ABILITY House Magazine Article IllustrationWomen and Heart Disease - by Dr. Gillian Friedman

One of the downsides of going to medical school is that one is then consulted for every family medical problem, from hiccups to high blood pressure. When my father complained of “asthma” after climbing stairs a few years ago, I knew immediately that he was really experiencing symptoms of heart disease and told him to see his physician immediately. Within a week of his appointment he had angioplasty to clear several blocked coronary arteries, one of which was almost completely impassable. The procedure almost certainly saved him from having a heart attack and quite possibly saved his life—one of the upsides of my going to medical school.

A few years later my mother had extreme fatigue and difficulty catching her breath while bicycling. I thought she might have had a spell of low blood sugar, asthma, or possible dehydration, but it turned out she also was experiencing symptoms of heart disease.

Why did I have different initial assumptions about the underlying causes of my parents’ symptoms? Partially it was their medical history—my father had known risk factors for coronary artery disease (CAD) and my mother did not. But also my response was typical of a known bias among both doctors and the general public. Heart disease is the leading killer of women, responsible for one-third of all deaths of U.S. women (more than all cancers combined). Heart disease kills six times more women than breast cancer each year. Nevertheless, our automatic mental images still portray it as a man’s illness. A recent American Heart Association survey showed that only 13 percent of women consider heart disease their greatest health threat.

Marianne Legato, MD, discusses this bias in her 2002 book Eve’s Rib: The New Science of Gender-Specific Medicine and How It Can Save Your Life. She details a 1987 study showing that cardiologists were twice as likely to ascribe a woman’s symptoms to hysteria or emotion than a man’s. This pattern held true even when a male and a female actor read an identical script describing cardiac symptoms to the doctor.

Subsequent studies have shown that women also receive more conservative treatment for heart disease. Dr. Legato quotes a study showing that women with abnormal results on preliminary tests for coronary artery blockage (the major cause of heart attacks) were ten 10 times less likely than men to be referred for cardiac catherization, the definitive test for CAD.

Statistically, heart attacks are more deadly and disabling for women than for men. Among women, 38 percent die within one year of their first recognized heart attack, compared with 25 percent of men. Similarly, 46 percent of female and 22 percent of male heart attack survivors have disability from heart failure within six years. Nevertheless, women are less likely to be referred for interventions such as angioplasty, coronary artery bypass surgery, or clot-lysing therapy. They are also less likely to be prescribed medications like beta-blockers, ACE-inhibitors, and aspirin, which have the best evidence for improving outcomes and prolonging life after heart attacks.

How Is Heart Disease Different in Men and Women?
1. Women are less likely to have the traditional symptoms of crushing chest pain, difficulty breathing and left arm numbness. Two-thirds of women have none of these signs. Heart attack symptoms in women are often subtle, frequently presenting as fatigue, sweating, nausea, or jaw pain.

2. Current diagnostic tests for clogged arteries may be less useful in women than men. Plaque along the walls of coronary arteries accumulates more diffusely in women than in men. Men tend to have bulges of plaque, whereas women have it spread more evenly on vessel walls. Diagnostic tests, however, look for clumps of blockage, which may explain why one-third of women who have heart attacks have no clear clogs on these tests.

3. Women’s hearts are more susceptible to irregular beats than men’s. Testosterone provides a protective effect by shortening a resting interval called the Q-T interval during which abnormal beats can arise. Estrogen fluctuations, however, increase sensitivity to palpitations and abnormal rhythms. Consequently, women are more likely than men to experience abnormal heart rhythms as a side effect of medication.

4. Because of ovarian hormones, women have, on average, lower blood pressure than men until menopause. By age 60, however, high blood pressure (hypertension) is more common in women than in men. Blood pressures above 130/80 (the upper number is the pressure when the heart is contracting, the lower number when it is relaxing) increase the risk of heart attack, heart failure, and stroke. Women, however, respond differently from men to medication for hypertension. Women have a better response to diuretics (“water pills”), particularly a class called thiazide diuretics, which have the added advantage of helping retain calcium and preserving bone structure. With other types of blood pressure medications, women may be more likely than men to develop side effects. For instance ACE inhibitors relax blood vessel walls, but more frequently in women cause persistent nagging cough. Similarly, another type of blood pressure medication called calcium-channel blockers sometimes has to be stopped because of leg-swelling.

One of the most important classes of blood pressure medication for both men and women is the beta-blockers, which work by blocking the sympathetic nervous system (the “fight or flight” response). These medications are prescribed for blood pressure, exertional chest pain, congestive heart failure, and heart recovery after heart attack. Although these medications are still important as a first-line treatment for heart disease in women, they are somewhat more effective and better tolerated in men.

5. Hormonal difference may provide a protective role in lowering blood cholesterol in younger women; after menopause, however, higher blood cholesterol makes women more susceptible to blocked coronary arteries, particularly in the presence of high triglycerides, another fatty substance that circulates in the blood.

6. Other major risk factors for heart disease, such as smoking and diabetes, can be more damaging for women than for men. For instance, women who smoke may be twice as likely to have a heart attack as male smokers.

What Is Your Risk For Heart Disease?
If you have heart disease or atherosclerosis (“hardening of the arteries”) already, or if you have diabetes, chronic kidney disease, or certain types of genetic high-cholesterol conditions, you are already considered high-risk for further heart damage or heart attack. Other risk factors for heart disease are older age, smoking, high cholesterol, hypertension (high blood pressure), obesity, and family history of early heart disease. Women who smoke risk having a heart attack 19 years earlier than non-smoking women. Women with diabetes are two to three times more likely to have heart attacks.
Public health organizations have been trying to raise awareness about heart health particularly in African-American, Latina, Asian/Pacific Islander, and other minority-group women. Statistics show that women from these groups have higher rates of obesity, more sedentary lifestyles, and lower levels of physical activity than Caucasian women. Almost 40 percent of U.S. Caucasian women get no physical exercise, compared with about 60 percent of African-American and Latina women. Differences in lifestyle factors may be critical because some minority women are already at higher risk for heart disease. The age-adjusted rate of heart disease for African-American women, for instance, is 72 percent higher than for Caucasian women. African-American women aged 55 to 64 are twice as likely as Caucasian women to have a heart attack and 35 percent more likely to have coronary artery disease.

You and your doctor can assess your risk for heart disease using the Framingham Risk Assessment Calculator for women. Find your point scores for age, total cholesterol, smoking status, HDL, and blood pressure. Add these points together to determine your overall risk. A risk greater than 20 percent in 10 years indicates high risk of a heart attack or heart disease within the next 10 years; between 10 and 20 percent is intermediate risk, and below 10 percent is considered lower risk.

How Can You Lower Your Risk?
1. Schedule an appointment to talk to your doctor about your risk for heart disease, based on your family history, other health conditions, diet, and fitness level. Ask what health screenings you should have to detect risk factors you can change with healthier habits, medication, or other interventions.

2. Stop smoking, learn about a heart-healthy diet, and get at least 30 minutes of exercise most days of the week. Lifestyle factors account for over 80 percent of heart disease in women.

3. Follow your cholesterol. The target level for total cholesterol is 200mg/dL or lower, but women with some risk factors for heart disease should aim for lower levels yet. However, total cholesterol levels do not tell the whole story. High-density cholesterol (HDL) is the “good cholesterol” and helps protect the heart if levels are above 50 mg/dL. Low-density cholesterol (LDL), the “bad cholesterol,” should ideally fall below 100 mg/dL. Triglyceride levels should fall below 150 mg/dL. For women, good HDL and triglyceride levels are particularly important in preventing heart disease.
Exercise raises HDL and lowers LDL. For people who cannot bring their cholesterol into a healthy range with diet and exercise alone, medications called statins (Zocor, Lipitor, Pravachol, and others) can reduce cholesterol by more than a third and have been shown to substantially improve outcome in high risk groups, such as those who have already had a heart attack or bypass surgery. Some studies suggest that statins are beneficial for people at high risk for heart disease (like diabetics) even when their cholesterol levels are normal. Prescription niacin and medications called fibrates are also used (do not use over-the-counter niacin, however, as medical complications like liver problems may occur with some forms).

4. Have your blood sugar checked every three years beginning at age 45, or earlier if you have a family history of diabetes, are overweight, or have symptoms such as excessive thirst, frequent urination, or fatigue. If you are found to have diabetes, check your blood sugar regularly as directed by your doctor and keep a log of readings to bring in to your appointments.

5. Control your blood pressure. High blood pressure has no immediate symptoms but over time causes extensive damage to the heart, kidneys, and blood vessel walls; consequently, it has been referred to as a “silent killer.” Optimal blood pressure is 120/80 mm Hg. For heart health it is important that both pressures fall within normal range. If the numbers fall frequently above 140/90 (130/80 if you are diabetic), you need to act to bring your blood pressure back under control. Eliminating salt, losing weight, and increasing exercise can all lower blood pressure. If these steps are not sufficient, there are a wide variety of medications effective in controlling blood pressure. Your doctor will choose the best type of medication based on your other medical problems. For instance, research shows that often people with diabetes should take ACE inhibitors, which can help protect the kidneys; those with previous heart failure, heart attacks, or angina frequently benefit from beta blockers; others may do best initially with diuretics, especially thiazide diuretics. Sometimes a combination of medications is needed, and your physician is in the best position to advise you based on your individual response and history.

6. Use baby aspirin (81mg) daily if you are at high risk and if your doctor clears you to do so. Women who have aspirin allergies; stomach ulcers; bleeding conditions; or liver, kidney, or stomach problems, should discuss specifically with their doctors whether they should take aspirin with these problems. The American Heart Association does not recommend aspirin for low-risk women because of the increased chances of bleeding and gastrointestinal problems, but many cardiologists and vascular surgeons believe that women over the age of 45 do benefit from low-dose aspirin to prevent strokes and heart attacks and that risks are minimal with low doses.

7. If you are psychologically depressed, get treatment for your depression. When other cardiovascular risk factors are taken into account, depression causes the mortality from heart disease to double. The proposed mechanism relates to a chemical called serotonin. In the brain abnormalities in serotonin can lead to depression. Serotonin is also present in platelets, blood cells involved in clotting. The theory is that people with depression have serotonin irregularities that cause platelets to stick differently to the walls of their blood vessels and make them more susceptible to atherosclerosis and blood clots.

8. Do not use hormone replacement therapy (HRT) for heart protection. At one time it was believed that HRT offered cardiovascular benefits as estrogen levels declined at menopause. Recently, however, the Women’s Health Initiative, a long-term, prospective, randomized trial enrolling thousands of women, found that HRT had no benefit in preventing heart disease and in some women increased the risk for heart attacks, strokes, and blood clots. Use HRT only if needed for severe perimenopausal symptoms.

9. Do not take antioxidants such as beta-carotene and vitamin E to lower risk of heart disease. Several clinical trials have shown no benefit from these supplements, and some have shown an increase in the risk of hemorrhagic (bleeding) strokes. In addition, some studies have indicated that antioxidants may interfere with the beneficial action of statin drugs in cholesterol therapy.

10. Avoid fad diets. Most diets popular for weight loss today (Adkins, South Beach, etc.) have not been stringently evaluated for cardiovascular effects over time, and physicians are divided about whether patients should use them for weight control. The American Heart Association continues to recommend a diet that includes fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes and sources of protein low in saturated fat (such as, poultry, lean meats and plant sources). Read labels to avoid hydrogenated oils; hydrogenation adds water molecules to fats, basically changing unsaturated fats into saturated fats, and saturated fats are worse for contributing to atherosclerosis. Health food stores often sell “cold-pressed” margarines and oils, which are made without hydrogenation.
How Can You Find More Help?

The American Heart Association’s Go Red For Women website, launched at Mother’s Day, was designed both to help raise awareness of women’s risk for heart disease and to help women translate awareness into action. It offers practical tips for nutrition and fitness (such as physical exercise that can be done at work or on the road), as well as newsletters with tips and information to help women reduce their risk for heart disease and stroke.

The Black Women’s Health Imperative is a leading African-American health education, research, advocacy, and leadership development institution. Its website provides excellent information about a wide array of women’s health topics. The site includes a physician locator service, a guide to safety and efficacy information for vitamins and herbal supplements, and women’s health research findings.

by Gillian Friedman, MD

American Heart Association

Women’s Heart Foundation

Black Women’s Health Imperative

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