid becoming one of the participants in your study? Well, what I, what I want, what I will say is that I would hope that women don't fear in the sense of that we don't know what to do about things and that we don't have ways to fix things.

28:25 We do the, the issue more so is identifying the problem. So, you know, I don't think the guidance is any different than the guidance that we were dealing with five and 10 years ago, which is that, you know, getting yourself to a General practitioner and getting yourself with your, you know, your annual check UPS, making sure that you're having the, the, the known documented screenings that we know that work for your blood pressure, your cholesterol. And one of the things I want to are, are critical.

28:49 And one of the things I want to emphasize that doesn't get talked about as much. And I think are, is particularly important within young people overall. But you know, again, also within young women is understanding two things. One is women also have, like I mentioned, the greater burden is non traditional risk elements. And some of the non traditional risk, one of the sort of compartments that we didn't discuss is female specific nontraditional risk factors which stem from pregnancy. So gestational diabetes, preeclampsia, these things that you wouldn't have thought about that, you know, were an issue for you during your pregnancy suddenly might have been maybe the first sign that maybe you need to have keep a closer eye on your cardiovascular disease health and your health in general.

29:25 So that's one. The second one is family history. And that applies to both young men and young women, which, you know, we don't do a great job as providers, I say, of asking the questions about family history. But what's becoming very apparent in these studies is that family history is quite prevalent in these events of these heart attack events in in young people. And maybe it's a proxy for genetic risk. But I think it comes on to the patient as well for young women and young men to sort of get to know their family history to, you know, start to understand it in a more granular fashion.

29:53 I mean, maybe grandma had this, but what exactly did grandma have? And trying to make sure you communicate that to your doctor when you do show up for those general visits. So I think those are all all things that are applicable both with the young population and likewise with women specifically, right? Did you find any data on on menopause as a as a risk factor? I was under the assumption that estrogen kind of protected you from heart disease. Is that true? So we didn't look at menopause specifically, but in our prior analysis that I cited earlier, when we looked at risk factors, we did see that just the overall trend and what we say female specific factors are you know such as preeclampsia, gestational diabetes.

30:33 When we looked at a composite, we saw that that was increasing over time in terms of heart attack, the prevalence within heart attacks within young, young women. And then in addition to that, in terms of what you just brought up in the context of the hormonal benefit. One of the things that we see is that the age of the young woman and the age of the young men in our study were fairly similar. And this is very different from the epidemiology of heart attacks and myocardial infarction in the past where for the most part, women present later and men obviously present a little bit earlier.

31:02 And some of that was actually the thought that because women have some hormonal benefits that they lose only later on in life with the with the start of with the inception of menopause. But what I think we're seeing now is that because of the rising burden of these traditional elements and these non traditional elements more so and likewise more so in young women, I think we're overwhelming some of the more protective factors that women might intrinsically have that we're starting to see women present much, much earlier than they were.

31:27 And I think that is a shift in the epidemiology of heart attacks and myocardial infarction that we've not seen previously. And you know, this analysis and likewise other analysis are are starting to show and I think it's quite concerning. Right. So even premenopausal women. Yes, absolutely. Right now, you mentioned earlier that there's similar in hospital complication rates between sexes, but clear outcome disparities. So what changes to clinical guidelines or hospital protocols do we need to make for treating young heart attack patients?

32:01 Absolutely. I, I think this is a very multifaceted question. And I think that what I'll say first is that it's very easy to say symptom recognition, not having, you know, treatment biases or, or clinical care biases when we see young women with all these non traditional risk burden or atypical symptoms. But also we have, we have risk calculators that assess somebody's in hospital risk of death from a heart attack when they come into the hospital and they're called the grace risk score, Tini risk score.

32:29 These are these are things at the disposal of the provider to get a sense of, you know, this is somebody that I need to risk away for an angiogram to look for a blockage. And some of those risk scores were developed in ways where they were predominantly populations of, of men and developed in ways that were not particularly beneficial maybe to women. There's been a great, great initiative in the community, particularly combined within Europe and, and within the US trying to improve that in a sex based fashion, to try to improve those risk scores by validating them within larger populations that incorporated women and likewise with models that were sex stratified models.

33:05 So that we're studying the specifically in women and studying this performance specifically in men. And actually there is a, there's from the university deserve one of my colleagues who has come out with what's called the GRACE 3 point O risk score to help clinical clinicians make decisions on whether or not this is somebody that needs to be whisked away. And we, we're already seeing that the predictive performance of those risk tools are much better than the, the prior grace risk scores that were previously utilized.

33:28 So that's one. And then two, I talked about it in terms of the, you know, the context of of risk factors. And I think that we have gotten very good at developing even these prevention based risk tools in a sex stratified way. But they are so grounded in these traditional risk elements that if women have a greater burden of nontraditional risk, I think what we're seeing in the hospital is that maybe some of their outcomes and complications are products of the fact that they just have very delayed disease presentation, which is that no matter how good things go in the hospital, it's, you know, or how good things could be in the hospital, they're just presenting way too late.

34:03 And I think we need to get good at recognizing this risk earlier on in women to to to rightfully so improve the outcomes of what happened to women who potentially have a heart attack in the hospital. So, so trying to understand the non traditional risk is particularly important within the within women and trying to leverage that with the traditional risk models that we have. But recognizing that the traditional risk models go only in so far as recognizing somebody's risk based on, again, their traditional risk, and trying to find ways to understand the association between the two would be absolutely critical.

34:35 Right now you mentioned in your study about the substance or drug abuse as being a a risk factor. How does that become a risk factor for for heart attacks, drug abuse and and substance abuse? I know cocaine can have harmful effects on the heart, but what about other drugs? And which drugs specifically? Sure. So in the in the context of this study, it was very much a composite of what we call basically non alcohol and non tobacco based drug use. So this included stimulant use, this included cannabis use.

35:06 So it was a wide variety of of drug, non tobacco drug drugs that were that were assessed. So for that reason, it's hard to make individual associations with specific non tobacco drugs. But having said that, there's obviously been some literature to suggest from a purely from an observational standpoint, I think some of the mechanistic data is yet to be seen that there's independent associations and potentially independent mechanisms associated with myocardial infarction and heart attacks itself.

35:34 So that's that's one. But two, what I think is overwhelmingly present when we see this is that is this a proxy of somebody who has difficulty in controlling their traditional risk, right. So we know that a lot of non tobacco drugs actually do increase the risk of the risk factors themselves like hypertension. I mean cocaine and many and many of these stimulants increase your risk of chronic systemic hypertension. And if that is going to be sort of the first thing, I mean, now we're talking about primordial prevention, which is how to prevent the risk factor itself.

36:04 And that sets the stage, of course, for, you know, developing A chronic disease that later becomes potentially the precursor for your, for your disease event, your cardiovascular disease event. But it also could be that it also signifies that non tobacco drug use shows issues with adherence and, and compliance with traditional risk factor control as well. And that's the same thing that we're seeing with some of the studies that have assessed psychiatric illness and risk factor control, like, you know, somebody who's trying to control their hypertension, but seems to have comorbidities that are include psychiatric illness.

36:35 So I think it's there's sort of three different things, understanding the biology and potential mechanisms that could exist, understanding that this could impact the traditional risk itself, the the the risk factors themself. And then trying to understand some of the the more nuanced aspects as to maybe this is just a proxy for somebody who's not controlling traditional risk. And that's really what it is and it doesn't have something to do more intrinsic with the risk factor itself, the non traditional risk itself, right?

36:58 So there's there's probably a big overlap between the traditional risk factors, the the newer non traditional ones and the various socioeconomic and drug abuse factors. They all overlap. They're not completely independent risk factors. So it's it's difficult to weed them apart. Absolutely. And what I will say is that when we did our first analysis that I had described, but the risk factors within first heart attacks, 96% of those young folks had at least one traditional risk factor. And that in itself sort of speaks to the fact that, you know, if I do see non traditional risk, you know, how much of that is impeding even that one traditional risk element, which is again, either obesity, smoke, tobacco smoking, hypertension, diabetes or dyslipidemia.

37:39 So it, it is very much a question that we need to understand and, and answer because especially when we see the, the, the shift in the phenotype of heart attacks in young folks towards more of this cardio metabolic where we're seeing a higher rates of obesity, higher rates of diabetes in, in this population and likewise be the reason for for cardiovascular disease events early on. So that's good. So I, I want to congratulate you on doing this, this great study, which hopefully will bring to light all these non traditional risk factors that maybe doctors are kind of ignoring or not aware of.

38:14 And hopefully this study and many others like this and your continued research will bring this to light and we can reduce the risk of people getting heart attacks and other morbidities associated with that. So thanks very much. I also want to thank you for taking time again from your busy schedule to educate us and sharing your knowledge and wisdom with us about this topic. Hopefully it'll get people to look into this some more, see their doctors, and control all the traditional as well as non traditional risk factors.

38:47 So thank you. Thank you very much. A lot of work to be done. This is just the start, but I appreciate having a platform to talk about these things. And I hope that we can all make a small dent in this in one way, whether it be in our community, in our clinical practice or just otherwise in the discussions that we had with our family and friends. So thank you again. My pleasure. Thanks.