Heart to Heart with Merz

A local cariodologist, recognized worldwide, speaks on heart disease

Palisadian Dr. Noel Bairey Merz is a world-renowned expert on heart disease in women and has appeared on numerous national television and radio shows to speak on the subject. She took time from her busy schedule as medical director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center to get the “heart” message out to women. ‘Heart disease is the leading killer in women,’ Merz says. By heart disease she includes cardiovascular disease and stroke. ‘As a proportion, there are more strokes in women than in men.’ Every year since 1984, more women than men have died of heart disease. Heart disease also claims more women’s lives every year than breast cancer, although most women would say that breast cancer is a greater danger. In 1999, 41,000 American women died from breast cancer: cardiovascular disease killed 513,000. Both sexes suffer large artery blockage, which means the artery lining becomes hardened and swollen with plaque (calcium and fatty deposits and abnormal inflammatory cells), minimizing or stopping blood flow. An angiography is used to diagnosis this condition. Unfortunately, in addition to heart disease, women also suffer from large and small artery strokes in a ratio of 3 to 1 to men. In the artery lining in women, the plaque is smooth and even, unlike in their male counterparts, which means the condition isn’t diagnosed through an angiogram and, quite often, is misdiagnosed because the symptoms for heart attacks in women are different from those in men. ‘Symptoms in women can include persistent chest pain or pressure,’ Merz says. ‘Patients describe it as a constricting band or ‘elephant on my chest’. They have fatigue and shortness of breath. Often the women have already had an angiogram and were told that nothing is wrong.’ Why do more women have small artery disease? Women have smaller arteries than men and although size might be part of it, more probably, it’s sex-related. “If you take a male donor and transplant that heart into a female, the arteries will not change, they will stay large,” Merz says. “If you take a female heart and transplant it into a male, the arteries get larger.” Part of the problem with heart disease in women is that it has been studied extensively only in the past 10 years. Tests that have been developed over the years have been geared towards males and large-artery blockage. At Cedars-Sinai Women’s Heart Center, doctors look for heart disease that may have been overlooked by using invasive coronary reactivity testing. In addition, Merz is at the forefront of trying to validate whether cardiac Magnetic Resonancing (MR) can also pinpoint small artery disease, which would be preferable to any kind of invasive testing. If a woman is diagnosed with heart disease, the treatment is medical and can take four different routes, depending on the cause: 1) If it is endothelial (the single layer of cells that line the heart and blood vessels) dysfunction caused by smoking or borderline cholesterol, the risk factors are addressed. 2) If it is a genetic micro-vascular disfunction, the patient may be given beta blockers. 3) If it is a smooth-muscle disfunction of Princemetal’s angina, the patient may be given a calcium channel agent or a smooth-muscle relaxant. 4) If a patient has a combination of problems, she will be treated with a combination of medicine, diet and exercise. Merz is convinced that the heart disease found in women in their 40s, 50s and 60s coincides with their slowing metabolism as well as less exercise. When you exercise, nitric oxide is being stimulated, which is important for the heart. ‘I had one lady who was doing well, then went on a cruise, stopped exercising and started eating and when I saw her again, she had slid back,’ Merz recalls. “Generally, the ladies who exercise every day can minimize their medication,’ Merz says. Merz, who in addition to being a full-time doctor, is a mother of three girls. ‘After having children, I became the last priority,’ she says, so she understands when people tell her they don’t have time to exercise. After having her third child, who is now 14, Merz stopped eating dessert. She runs two to three days a week on average, but on the days she doesn’t run, she takes the stairs to her office on the ninth floor rather than the elevator. “Fewer than 20 percent of Americans get regular aerobic exercise, which contributes to heart disease,” Merz says. She is sympathetic and understands that people do work hard and don’t feel as if they have time to exercise, or they work in areas that are unsafe, which doesn’t allow them an environment to exercise. According to Merz, the healthy-heart formula is simple: 30 minutes of walking a day, which is about 10,000 steps. ‘If people want a cheap insurance card, that is it.’ Merz urges people to buy a pedometer and wear it. By doing so herself, she has discovered that she takes about 6,000 steps a day at the hospital, so by adding the stairs instead of the elevator or walking a little more, she reaches the prescribed amount. The doctor also enjoys a glass of wine with dinner. ‘Research is clear that people who do enjoy alcohol in moderation have a greater longevity than those who don’t drink or drink too much.’ Her husband, Rob Merz, is also a cardiologist. ‘After taking care of heart problems all day, we shifted our style of eating to a more Mediterranean model,’ she says. ‘Half of our plate is fruit and vegetables–or something that grows out of the ground. Meat is no longer the largest portion on the plate. We don’t eat steaks and burgers.’ The Merz’s daughters are all athletes. Alexa is a sophomore on the swim team at Stanford and still holds several records on the Palisades Y Swim Team (PALY) Record Board in Temescal Canyon. Carolyn, who attends Harvard-Westlake, is a fencer and runner, and Allison, also a freshman at Harvard-Westlake is a swimmer. Merz made an effort to make sure they have enough meat for protein, but also she made her children drink milk at every meal. ‘I get the mean-mother award,’ she says. ‘Fine.’ As a physician, Merz points to the idea of early medicine in this country, which was a combination of medication and regimen, and feels we need to get back to that idea. Treating disease should include diet and exercise as well as drugs. James Fixx, the famous author/runner who died of a heart attack at 52, had a family history of heart disease and was prescribed medicine for cholesterol, but didn’t take it; he thought that he could exercise away the problem. In this case, he needed the balance of medication. ‘There’s a belief right now that over-the-counter supplements, which includes ‘natural’ in the label, are better,’ she says. ‘Supplements are unregulated and unpurified, so you have no idea what you’re taking,’ Merz says. She calls many of the products that people take ‘talcum powder,’ which means that unscrupulous manufacturers could put talcum powder into products while labeling it something else and no one would be the wiser. She points out that statins, taken by people to keep their cholesterol down, are made from natural products and are monitored and followed by the FDA; patients know exactly what they’re taking, the exact dosage, and the expiration date. According to Merz, a product labeled “natural” red-rice yeast, sold over the counter, could have the same results, but there is no guarantee of potency or purity or that the pills even contain red-rice yeast. When making the decision to take supplements one should ask is: ‘Is it doing any harm I’m not aware of?’ Merz wants to educate all of America about the dangers of heart disease in women. She tells a story about a mom whose son was a friend of one of her daughters. “She always said she should come and see me,” Merz says, “because her family had a history of heart problems. One day, she was found dead on the sofa. She was in her 50s. She left a family. She won’t be at any more PTA meetings, she won’t be here to watch her child grow up. With heart disease, you often get no warning.’