Nicole: I went to sit up, approximately 10 minutes after this strange feeling. I was just almost struck by lightning by this pain that just radiated through the right side of my body. Jay: At age 42, Nicole McLaughlin thought she was in peak health until a sudden life-threatening emergency brought her heart and brain health into sharp focus. Allison: Welcome to Defy Dementia, the podcast for anyone who has a brain. Jay: Defy Dementia is all about living in ways to keep our brains healthy and reduce our risk of dementia. Because dementia is not dictated by our genes, genetics can play a role, but lifestyle risk factors like uncorrected hearing or vision or chronic loneliness and social isolation can also have a powerful impact. Allison: And according to the best evidence, scientists are saying that if we all make healthy changes to those lifestyle risk factors, we could reduce dementia cases worldwide by at least 45%. And that is a number we cannot underline enough. Jay: Today on the show, a fascinating look inside our hearts, veins, and arteries, we're pumping up the volume on cardiovascular risk factors for dementia. Allison: I'm Allison Sekuler, President and Chief Scientist at the Baycrest Academy for Research and Education and at the Centre for Aging and Brain Health Innovation. Jay: I'm Jay Ingram. I'm a science journalist and broadcaster. I've been writing and speaking about dementia for more than a quarter of a century. Allison: Join us as we Defy Dementia and take heart, because you're never too young or too old to take care of your brain. Jay: We've produced 20 episodes of Defy Dementia, and when we talk to experts, one piece of brain health advice that we've encountered consistently is: if it's good for the heart, it's good for the brain. And so, today we're dedicating a whole show to cardiovascular risk factors for dementia. Allison: If you're a regular listener, you know that a lot of the dementia prevention information that we talk about is based on recommendations by The Lancet Commission. They're an international group of scientists who specialize in dementia risk. Jay: They're called The Lancet Commission because they publish their reports in The Lancet, one of the world's foremost medical journals. Every few years, the commission gets together to look at all the research on ways that people at any age can reduce their risk of dementia. Only when there is consensus that the evidence is really strong does a risk factor make it onto their list of dementia risk factors. Allison: And the key thing to keep in mind today is cardiovascular risk factors loom large on The Lancet Commission list. As of right now, eight out of the 14 risk factors are related to our heart, veins and arteries. Jay: They are: insufficient exercise, obesity, smoking, diabetes and high blood pressure, air pollution, traumatic brain injury, and last summer the commission added high LDL cholesterol. Allison: On today's episode, we're focusing on just some of those risk factors, the importance of exercise and lowering blood pressure and levels of LDL cholesterol. Jay: To get us started, a real life story. It's about a cardiac condition that can hit apparently healthy, young and middle-aged women like a bolt from the blue. Allison: Nicole McLaughlin is a 46-year-old from Toronto. She works at a major Canadian bank as a senior consultant, coaching the bank's investment advisors. But what you need to know about Nicole is this. She's a lifelong athlete. Hockey, football and figure skating have played a part in her life, but first and foremost, she's always been a runner. Then one day in 2021, everything changed. This is a story about a life-threatening cardiac event, but dementia also plays a role. Nicole McLaughlin joins us from Toronto. Nicole, thank you for helping us defy dementia. Nicole: It's my pleasure. Thanks for having me. Allison: Can you tell us about this life-changing cardiac event? Where were you and what happened? Nicole: Sure. Well, it was the throws of Covid. It was August of 2021 and I was actually just working from home at my desk. I stood up to go for a walk with a girlfriend of mine who was in my Covid bubble, and this feeling that I've never had before, I've never experienced anything like it, it wasn't nausea, it wasn't lightheadedness, it wasn't pain, struck me. I laid down on my bed for a bit and I called telehealth, which is essentially the government system whereby you call to see if your condition warrants a trip to the hospital. I left a voicemail with my symptoms and basically just laid there hoping that I would sit up and feel better in just a couple of minutes. I went to sit up approximately 10 minutes after this strange feeling and I was just almost struck by lightning, by this pain that just radiated through the right side of my body. My jaw, my neck and my shoulder were the worst of things. Luckily, I had called telehealth because they were the ones who dispatched the ambulance to me. I was unconscious when they got here. And my girlfriend actually met the paramedics at my condo doors and let them in. I was rushed to St. Mike's trauma center, but at the time didn't know it was a heart attack. I almost didn't go to the hospital, so I was very lucky that a very convincing female paramedic talked me into going. Allison: And when you got there, it was a heart attack, but it wasn't necessarily the kind of heart attack most people think about. What sort of heart attack was it? Nicole: They rushed me back into the ER and announced I'm having a massive heart attack. The cardiologist was already on his way down and he took a look at me and all of five seconds later said, "My suspicion is that it's spontaneous coronary artery dissection," which I had never heard of. Allison: Spontaneous coronary artery dissection. What is that? How common is it? Nicole: So it's typically considered rare. It's becoming more and more common only because the awareness is getting out there. And so, what happens with coronary artery dissection is that your coronary artery literally spontaneously just tears, but it tears into your coronary artery. So essentially that interior lining tears open, which created for me a blood blister - It’s the easiest analogy I have to explain to people - and created this blockage. So it stopped the blood flow to my heart. Allison: Did you have any of the same kind of warning signs in advance that people might have, like high blood pressure or high LDL cholesterol? Nicole: Nothing at all. Found out through tests afterwards that cholesterol levels are completely normal. My blood pressure, if anything, is on the low side. I was about to turn 43 at the time, and again, athletic female, but it actually turns out that 42 is the average age of spontaneous coronary artery dissection. So I just made it. Jay: Well, I'm glad you can laugh about it now. Tell us about your rehab after the heart attack. Was it like what most people who've had a cardiac event go through? Nicole: Unfortunately, I had to wait a bit for my rehab only because they do a lot of scans to find out if you have issues with other arteries in your body. So a lot of times SCAD (Spontaneous coronary artery dissection), I'm going to use the short form, SCAD patients typically have arteries that look like they have beading in them. Thick in some places, thin in others. I actually had a carotid tear as well. So walking around my kitchen table was my only form of exercise for the first almost six months of recovery. I then went to cardiac rehab after that because I wanted to and because my cardiologist thought it would be just a great way to gain confidence again to get it running. Jay: So that was 2021. How are you doing now? Nicole: I'm doing really well. I am followed closely by my cardiologist as well as neurologist because I'm left with a pseudoaneurysm in my carotid. So with all of that, the monitoring, the blood tests, lots of cholesterol tests, everything is still very normal. I don't take any medication with the exception of a baby aspirin just for blood thinning properties around the pseudoaneurysm. But things are great. I am back to running. I'm doing everything I used to be able to do within reason. I have to be a little bit careful that I don't overexert myself too much. So I'm more aware of how my body feels and what my heart rate is, and I don't push it as much as I would've previously. Allison: This show, obviously, is all about cardiovascular risk for dementia. Given your history, do you think that you might be at risk for dementia? Nicole: I definitely think there's probably an increased risk, and I think that for a couple of reasons, just based on the readings that I've done on dementia and Alzheimer's. My dad unfortunately has Alzheimer's as well as vascular dementia. So I have to imagine there's some sort of familial genetic anomaly there that I have to be aware of and to the best of my ability, protect myself as much as possible. Jay: So if you think that your risk for dementia might be heightened from what it was, are you doing anything to lower your risk? Nicole: Yes. I mean within reason. I would say that just trying to keep my brain sharp. Obviously work helps a lot with that. But also I'm a lifelong reader. I really love reading. Exercise is huge. And just keeping up social connections with friends and family, doing what I can to be protective, but also not going too far down the rabbit hole, because I think I could probably come up with a million different things to try, but I stick with the basics. Jay: So Nicole, you mentioned some of the things we talk about a lot on Defy Dementia as dementia risks lowering things, like you keep your brain active, you have good social activities, you're fitness oriented. We also talk about other things like eating well, in a friendly to your circulatory system way, sleeping well. Do you think about those other possible risks as well? Nicole: I do for sure. I've never really had issues with sleep or insomnia or anything like that, thankfully. I know I'm lucky in that respect. But diet for sure plays a big role. It's always played a role in my life. I've been a vegetarian, sometimes pescatarian, for the majority of my life, and so that's just normal for me. Allison: If there were one thing that you could have people take away from your story, what would it be? Nicole: I think it would be for women to really pay attention to their bodies. I've heard so many stories from SCAD survivors through a Facebook group. It is actually where I found the most support. And women especially try to push through and almost ignore what's going on until there's a more convenient time to deal with things. I was told at the hospital that had I decided to just stay home and rest like I suggested to the paramedics after I regained consciousness, that there's a good chance I probably wouldn't have made it. The prognosis for SCAD patients when they tend to ignore things or think it's just going to get better, it's not good. Allison: We are certainly glad you did not ignore it and that you sought the medical attention you needed and that you're here with us today sharing your story. Thanks so much for helping us defy dementia. Nicole: Thank you very much. It was my pleasure. Allison: Nicole McLaughlin is a senior consultant at a major Canadian bank, and after a heart attack, she survived and thrived. Nicole joined us from Toronto. Jay: Our next guest has been listening to Nicole. Dr. Paul O is a specialist in cardiac rehabilitation. He's helped many people recover from heart attacks and other cardiac events. In fact, he helped Nicole recover from her heart attack. And full disclosure, he's the one who introduced Nicole to us. Paul is the medical director and senior scientist in the Cardiovascular Rehabilitation program at the University Health Network. Paul, thank you for joining us on Defy Dementia. Paul: It's such a pleasure to be with you today. Jay: We want to ask you about Nicole's case, but first, you're a heart health guy and yet we're talking to you about the brain. What's the connection? Paul: Well, the heart and the brain are so closely intertwined as are all of our body systems. We know that what is good for the heart is often good for the head as well, in terms of shared risk factors, shared healthy behaviors and things that we can do that are in our own control to help both our hearts and our minds. Jay: Now, I mentioned Nicole, we just listened to her, and her heart condition was and is uncommon, but is it relevant to everybody? Paul: Yeah, absolutely. I mean, there are so many people who will experience some sort of heart event this year in Canada, and many people will be concerned about what are the downstream consequences, not only for the heart itself, but for the rest of our bodies, and in particular, what's going to happen to our brains. So we can think about ways to recover or prevent issues and do things that are going to help us out in both domains. Allison: So Nicole said that she's concerned about dementia risk after her heart attack, especially because her dad is living with Alzheimer's and vascular dementia. How might she be at risk? Paul: Anyone that has a heart experience may be concerned about what's going to happen to the brain in the future. There are these shared pathways of injury and insult we might call it. If we have had some sort of blood vessel problem that's affected our heart, then those same kinds of blood vessels may be up in our brain and at risk. Nicole's condition is somewhat unique and special. She had a spontaneous coronary artery dissection, but the more common kinds of heart problems like the coronary artery disease related to atherosclerosis or harping of the arteries, there is a very close connection between those blood vessels in the brain and those that are in the heart. Allison: So let's focus on some of the major cardiovascular risk factors for dementia. You've mentioned some of them already. We know high blood pressure, for example, can be bad for the brain in terms of dementia risk. Why is that? Paul: High blood pressure affects such a large proportion of the population. If we think of older adults, 40 or 50% may have high blood pressure. If we think of blood pressure as the load on our blood vessels, with every single beat, then 25,000 times a day or more, we've got the stress on our blood vessels. The response to stress in a blood vessel is to get tighter over time, and if there's enough damage that occurs over time, then those blood vessels may actually block off. So both of those things can be in play not only for vascular risk to the brain and things like strokes, but also those blood vessel problems may lead to damage to the brain tissue there, leading to dementia or vascular dementia. Jay: The Lancet Commission's ongoing list of dementia risks just added LDL cholesterol as a risk for the first time. How does that work? Paul: That's a complex one. In terms of our discussions around heart and the brain, LDL cholesterol is well known as a risk factor for developing atherosclerosis. Again, hardening the arteries. Cholesterol deposits in arteries are not a good [thing] in the heart, in the blood vessels in the neck that feed the brain or in the small vessels that are in the brain itself. So plugging of those arteries, again, leading to brain damage or strokes can lead to vascular dementia. The other cholesterol story in the brain is very interesting. We know that the brain actually has a great deal of cholesterol contained in the tissue and its neurons. And if we think of cholesterol as a substance that gums up things, whether it's the blood vessels or it's brain tissue or it's neurons, there is this interesting relationship that the more cholesterol one has, the higher amount of cholesterol metabolism that's going on, and that may also be associated with higher levels of amyloid beta and tau proteins for exemple. There's a strong linkage between deposition of these proteins and the development of Alzheimer's, so that kind of wreckage that happens in the brain that's tied to cholesterol. Conversely, there are some interesting studies that say that if we can actually clear some of that cholesterol and interrupt its metabolism - there are a number of medications that can do that - it might actually be good for brain health as well. So there is this dual role of keeping our blood vessels clear as well as the brain tissue wreckage garbage deposits a little bit clearer as well. Allison: What are some of the key steps that people can take to reduce the dementia risk that's posed by high blood pressure or high LDL cholesterol levels? Paul: There are things in our personal control with lifestyle. There are medication approaches as well, of course. So for blood pressure from the dietary perspective, we can turn to programs like the DASH diet where we emphasize lower sodium, more fiber, more fruits and vegetables and healthy proteins. And of course those are the things that we talk about for heart health as well. Similarly, for cholesterol, that sort of pattern of eating is probably good for our cholesterol. But to really get cholesterol down and for many people with high blood pressure to really get the numbers optimized, then we may need the help of one or more medications. It's not a failure of lifestyle. It's the things that work best in a complementary way to help us control these risks. Jay: Nicole did not talk about it too much, but exercise played a big part in her recovery. In general, how important is exercise in preventing a heart attack and in recovering from one? Paul: I think exercise is really important when we think about the heart and the brain. In Nicole's particular situation, she was already quite active and fit before her event. And her particular type of heart attack, a spontaneous coronary artery dissection is somewhat atypical and exercise may actually have provoked the particular heart attack that she had. For most people with a heart attack, exercise is extremely important. And people who are fitter and engaging in regular physical activity tend to have a much lower risk of having that first heart attack. And for those who are recovering, exercise is such an important cornerstone of recovery over the long term. I, of course, think that exercise is key to everything. We could start with just don't be so sedentary. Get up and move around in any way that you can. That actually has a beneficial impact on issues like heart disease or diabetes or cancer risk and brain health. And then getting active in a planned way throughout the day is also really helpful. The combination of cardiovascular or aerobic exercise where we get up and move around, get our heart rates up, get a little bit sweaty and out of breath, that's really great to stimulate the circulation. The other component is strength training and is not to be underestimated either. For all of us, that combination of aerobic training and strength training or weight training or resistance training is really great. But the other interesting thing that we've seen in our populations is that one can actually draw a correlation between muscle mass and brain health. So lots of good reasons on why we should be active. Allison: So we've talked about how healthy changes can make a difference in your life, but we've heard many, many times on this show that change is hard. Now you've actually studied how people can make successful changes stick over time, and I'm wondering if you've got one or two different tips that you could share with everyone on how to do that. Paul: Yes, thank you for that [question], Allison. And I think the first thing that we start with often is finding out what's important for us. What makes us want to seek out healthier behavior. So if you've got a vision of where you want to go and why you really want to do it, then the rest of the pieces: what am I going to do and how am I going to do it, I think those things can fall into place [easily]. In our program, we spend a lot of time thinking about so-called “smart goal setting”. [That is to say] how to take a long destination and make it a short one [by] figuring out the real practical steps on what am I to do. It might be what's in it for tomorrow or next week, in small measurable ways that I can actually derive some confidence from. I can be successful in small steps, therefore I will be on my journey to big steps. And the other really important thing is to identify from the outset what's going to get in my way, what are the barriers? Because without thinking about that, we are probably destined for failure. And many folks have had that wonderful experience when embarking on, maybe a new dietary program, or maybe a new physical activity program, [and hit a barrier]. We like to reframe so-called failure or relapses. That's part of the journey. That's fantastic. You stop doing this, great. You're right on the pathway, you're ready to get up and go again because you know how to do this. Allison: And you learned from it. Paul: Absolutely. Yes, I agree completely. Jay: Well, that's heartening to me because I've always feared that laziness is the reason I don't do many of the things I know I should. But speaking of doing things that you know you should, how do you manage to look after your own brain and cardiovascular health? Paul: Yes, thanks for that, Jay. In preparing for this session, I was trying to do my own little grid, and here's what I've come up with. I start with why do I want to do this? Having just turned 60 - I'm revealing it on this podcast - I'm in the demographic where [lifestyle changes] might be relevant. What do I want to look forward to over the next decades? I want to be well, I want to be healthy, I want to be strong, and I want to have a good, clear head along with my body. So here is my “why”. Then I need to think about what I'm going to do with my body. What am I going to put in my body? Who am I going to do it with and where should I do it? That gives me some framework, some goal setting. [So] there are a few things that I could think about in my day-to-day activities that may be helpful or harmful along those pathways. Some simple things that I'm going to pay attention to [such as]: Can I somehow move [more] or sit less in the next hour? And hopefully I can. Can I eat a little bit better? And that's with every meal. Can I eat something fresh or colorful or fibrous? [some] fruits or vegetables that's going to be good for my heart or brain? I'm not going to smoke. I can make that decision very actively. I probably won't drink either, because alcohol is not the best thing for our bodies, but people will make their own choices. And then I'll think about those risk factors of blood pressure, cholesterol, blood sugar, and make sure those can be optimized as well. I will do my best to be social at some point in the day. Quiet time is also good. I'll have some stress likely in my day, and that's okay because that keeps us enlivened and invigorated. But then I'll remember to relax. And finally, I'll try to feed my brain as well. Try to do something every day that's a little bit challenging, a little bit new, a little bit stimulating, maybe even listen to a great podcast like Defy Dementia. That's how we're going to be healthy over the long term. Jay: That is a great list, and I'm not saying that just because you mentioned Defy Dementia. But thank you very much, Dr. O, for helping us defy dementia. Paul: Thank you, Jay. Thank you, Allison. It was such a pleasure to be with you today. Jay: Dr. Paul O is the medical director and senior scientist in the Cardiovascular Rehabilitation program at the University Health Network. He joined us from Toronto. You know, Allison, it really struck me hearing Nicole's story because her heart condition, it's important, but it's relatively rare, and yet even this rare condition is an alert that she may be at higher risk for dementia. When you combine that with the fact that The Lancet Commission risk factor list incorporates so many that have an impact on the heart and the circulatory system, it just brings home that not only are these a number of risk factors that should be important, but overall, honestly, if you had to tackle one central thing in your life, you should be paying attention to your circulatory system, especially your heart. What about you? What did you take away from today? Allison: I thought it was really interesting when we asked about what were the tips for someone, not just to start changing their lifestyle, but how to maintain it. One of the tips was to think about the why. Why is it that you want to change your lifestyle? What is it that you want to achieve? Who do you want to be? And I think having that understanding of what your goals are ultimately, is just so important in understanding why you should do it. We heard this in some of our previous episodes when we talked, for example, with Ernestine Shepherd on exercise. She had a really strong why, for why she wanted to change things, and I think that helped her really follow through with it. And then of course, we did hear again the suggestion that you should just start with baby steps, small things, adding a little bit of extra fruit and vegetables to your meals and so on. Even that can make a change. But I think it was also really interesting that [Dr. O] highlighted that you can make those small changes both in terms of lifestyle and medication. Jay: The fact that we talk about lifestyle risk factors and really don't spend a lot of time talking about medication should not be taken as, and doesn't imply that we don't think medications are appropriate and important in the right situation. It's just that in addition to them, there are all these risk factors that we've talked about that are truly important. And I'll say it again, you're never too young or too old to take care of your brain. Allison: To find out more about how we can all boost brain health and reduce the risk of dementia or slow its progression, please visit us at defydementia.org. There you can find at least 20 other episodes of this podcast as well as our videos, infographics, and other resources. Jay: Our podcast production team is Rosanne Aleong and Sylvain Dubroqua. Our writer and chase producer is Ben Schaub. Production is by Podtechs. Music by Steve Dodd. And our cover art is by Amanda Forbis and Wendy Tilby. Allison: We'd also like to thank the funders of this podcast, the Slaight Family Foundation, as well as the Centre for Aging + Brain Health Innovation and Baycrest. And we are deeply grateful to you, our listeners. Please support us by hitting that subscribe button for Defy Dementia wherever you get your pods. And don't forget to leave a like, a comment or maybe even a five-star review. Jay: And next time on Defy Dementia, a peek inside a hidden and largely unrecognized population that's facing increased dementia risk, adults with Down Syndrome and other developmental disabilities and their caregivers too. It could sound like a dire situation, but you'll also hear how it's being answered by the power of love. I'm Jay Ingram. Allison: And I'm Allison Sekuler. Thank you for listening to Defy Dementia. Jay said it before and now it's my turn to say it again. Always remember, you're never too young or too old to take care of your brain.