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Good evening, everybody and welcome to another session at Learn with nurses. Now, I apologize for, uh, the complete lack of make up today. I don't know about you guys, but it's been a bit warm and I think I, everything has just, well, even if I attempted to put it on, it would all slip off. Um, so I hope you're all well and not, not too hot, although it is quite lovely and I do have a lovely breeze that's coming in for now. I'm just going to share my slides. Let me see if I can remember how to do this window here. Window. Oh. here we, oh, it's moved here. It is. I think I've got it right. Yes. Oh, isn't it awful when you forget what you're doing? Ok. We're sharing. Oh, I don't know why it's not in slide mode though. Oh, come on, Michaela. Sorry. Chaps. Sorry. Chaps over there. Hi. Says Katie. Hopefully you can see these. I don't know why it's not. Oh, cos I'm sharing my slides. Bear with me a second. I'm supposed to be sharing a PDF. Heavens. Hi, Amy. So everybody, while I'm sorting this out. Po in the chat where you're from. I can see somebody already really started it. Some names I can see. Coming back again. Love a repeat booking. So I've got this as a PDF. Why isn't this working? It's a PDF. There we go. Why isn't this working? Let me try again. You can all just chat amongst yourselves. I share lots of people. Look. Oh, from Swap Lindsay. My friend lives near there and Dawn is here as well. That's lovely. I don't know why I am struggling. Uh It might take a while. I do the window and I do. Oh, why can't I get it? So this is just showing you that things don't always go. Right. So, um, if I run it from a PDF, oh, hang on, hang on. I need to wait for it to load beautiful screen. Ok. Hopefully it's coming up height. Oh, bear with me everybody. Um, oa, can you help me call me? Stay. We, I'm going back to the old fashioned way. So sorry. Um, with these cheeky glitches. If I run this, if I run it as this, now, I'm gonna do it the old fashioned way and now I'm gonna share my slides. Yeah, the slides, the sound should be back on. I turned it off for a moment. Oh, choose slide deck. It wasn't. We do it. So stay with me. I'm so sorry. But carry on chatting amongst yourselves. I've found a way to do it now. So let me upload it. Gee whiz. Just what you need when it's really hot lanais. Uh Women's health right after slide, three is processed. I can do it. I don't know why it wasn't letting me do that then, but it's just processing now. As soon as it's all processed, I can um make a crack. Now whilst we're doing this, you'll see that in the chat. Mary Galbraith has put a um put a note in there and that's because Mary Gilbraith. There we go. The magic is happening. Um I was on mute. Sorry about that. Everybody for a moment. I was on mute. So um I'm still thing didn't go quite well as planned. So this is part of a three part session that was triggered, triggered by Mary Gilbraith who is on the call tonight, who's on our session. Um And cos I used to run sessions and I still do around cardio about heart attacks, heart attacks, Angina at the end of the day. It's always atheroma and she dropped me a note over Twitter to say OKA it's not always atheroma. And um and she's so right and it reminded me of the challenges and the some work I did a few years ago about women and heart disease, which has then triggered this three part session, but I suspect we'll go on and do some more as well. So part one we've already covered. Now, I don't know if Becky's been able to come on and say hello. I can't see if she is or isn't Becky? Are you saying a quick hello? If not, it might be in the chat. I don't know how to make that. Um, but no microphone's still off. It's not working. So, Becky also, when I, her and I got together a couple of weeks ago about six weeks ago now we said, oh, let's do this. Oh, Becky, you're there. Do you want to say a quick hello? I just say quick hello. Thank you, Michaela. After my debacle. Um, and so our session will run five minutes longer for the complete debacle of the lads. But that's part of the joy of learning with nurses, I think, you know, is that we all do this in our own spare time. We don't have any big glamorous it department or anything like that. Um, which just does lot doing it in our own little way. So it also shows that it's ok for things to go a little bit sometimes. And even when you think you've prepped as good as you can prep and you've done all of that. It's been a couple of weeks since I've done one of these and it didn't show what I could share or I wasn't looking for it anyway, Cathy is here and she said she's so glad we're doing women's health and this is the start of many different things I think we've got with women's health. So if you do your social media at LW Nurses, hashtag LW n hashtag Nurses, Becky's on warns underscore Becky and I'm on, this is Michaela and OA is the amazing person that does all of our social media for us. Now, let's see if I can get that along. So don't forget we're all in the middle of medal. So at the end of this session, I'll be pressing the button which allows you to do your evaluations. We will do the follow up one to push another button and it will keep reminding us within there you toggle this thing that says request catch up content. The slides are already loaded. Uh Well, there are a PDF of the slides. They're all sitting there waiting for you and you tickle toggle this thing here to get your certificate. So um and you can go back as many times as you want to and get them in case you ever lose them. Which is good. Oh, we've got a paramedic. So Dave the paramedic from Cornwall is here. Lovely, lovely. Right? So med all is perfect. If anyone doesn't, hasn't come across med all yet. It is the perfect thing for training. And I do sound like I am a on, on, on commission for med all I'm not, but I love its Bitter Kit and I love the fact that it's free for healthcare professionals. So let's see what we're doing tonight. Oh, and this is all. Sorry. Let me just, I'll come back to that one because I haven't got a lot of time, but we do have a Facebook group and the socials will come out another time. So we've done part one when it's atheroma and some of you won't have been on that one. So I'm gonna do a very tiny little recap and Becky did that one with me. Part two is when it's probably not atheroma. And that's the session we're doing now. And session three is the hormone session. And we've got um V Vikram, I think his name is um from UCL. Sorry, look at the chat Dame Amy's here. So I think that's so funny unless they're maybe not related and they've just got the same name. Then I think that's quite entertaining. And of course, there is the quiz. Um, and um over 300 people have taken the quiz so far. 340 we, you know, lots of people are scoring 49% were in this band here. So we'll keep the, keep the quiz going. It's always interesting to see how it goes along. And in fact, I was at a session last week, Heart UK and I sat with um some very, uh some very clever lipidologist who couldn't get over 50% either, which made me really think it's very important now, very quick on heart attacks again, on that chest pain on people. That's very good, Deane. I love that. Oh, my God. I think this is our first married couple on AZ on, on a, on a line with nurses together and he's really cool. Nah. So we know that lots and lots of people have heart attacks every year and we have an admission one every five minutes to do with heart attacks and we're not taking anything away from those heart attacks. Ok. They are happening and they're happening more and more. But what I want us to think of as well is not just when it's heart attacks, but what happens when it's not because we rush people to hospital in the same way. And we know I've just realized I've gotta click this thing, the, the studies that are out there, the research that's out there and this is one of my most favorite studies. It's called the inter heart study. And what this actually showed us is the association of risk factors for heart disease across many different countries. And this is an odds ratio. So what that means is anything that's greater than a number one is a harm and anything less than a number one is a benefit. And the pink blobs are women and the blue blobs are men. And so this really um really was amazing when it came out and it still is in fairness for the majority of people. So smoking is not good for us, diabetes, hypertension, abdominal obesity, um psychosocial. Um so that that locus of control and this is the APO A and this is the, um A B. So this is cholesterol. So all of this, whether you're men or women is a harm and these things here, fruit and veg exercise and a bit of alcohol are all benefits because they sit the other side and this has really been the cornerstone of lots of prevention. So when we're thinking about people who are having heart attacks, we think of why they happen and they happen for when you're, when you've got these reasons and you haven't got a lot of these reasons going on, that's our traditional route to heart attacks. And if people don't f this pattern, then you're less likely to be considered, this might be a heart attack that you're having. And we saw this play out when we started to look at the first session and this is people having heart attacks. Now, this is our traditional model of somebody having a heart attack. We learned from session, one that, that's not how a lot of women have their heart attacks. And even when women go to hospital, um, we know that there are issues they get seen to be out of first thing to look at and day, I'll day I'll pick you up here cos you're a, you're a paramedic and you'll be thinking chest pain and we're always, we're always taught, we always consider chest pain to be cardiac in origin until it's not ok until it's not. But we have quite quick ways of deciding whether it is or isn't. Um, and we're missing some women, particularly women when we think it's not cardiac. So we know the traditional ones are syndrome, stable angina and those other ones, whether it's pericarditis, tamponades, uh, different arrhythmias can cause chest pains. Then we have all the non cardiac causes of chest pain and they might be our respiratory ones or this other general global thing. That could be a little old bit of anything from cancers to musculoskeletal to gi issues. So there's lots of reasons why somebody might present with chest pain. Now, in the context of, I keep thinking, I've got my slides in a different order and when people get to hospital, then we have the nice guidelines. So this is for people in, in England, you need to think about what you've got in your own countries. Um, then, then they present with chest pain and we need to decide, is it acute chest pain or is it stable chest pain? And if it's none of those, we follow another route. And all of our, all of our er management that we really start to think about is a wrong this bit. You know, we think about protecting that myocardium time is muscle, all of that sort of language that we use yet we know that from session one that women. Ok, all of the research and everything that I've just shown you there on that time and that inter heart and even the decisions of which bit people go for, which investigations they might have is all based on research. Now, women only form 38% of the research that's there. So that already starts us to think. Well, that's, you know, how do we know if it's gonna work in women in quite the same way? And we know the answer to that now is that it doesn't work in quite the same way. So, something like an angiogram isn't so good in women. We certainly learned quite a while ago. Exercise tests aren't so good in women. So what we always thought was good for both genders, cos we've tested on men and actually in, in, in research when they've got little mice and things, it's always men rights mice. It's never women mice that it happens in men rats. So it's always down as male, but we don't get to see what happens to them being female. We know that actually women delay more than men. So this is the right answer here between one hour, 48 minutes to seven hours, 12 minutes when getting to hospitals. So there was this bigger delay in women rec recognizing chest pains in themselves. Half of the women who have got chest pain, get at the wrong diagnosis when they're actually having a heart attack. So they'll be sent away. Um, they might be given lots of different misdiagnoses. And all of that leads to, um, is because not enough is known about women having heart attacks. And we know that this traditional thought of atheroma is, is not what comes to play with a lot of chest pain. And this, I lifted from a quote saying they told me and this was about a paramedic day. Oh, I'm sure it wasn't you that a woman was having a heart attack. And when they came out of her cos she didn't look like the traditional view of somebody having a heart attack. She was told it was just a panic attack. And um, they sort of gently took her to hospital with absolutely no sense of urgency and all this leads to those bigger inequalities. So that's a very quick recap for session. One, let's do. So we're not taking anything away from that traditional heart attack route that that still happens to, you know, women, lots and lots and lots. But we need to speed up and increase our awareness of women having that. But what about when it's not the traditional atheroma that our systems are geared up to look for chest pain that's cardiac in origin. Um That's the cardiac in origin that we know about from the research that was on the 62% of, you know, where it's men. It's a, it's a different sort of process and this is what we're gonna start to look at. Now. We'll spend a bit of time with SCAD and we'll explain what this is in OCA to in OCA spasms. And this thing called pots and cos this is what other things that women have, particularly when it, when they get sent away to be told, it's not your heart, your heart is ok. And there's lots of other things that can happen. So this was a question on one of the quiz questions, the spontaneous coronary artery dissection and many of you will have done the quiz. I know. And so we asked, who does it most commonly affect? And um whilst it was great that the majority of people, 50 just over 50% of people got the right answer. That means that nearly half of the healthcare professionals that did the quiz didn't guess either that it was um women in this age group and, you know, quite a significant proportion still put down that they thought it was something that happened to men. So if that perception is there that you've got to look like someone who's having a heart attack or having a cardiac event, and it's more likely to be a man, then that is also less likely to have people um particularly women um included in that. Should we progress a bit further when we're trying to look for a diagnosis? So let's start with SCAD then and I'm gonna spend a bit more time on SCAD than the other ones that are there mostly because there's a little bit more known about them. Um, so, um, there's a whole age range that ha scab happens in. Ok. Now it can occur from adolescents. Ok. You know, it doesn't have to start when you're from adolescents up until the late sixties. It's not saying that it won't happen after, but that's where it most commonly happens. And that 90% of the people who have scab spontaneous coronary artery dissection, 90% are women. 90% of women. Now, these women don't have what we would consider or what is considered by the healthcare professionals, by the studies of traditional risk factors. So you don't have to smoke. You don't have to be overweight. You don't have to have high BP. You don't have to have diabetes that though it doesn't form part of it. So it's really easy to dismiss somebody coming in with pains when they're like this. And the thought that it's, in fact, it's more than a thought. Now, they're thinking that estrogen and progesterone have an effect on the inside of our artery wall. So that endothelium, it sort of weakens it and that makes it more uh more vulnerable to this tearing, causing this dissection. Now, some of you may not know who this person is here, but this is Captain Sandy from below deck. And when I was at dinner week with these lovely, um lipidologist, they were a little dismayed that I, I'm heavily addicted to Belo Dex, but it's a fantastic program. And actually I went to see Captain Sandy live at the Lyric Theater and um, Captain Sandy has had SCAD, she had SCAD and she didn't know she was having it. She was um, doing the Cyclops and felt very unwell and then left it and finally, finally made it to hospital and they diagnosed SCAD and she's all recovered now, feels lots lots better. But it's there. And if you look, if you ever look at K Sandy, she's young, she's fit, she exercises, she doesn't smoke and you wouldn't put her down as a typical cardiac patient. You really wouldn't be thinking that. So if somebody presents in A&E or calls a, a 999 or even goes to the GP practice saying I've got these awful chest pains and they look like Captain Sandy, you're not gonna think heart attack, unfortunately, but we need to start thinking much wider. So, what is scab? Well, this is our heart and for anyone that's done the heart attack and angina ones, we talk about these coronary arteries and they're like the, the tube map, the big tube map that goes around London. Um And so when we do an angiogram, we look at these coronary arteries here and we're usually looking for what, like a blockage, we're usually looking for some form of occlusion that's in it and we'll, and people get a percentage, it's 50% blocked, 70% blocked 90% blocked. And that's that process of atheroma that builds up inside the art arteries. Yet in scat what happens? There's no problem with the blood flow. Ok. Absolutely. No problem with the blood flow here. It's going, we get no angina as such because we've got this lovely big artery, great big white hole through it and the blood flows through and then you start with this little intima tear. It's a tiny little tear that happens and it's in the, you know, it happens as a result of the direction of the blood flow and there's a weakened lining of the artery. So what happens is blood will start to collect under this tear and this flap can flap around. Ok. The flap can flap around, it can be a big long shearing off. These clots can start to form because the blood's pooling inside that flap and then you can end up with a completely occluded artery. So it can be occluded because it's got this blockage. But not everybody has to get a clot for here as well. It can be that you've got a flap and that can be really difficult sometimes to see in an angiogram if the flap isn't flapping. And that sort of point in time when they're looking down there, so it can be quite difficult to find this. Um but it's a totally different thing and if you don't see it whilst it's happening, if you, if you don't get somebody towards the angiogram, then you're not gonna stand a chance of looking for it. And so we really have to think differently. Now about women going towards angiograms, we know that they're less likely to be sent for one. Now, the symptoms are very similar to people having heart attacks and in essence, it is a heart attack. It's just for a different reason, a heart attack, you think about it is an occlusion of a vessel where the blood doesn't flow down the coronary arteries to that heart muscle causing, causing death of the heart muscle. And this is the standard pains. Now, people can have lots of different pains. They don't have to have all of these, they can have some of these, they can have it in a range. You know, it can come and go. Sometimes people just feel sens of uneasiness, they can feel really nauseous, they can feel really sweaty. So it's hard to describe, but it usually is this something's going on that's not quite right and to diagnose it well, to have an ECG, however, ECG S can look totally normal. So if you're going, if you're going into a hospital or if you're in Dane's, you're in Dane's ambulance. Sorry, Daane, I'm gonna, you, you shouldn't have told me you were a paramedic. You are gonna be responsible for all ambulance services and all of that. But I hope you realize I'm doing it in a, in a, in a, in a light hearted way. Um, so, but if you've got your patients and you've come to see them and they don't look like they're the sort of person to have a heart attack and you do an E CG and it's all normal, you think? Oh, thank heavens. At least it's not that, but actually it could still be SCAD. Uh, we do the blood test, we need to do troponins that happens in hospitals. Unless you're out in the rural back end of nowhere, then you might be doing a more localized set of troponins and they need an angiogram and a CT scan. We're trying to look for it. Ok. We're actually looking for it rather than eliminating it. And it may well be that that person will need a stent, some people but not very often will need a bypass depending on the um the severity of that shearing off. Now, traditional things like aspirins, BP medication, beta blockers, all of those things. They, they're probably used in medical management. Now we give statins as well, but I've started to read a little bit that actually statins may not be as useful in SCAD as first thought of. Um So that's a bit of a watch this space and of course, cardiac rehab. If anybody's had a stent or a bypass, they need cardiac rehab. But for me, it's thinking they're the women who get to this point, they're the women that actually get the scab diagnosed, we don't yet know of how many don't get scab diagnosed. They get sent home from the GP, they get sent home from hospital and that's why it's brilliant. You guys are all here. It's about raising that awareness some more. So SCAD is one form of a chest pain that people can present with. That is not often thought about the next one. Oh, hang on. What might increase scan? 00, no, I'm sorry for about this one. Cos I noticed some of this and thought, oh, so there might be abnormalities of the blood vessels. So those blood vessels that um so people with fibromuscular dysplasia, just as simply the vessels not being as, as good as they were as robust as they could be, can increase it. Things like um inherited connective tissue diseases. So that's um Ehlers, Danlos, the joint hypermobility or Marfan syndrome. And we certainly know that lots of people with Marfan's, they di quite, quite suddenly from aortic dissection. Um So not those little arteries but the bigger arteries that sit there. And Earl as Dan lost. Well, I put this in, I did a bit of research, put this in and I thought, oh, bloody hell, my daughter's got that one. So I must keep an eye out on that as well. But also these extremes, if you think about when you push your body to extremes, then the BP goes up, the blood flow goes up the turbulence goes up inside those arteries. So extreme physical exertion can increase pressure inside those arteries, making those happen. And being female makes the inside of those arteries more vulnerable to the tears because of the estrogen. So SCAD is the number one cause of heart attacks in women under the age of 50. It's the number one cause of pregnancy related. That's a big pregnancy related heart attacks. And it's not something we think about is women having heart attacks when they have a baby. But it's really a big killer of anyone that dies. Women don't often die after having a baby, but it's the number one killer for women and most people who have SCAD are young and healthy and female with no family history of heart disease. It really is a group of women that are being missed the next one. So in ok, I think I've pronounced it right. Uh That's ischemia with non obstructive coronary arteries. So we get this is imagine your heart and you get the heart's blood supply, which is our coronary arteries. There's problem with the blood flow to the muscle. That's where the chest pain happens. That's the ischemia, but it's not due to the traditional things that we think about that we see on an angiogram like the blockages in the coronary arteries. Now, patients that will come backwards and forwards into A&E and will be told there's nothing wrong, there's nothing wrong with the heart because their ecgs are normal. The angiograms are normal and I can certainly think of some of the women I know, um, that have had this happen to them and they're sent away and this is where we start getting told. Oh, it's all in your head or you're a bit anxious, you know, she's a bit of a hypochondriac type thing and actually, people can spend years and years and I say people, I mean, women can spend years and years going backwards and forwards to the GP to A&E really worried that there's this pain is very real and yet they get dismissed and we get that with a lot of other conditions as well. So the first one we're gonna look at is something called vasospastic angina, which is also when in my day, when I was younger, it was called Prince Metals and then sometimes it's called variants. Now, here's your heart. Here's your coronary artery. Oh Gifted. That's OK. Spontaneous coronary artery dissection. Ok. Spontaneous coronary artery dissection. Sorry, I thought I had that in a thing but I clearly haven't. Sorry. Gifting. Um I might somebody popped that in the chat. Becky, Becky pop that in the chat for us if you can. Oh yeah. So vasospastic Angina Prince Metals. So, here we go. This is your heart. This is your coronary arteries that feed the heart's blood supply. Now, instead of having a blockage that builds up the artery spasms and when it spasms down it. Oh, it gonna beat you too at Becky. So, so when it spasms, it restricts the blood flow that goes through now. And that means your heart muscle gets less blood, therefore less oxygen and you will get pain, you'll get this pain. So it usually happens at rest. Ok? And often early in the morning or late at night. Ok. And I'm starting to think about the pain, which has gone away since I've asked somebody about the pain that I've been getting, it was called left arm pain. I see. And I've got a pain in my left arm. So, um so which is really odd. So I think it's been postural actually. So it usually cares then now it often can be really quite severe, but it doesn't always have to be severe. But if you think about it, if that, depending where that artery is spasming, there can be a reduced blood flow to a lot of that heart muscle, a lot of the heart muscle. So if it was down here, there would be less of a heart muscle involved as opposed to up here where you might have more of the heart muscle involved. The pain can happen. Ok. Um In different parts. And actually, it can actually spasm, we can spasm in all different places. It can also make you feel quite sick. There are triggers to this happening, triggers to this one. And um so emotional stress again. So this for, you know, this forms quite a, quite a big part of the, the thing that's coming through. And we think about when we're under emotional stress, we don't breathe in the right way, our blood pressures will go up. Certain chemicals will be produced by our bodies. Really putting our bodies under quite, um, quite strenuous type, um, responses to have so drops in temperature. Ok. So, really cold weather, everything's restricting down now. Hyperventilation, that's something we all need. We all need to learn how to breathe better for sure. And then even some medications. So too much alcohol, antidepressants, some uh migraine and cocaine can also cause spasm to happen because it puts your body which your BP up tachycardia, the whole lot those vessels spasm. It's more common in women and especially when we're going through the menopause that perimenopausal early menopause uh postmenopausal, we're more likely to get um spasm. So this is another woman goes back in and out of A&E I'm getting these awful pains. You might even get as far as an angiogram and it's probably not going to show up. So how do we get it diagnosed? Oh, I thought I had the diagnosis. Sorry. So to get it done. Oh, I can't go backwards. I think I've got an old, slightly older version. Maybe I updated them when I'm using the slightly older version. So to get this diagnosed, we have to put the heart under a bit more stress when we do the angiograms to try and induce, to try and induce those spasms to happen. And the treatment of them is things like um a calcium channel blocker, uh a Nicorandil. Uh um the stuff that might slow your heart rate down and steady your heart rate a little bit your ivabradine, those sorts of things that can help just take some of that pressure off the heart to try and reduce the chances of it spasming in the way that it's gonna do when it's up and tight like this. So really just look after that heart and take some pressure. Also with all of these, it is about lifestyle too. It's helping to reduce the risk factors that, that we might have for the more traditional heart disease. So being a bit fit and not smoking, exercising all the usual stuff. So then we have microvascular angina and I remember this one as well from when I used to work in the cardiac wards and they say, oh, she's syndrome X and what that was and got a clue what it is. Syndrome X. She's clearly feeling pain. She's probably a bit of a, you know, a little bit of a whinger. But now, now we know there was a definite thing called syndrome X and it's called and, and actually now it's called microvascular angina. People will take more, more um interest in it. Now, this type of angina pain. Well, this can last for longer. Ok. This can last for longer and it could be quite severe too. You might also get lots of other problems with it. Like being really breathless, not sleeping so well, there's real fatigue, a drain on the energy. And again, it might be first noticed in those early morning daily activities and in times when you're under where you're having to exert yourself a bit more physically and, and emotionally and mentally. Now, when do an angiogram, I say we, I've never done an angiogram, but when they do an angiogram, they look for these big arteries here. OK? These are the big arteries that you can put a stent in, that you can bypass that you can angioplasty. That only accounts for 5% of your coronary arteries. There's 95% of your coronary arteries that we don't see that we don't look at that we don't bother with and they're the ones that have problems in microvascular angina. These little bits here. So how does that work? Well, it's not always look for, it's not always diagnosed. OK. So women will go and have an angiogram and be told you've got normal coronary arteries go away. It's all in your brain. There's this big lack of awareness of it and it's, it's on its way, it's slowly slowly getting there. And I was doing some reading about it, particularly in the UK. We don't seem to have as much as what there appears to be in other countries. So we have something called um beat SCAD um which is more for the SCAB but that all about women and heart disease for the UK. And then there are some really amazing places, hair heart are down in Australia and in Canada there's quite a lot and some amazing studies going on. But in the UK, we've, we've yet to catch up. So the diagnosis is not very well done because where we don't know to look for it and then it's not an easy diagnosis to do, we can't just do a regular angiogram. We might have to do an MRI or a stress echo or put some acetylcholine in to try and see. Can we make that artery spasm to find evidence of it? And in the trip. So once we've found evidence of it, so, and like anything getting a diagnosis is always the first step and letting you know that it's not all in your mind and you're not going mad. There's a real reason for all of these pains and symptoms that you're having. And it's the more traditional cardiac type medication that we'll go for. So those calcium channel blockers uh that just takes some pressure reduces the afterload, just take some of that strain away from the heart, the beta blockers will slow that heart rate down. The nitrates will open up the arteries. So if they open up the big arteries, they'll open up the little arteries um And what's becoming a little bit more popular now is your Nicorandil that work a little bit like a nitrate or your fris, which works like a beta blocker but doesn't drop the heart rate so much. It allows that heart rate to, to track OK. Movement. Um And H RT is even starting to be used a bit more now, particularly if when people start flushing with those chest pains. And I also saw this was from the Brompton. They have a lot of support, they offer CBT and Hypna therapy, um which I think is quite amazing. And you might and part of me, first of all, I was thinking, oh, that makes people think, oh, it's all in your brain and it's not, it's about you being able to control your response to the pain. Um And we use this in different, what I'm gonna talk about at the moment is response to pain from other conditions. So there are some conditions that makes your body um become more, well, I want to say more excited but you know, become more tachycardic and you produce all different um, hormones get surging and CBT can, doesn't stop the adrenaline but stops your response to the adrenaline, which helps to lower and lose things down quite a bit. So I got quite excited. Then when I was thinking, once you've got your diagnosis, then actually some form of CBD or hypnotherapy can help you manage and live with those symptoms and live with those pains, but not to jump straight in with it and say it's all, it's all in your brain because we know it's not. So, the last thing I'm gonna talk about and I'm gonna talk about it really briefly. Oh, fantastic. Mary's brilliant at knowing where everything is. She is such an advocate. Mary, such an advocate. And I hope I'm doing all right on this. Um, cos I'm not an expert on this, but I just know that um I know enough about cardiac disease and some of the other conditions that I think I can break things down into relatively slish ways to think about it. So I'm gonna end on pots and I'm only gonna touch on pots briefly because we run separate sessions on land with nurses with pots. Although I'm trying to persuade una to change hers because she's got COVID. So I've just, just done a disclaimer now. But, you know, it's all good. So pots stands for postural tachycardia syndrome. And that's um what? Well, basically our bodies when we lie flat, gravity doesn't do anything to us. When we go upright, gravity pulls down and our blood pools and in part, we don't have the system to push our blood back up and this causes your body to go into a lot of really unhappiness. So you'll produce a lot of adrenaline. You'll become tachycardic, you'll become, you become dizzy. If you feel sick, you um have so many symptoms that una will be able to talk about in a bit. But one of the symptoms that's really common in people with pots, particularly women in pos is chest pain and chest pain is really common. And so we know it's there, we don't know why it's there. You can hypothesize that it might be because the coronary arteries don't get to fill enough because the heart's really tachycardic. There might be lots of different reasons, but there's this reduced blood flow for whatever reason, through the heart muscle producing that chest pain. So when somebody comes to hospital goes to a GP practice, particularly if you're female and particularly if you don't look like your traditional heart attack patient, we don't just dismiss we need to be more, more mindful of these other conditions that sit there. So whether it's SCAD, whether it's microvascular angina, whether it's spasms, whether it's pots and they're all biggies, really. Um to be able to think about those other conditions, particularly when women don't fit the stereotypical profile for heart disease. So in summary, chest pain isn't always cardiac. So the first session we did was looking at when cardiac, when chest pain doesn't always feel like chest pain and women get dismissed and we're less likely to seek advice. So when it's not cardiac and it's not obviously cardiac from the things we know what to look for, we need to think of what else it might be and they are things like scans, pots, microvascular spasms in the arteries. There are so many other things and particularly if it's younger women, if it's women who've just had a baby, it's around the time of the menopause, you don't have to be an overweight smoker to have these sorts of conditions happening. We really need to be more aware of it. They've acknowledged there's a lack of women in research. It's one thing to acknowledge it. It's another thing to make that change happen. And we know that there's a movement for change cos it's happening, but it's going to take a while. So that's it. For me. The next session. We've got so chance for any questions. Next session we've got is in a couple of days time who um we're gonna be looking at hormones and cardiovascular disease. So we've got a menopause specialist. Um And we've got a fellow, it's not that, you know, we're not being in any way. We're not saying you just, only women are allowed to think about women's health. OK? We're not saying that at all. Uh He's also not a nurse, he's a doctor, but he's a really good guy and he's gonna be joining us. So it's time now in case anybody's got any questions or comments or thoughts, I apologize for getting it a little bit wrong at the beginning and we slide, it's not working quite right, but we fix that in the end. So, Becky anything interesting for you whilst people might wanna put a question in anything that you thought? Mm. I think, I think all of it really, to be honest with you, I think last week we covered heart attacks and the fact that women aren't, you know, aren't necessarily diagnosed quickly enough or even sometimes diagnosed at all. And this then really adds another level to it as well. II think what's going to be interesting later on this year, there should be a women's health strategy produced. It should have actually come out in the spring. It should already be here, but it's not. Um And one of the things that was mentioned with the input into that strategy was, you know, thinking about the life cycle, thinking about all those other conditions, not like we said last week, not just periods, not just pregnancy or menopause. What else is it that, that makes it up? Um So it's going to be interesting to see whether that actually comes into fruition and actually even includes anything to do with cardiovascular. Hopefully it will. Well, if it doesn't, we can campaign to make sure it does next time around and stuff like that before. Yeah, so I'm going to pop the feedback in the chat. There's lots of thank yous coming in and that it's interesting. So that's good. We're always happy for thank uh oh, so he's a below deck fan who, who, who gotta love below deck. Oh, I'm loving these learned a lot. So I think I had a slow bit of a thing that they're flurrying in now. Um, which is brilliant. So, um, I'm really pleased you could join both of us. Um, and it is about, you know, for sometimes it's not always about having to know everything about everything. It's about learning a little bit more about something else. So I think we'll leave it here. I'm gonna go off being live, but we'll stay on the chat for a bit and um, in case anything comes up and thank you, Becky. Thank you, Mary because you were the, the trigger for all of this. I always, when I say that I probably make her cry, but I don't mean to Mary, you were the absolute trigger for all of this. And um, oh think about seeing in clinic knowing how to convience those that we refer and prescribe for the right things. Ok. That's what you're saying. I think so. Yeah, how to convince those that you refer to and prescribe? Absolutely. It's really getting people to be more aware. Totally done. Thanks, cat. We will be doing more. I am sure I would definitely, we've got another one and then we might repeat this again later or see where else we go on this journey of well, women's health. But I've started with women with cardiovascular disease cos that's my space for now, right? Let's call it a day. Um So Sharon you get the slide as soon as you've done your evaluation. Ah, could you have, um, the slides to part one? Speak to uno, so we'll just repeat part one again. We'll repeat part one again. That's probably the easiest way because otherwise I don't know how you get the slides. I really don't understand how that happens. Uh, Mary's given us a little heart. Thank you, Mary. Hopefully I did. All right and, uh, we'll see you all soon. Take care, everyone. Bye, take care. Bye bye bye.