|FEATURE - Women in Diagnositcs|
Straight from the heart
Pioneering research on cardiovascular disease in women
PROF CAROLYN LAM
Prof Carolyn Lam is a Senior Consultant and the Director of the Women’s Heart Clinic at the National Heart Centre Singapore. In this interview with Dia:gram Prof Lam shares her passion for biomarkers and what she calls ‘truly personalised medicine’.
Professor at the Duke-NUS Cardiovascular Academic Clinical Program.
Basic cardiology specialty training from Singapore, heart failure and advanced cardiology specialty training from the Mayo Clinic and clinical epidemiology training from the Framingham Heart Study in Massachusetts, USA.
PhD from University Medical Centre Groningen, Netherlands focused on heart failure with preserved ejection fraction (HFpEF) and sex differences, as well as executive management training from Stanford University Business School.
Recognised globally for her expertise in heart failure clinical trials and her focus on women’s cardiovascular disease.
The case for amplifying women’s voices in the world of science and diagnostics grows stronger as diversity drives discovery and advancement. Many female scientists, researchers, and academics have brought pioneering approaches to complex disease areas such as preeclampsia, breast and cervical cancer, and cardiovascular disease, with a sense of urgency as well as a depth of personal understanding. Often their approach contributes a point of view on the nuanced needs and unique biological differences of the female population - an area that is often overlooked.
Prof Carolyn Lam’s interest in decoding the mysteries of the biomarkers B-type natriuretic peptide (BNP) and N-terminal (NT)-pro hormone BNP (NT-proBNP), started while she was a research student in a Mayo Clinic laboratory. She recalls being intrigued by their paradoxical nature: “They are the heart’s protective hormones. So why is it that high levels are bad?”
This curiosity continued unabated while she was training at the Framingham Heart Study in Massachusetts. Prof Lam’s research showed that there was cross talk between sex hormones and the heart. Her research delved into the fact that estrogens boost natriuretic peptides while testosterone suppresses them1 .
Prof Lam hypothesised that this could be why men have earlier cardiac events when compared to women. Exploration of this hypothesis continues to be at the core of Prof Lam’s pioneering work in understanding the ways in which sex and gender differences affect heart disease in women. Her work is increasing awareness on the need to personalise treatment for women and men.
A passionate advocate for women’s heart health
Research on heart disease in women is only just catching up to the knowledge and understanding of how it manifests in women, according to Prof Lam. She points out the interplay between sex-based differences and gender. “‘Sex’ refers to the biological construct such as sex chromosomes and sex hormones. When referring to ‘gender’ think about the social construct – for example, many young girls are discouraged from rough and tumble activities whereas boys are encouraged to be physically active, and these factors can impact heart health,” she said.
For all these reasons, Prof Lam felt that a heart clinic focused on women made a lot of sense. She was instrumental in launching the first such women’s heart clinic in Singapore. “It’s really not the case that women are a smaller version of men, as is often assumed. There are factors such as pregnancy, menstruation and menopause that we just do not have to consider in men,” she said.
Prof Lam cites heart failure (HF) as a condition that starkly illustrates gender difference. Heart failure is primarily defined on the basis of ejection fraction, a measurement that assesses the pump function of the heart. A heart attack can damage the heart muscle and thereby reduce ejection fraction. However, in heart failure with preserved ejection fraction (HFpEF), the heart pumps normally but is too stiff to fill up properly with blood. This condition represents almost 50% of heart failure cases worldwide and is a leading cause of death and disability. Studies show that HFpEF is particularly prevalent among women and the elderly who have comorbid conditions like obesity, hypertension and diabetes2 , Elevated NT-proBNP levels can be used to confirm whether a patient has HFpEF.
Prof Lam is particularly interested in utilising NT-proBNP as a prognostic indicator in Asian patients with established heart failure, as well as Asian individuals at risk of heart failure. Prof Lam’s research team, is currently studying the interplay between gender, ethnicity and the development of HFpEF3 . She is involved in several research projects that will help refine our understanding of how heart failure differs by ethnicity, gender, sex and other local and regional determinants. She is the Program Lead of the Asian Network for Translational Research and Cardiovascular Trials (ATTRaCT). She is also the principal investigator of an ongoing nation-wide heart failure study in Singapore (the Singapore Heart Failure Outcomes and Phenotypes [SHOP] study).
As part of the International Federation of Clinical Chemistry (IFCC) committee, Prof Lam is currently contributing to the development of an educational paper on natriuretic peptides for laboratory specialists and clinicians. Furthermore, as part of the European Society of Cardiology Heart Failure Association writing group, she is contributing to new international recommendations for the diagnosis of HFpEF, which are expected to be published this year. Prof Lam hopes the guidelines will help accelerate accurate diagnoses, especially for elderly women who may go undiagnosed due to the perception that breathlessness is a natural byproduct of ageing.
“It goes a lot like this in the female patient’s head: I’m unfit, I ate too much, it’s my own fault, I didn’t exercise… the list goes on! The first step is for patients to recognise that something is actually wrong and not just blame themselves. Then, the General Practitioner (GP)should know what to look for. When we look at the echocardiogram and see that the pump function is normal, we can’t just immediately say that the patient is unfit or anxious. We need to look at diastolic function, not just the systolic function. Is the heart muscle thick? Is it stiff? We all need to be aware that it’s not just about ejection fraction,” she said.
A connector, educator and mentor
Apart from her many achievements, Prof Lam is also a prolific author and broadcaster. She is an Associate Editor for Circulation and the European Journal of Heart Failure and even does a podcast for Circulation. To educate the public, she is seen regularly on television as the Resident Doctor of the health program “Body and Soul” by Mediacorp Singapore.
“We need to continuously upskill ourselves and embrace technologies that can help us to make a positive impact. Automation in pathology continues to be at the fore, with improved technologies reducing the requirement for labour intensive processes, promoting standardisation and consistency in laboratory testing, and alleviating manpower constraints,” she added.
She enjoys motivating her patients and mentoring women interested in cardiology. “I am so happy to see women pursuing cardiology and if I could play even a small part in that choice, it makes my life worthwhile,” she said.
Inspiringly, her dynamism is fuelled by a desire to bring out the best in others – whether it is family, patients or the people she mentors. “The singular focus I hope to have is to be a loving and positive force. If I bring out the best in my patients, they will naturally do well and have better health.”
1. Lam C., Cheng S., et al. (2011). Journal of the American College of Cardiology 58 (6) 618-626. Influence of Sex and Hormone Status on Circulating Natriuretic Peptides.
2. Oktay, A. A., Shah, S.J. (2015). Curr Cardiol Rev; 11(1): 42–52. Diagnosis and management of heart failure with preserved ejection fraction.
3. Lam,C., Anand, I., Zhang, S., et al. (2013). Eur J Heart Fail. Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry.