Women & Heart Disease.

It started as just a minor annoyance--some mild chest pain and shortness of breath. But by the end of that April day in 1996, Kathleen Butler's life had changed forever. That's the day the 40-year-old Wisconsin woman, who had never smoked and had normal blood pressure, but was 40 pounds overweight, had a heart attack. "Never in my wildest dreams did I think I could be having a heart attack," says Ms. Butler of that spring day eight years ago. She's not alone.

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A 2003 survey of 204 women with heart disease, conducted by researchers at the Mayo Clinic in Rochester, MN, found that many considered their condition "a man's disease." Almost half had been unaware they were at risk of coronary artery disease until after their diagnosis. The survey also found just over a third of the women reported symptoms to their doctors and, of those doctors, nearly one-third had failed to recognize the women's symptoms as related to their heart. (1)

"There have been some very real misconceptions about heart disease in women formed by the medical community as well as the public that are important to dispel," says Sharonne N. Hayes, MD, director of the Mayo Clinic Women's Heart Clinic. "Like the idea that women don't get heart disease. Or that it's not a big deal for women." In fact, she says, surveys still show that women perceive cancer, not heart disease, as by far their greatest health threat.

Hopefully, that perception will be changing soon. "The Heart Truth," a campaign aimed at raising awareness nationwide about women and heart disease launched in 2002 and sponsored by the National Heart, Lung, and Blood Institute (NHLBI), now is in full swing. Additionally, the American Heart Association released new guidelines in February 2004 for preventing heart disease and stroke in women based on a detailed review of nearly 7,000 studies. The guidelines urge women to work with their health care professionals to determine their risk and to come up with prevention strategies based on their personal cardiovascular health. (2)

The need to increase awareness among women and health professionals is critical since cardiovascular disease (CVD), which includes diseases of the heart and blood vessels, such as stroke, is the leading cause of death in women, accounting for some 500,000 deaths a year. One in 10 women aged 45 to 64 and one in five women aged 65 or older has some form of diagnosed heart disease. (3) Compare that to breast cancer, which in 2004 is expected to claim the lives of about 40,000 women. (4)

Heart disease strikes African-American and Native-American women particularly hard, since they are more likely to have risk factors for cardiovascular disease (high blood pressure, over-weight, smoking) and receive poorer health care than Caucasian women. Overall, age-adjusted death rates from cardiovascular disease were higher for African-American women in 2000 (397.1 per 100,000), compared to Caucasian women (285.8 per 100,000). (3)

There's a good explanation for the misperception about the impact of heart disease on women, says Dr. Hayes. "First, a lot of women do get breast cancer, but not that many die of it. So your average 50-year-old woman probably knows someone who is close to her who had breast cancer. But she may not know a woman who's had a heart attack or heart disease because that tends to happen later in life." Although younger women, like Kathleen Butler, do develop heart disease, it typically occurs about 10 years later than it occurs in men, generally after women have completed menopause.

After menopause is not the time to start taking care of your heart, though. The time to start is now, regardless of your age. Because, as Dr. Hayes notes, hardly anyone dies of a heart attack these days. Instead, you wind up with heart failure and in constant chest pain, short of breath and with the threat of another heart attack, one that will kill you this time, hanging over you. "And that's a terrible way to die," she says.

Heart Disease in Women: The Gender Gap

Heart disease looks strikingly different in women than it does in men. This is relatively new knowledge, however, since research into heart disease in women is about 50 years behind research into the disease in men, notes Noel Bairey Merz, MD, director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles, CA.

For instance, women are only half as likely as men to survive a first heart attack, and significantly more likely than men to experience a second heart attack within one year. They may also exhibit some unique symptoms in the month before a heart attack, such as unusual fatigue, sleep problems, indigestion and weakness in their arms. (5)

Dr. Bairey Merz is leading the effort to increase our understanding of heart disease. She heads the Women and Ischemia Syndrome Evaluation, or WISE trial. Sponsored by NHLBI, WISE has been tracking 1,000 women for more than half a decade to evaluate gender-specific issues related to women undergoing coronary angiography (a diagnostic procedure to identify artery blockages) and the diagnosis of coronary artery disease.

Since it launched, however, the trial has become much more. "It's a spring-board for providing a lot of answers to a lot of questions that we've never asked before," says Dr. Bairey Merz. Like, why do more women die of heart disease every year than men? Why do relatively young women under the age of 55 have a much higher risk of dying with their first heart attack compared to men of the same age? What role do hormones and, specifically, estrogen play? What is the best way to diagnose heart disease in women?

For instance, in 2000 WISE uncovered surprising new information regarding a form of heart disease more prevalent in women, but not frequently seen in men. Called microvascular disease, or cardiac syndrome X, it involves the dysfunction of the small blood vessels within the heart muscle. These smaller arteries cannot be seen during common procedures like angiograms, nor can they be cleared out via angioplasties or even bypass surgery.

"Because we couldn't see it, and no one bothered to study this form of heart disease, because it was fairly unusual in men, we didn't know very much about it," says Dr. Bairey Merz. "But from our estimates from the WISE study, there are more women with cardiac syndrome X in the U.S., than women dying from breast cancer. And, it accounts for much of the unexplained chest pain women have, pain often dismissed as psychological by health care professionals."

You don't have to tell that to Mary Olson, a 57-year-old community college instructor from Stewartsville, MN. Ms. Olson first began experiencing chest pain on her regular walks five years ago but dismissed the pain as a sign of aging. She ignored the symptoms for two years until finally mentioning them to her family doctor during a routine physical.

Although she wasn't overweight, exercised regularly, ate healthful foods and didn't smoke, she had a strong family history of heart disease. Her doctor performed an electrocardiogram to test her heart's electrical activity. The test showed some slight abnormalities, so he sent her to the Mayo Clinic in nearby Rochester. Two years and numerous tests and medications later, she received the cardiac syndrome X diagnosis.

"The doctor told me that at one time they would have thought the pain was 'all in my head', but now we know better," she recalled.

Today Ms. Olson takes a variety of medications for her heart condition and attends cardiac rehabilitation to learn how to exercise without triggering her chest pain, called angina. She also pays close attention to the messages her body sends and no longer ignores any symptoms.

Her message to other women: "Seek help sooner than I did. And once you're treated, if you're not getting what you feel is the optimum relief, go back and seek more help again and again until you're told they've done everything they possibly can. Then seek a second opinion before you accept that."

Shortchanging Women's Hearts

That's advice far too few women follow. In fact, notes Dr. Bairey Merz, one reason more women die of heart disease than men may be that they don't receive the same level of care compared to men. For instance, women are less likely than men to receive an aspirin during or after having a heart attack, a basic treatment recommendation.

Women also are shortchanged when it comes to receiving prescriptions from their health care professional for cholesterol-lowering statin drugs, known to significantly reduce the risk of a heart attack or heart disease. They're also less likely to be referred to cardiac rehabilitation than men. And, even though more women than men have diabetes, women are less likely to be prescribed the three medications recommended to prevent heart disease in people with diabetes: an aspirin, a statin and an ACE inhibitor, says Dr. Bairey Merz.

No one really knows just why women don't get the same treatment, but both Dr. Bairey Merz and Dr. Hayes suspect it may have to do with the way society undervalues women and women undervalue themselves as a result. "So whereas a man might demand to see a cardiologist, or automatically be offered a referral to one, women don't," says Dr. Bairey Merz. The disparity may also be related to economic factors, she says. Women, particularly older women, are more likely to live in poverty, and so may be less able to seek appropriate medical care.

Understanding Your Own Risk

Because heart disease and its risk factors can be silent for so long, often with few symptoms until the disease is well underway, it's important to know your personal risk factors, says Dr. Hayes. That includes your family history, cholesterol and blood pressure levels. Two major studies published in the summer of 2003 found that nearly everyone who dies of heart disease, including heart attacks, had at least one or more of the conventional heart disease risk factors: smoking, diabetes, high blood pressure and high cholesterol. (6,7)

A heart disease risk assessment tool based on the Framingham Risk model can be found online: http://www.americanheart.com. It estimates your 10-year risk of having a heart attack or dying of coronary heart disease based on your answers to questions about your personal risk factors.

No matter what your age, if you suspect you have heart disease or are at risk of heart disease, talk to your health care professional about having diagnostic tests such as an exercise echocardiogram or a nuclear stress test.

Young Women & Heart Disease

Getting at the heart of the differences between men and women when it comes to cardiovascular disease is important not just for women, but for men, as well, says Dr. Hayes. For instance, if researchers could figure out just what it is that protects women from heart disease longer than men, they might be able to extend that same protection to younger women, in whom the condition is more serious than in post-menopausal women, and to men.

For years, researchers thought that protection was estrogen, since women's risk of heart disease is so much lower than men's prior to menopause when women's estrogen levels are high. Then came the Women's Health Initiative (WHI), a major federally funded study of more than 16,000 women between the ages of 50 and 79, which showed that women who used menopausal hormone therapy containing estrogen and progestin had a slightly higher risk of heart disease than women who didn't. (8)

While the WHI results are important, says Dr. Bairey Merz, they don't address the issue of estrogen in younger women. For instance, young, premenopausal women are more likely to die from heart disease or heart attack than men of the same age even though these women tend to have few risk factors. "When young women have a heart attack, they don't just have it and get better," says Dr. Hayes. "They come back the next year and they've had progression of their coronary artery disease and another heart attack. And these are women who turn their lives around and control all their risk factors. So I'm convinced there is something there."

Research from the WISE study shows these younger women with heart disease often are relatively estrogen deficient usually because they menstruate without ovulating, a condition called anovulatory menstrual cycling. Conversely, young women who have had their ovaries removed and receive supplemental estrogen have a much lower risk of subsequent heart disease than women who don't. "So we think this is another story [about estrogen and heart disease] that needs to be told," says Dr. Bairey Merz.

Heart Health: Know Your Numbers (9,10)

Test            Range                   What it Means

Total           Less than 200 mg/dL     Ideal
cholesterol     Between 200 and 239     Borderline high
                240 and above           High
LDL ("bad")     Below 100 mg/dL         Optimal
cholesterol     Between 100 and 129     Near optimal/
                                        above optimal
                130 to 159              Borderline high
                160 to 189              High
                Above 190               Very high
HDL ("good")    Less than 40 mg/dL      A major heart disease risk
cholesterol     50 to 59                Preferred
                60 or higher            Ideal. Helps lower your
                                        risk of heart disease
Triglycerides   Under 100 mg/dL         Ideal
                149 or lower            Normal risk of coronary
                                        artery disease
                150 to 199              Borderline high risk of
                                        coronary artery disease
                200 to 499              High risk of coronary
                                        artery disease
                500 or above            Very high risk of developing
                                        coronary artery disease
Blood pressure  Less than 120/80 mm hg  Normal blood pressure
                Between 120/80          Prehypertension*
                and 139/89
                Between 130/80          Twice the risk of developing
                and 139/89              hypertension
                Between 140/90          Stage 1 hypertension
                and 159/99
                160/100                 Stage 2 hypertension
                or higher

* Hypertension is the medical term for high blood pressure.

Resources

American Heart Association

7272 Greenville Avenue

Dallas, TX 75231

1-800-242-8721

http://www.americanheart.org

Devoted to research, advocacy and education about cardiovascular disease and stroke. Provides heart-healthy lifestyle information and detailed information on heart disease risks and management.

American Diabetes Association

ATTN: National Call Center

1701 North Beauregard Street

Alexandria, VA 22311

1-800-342-2383 (English and Spanish)

http://www.diabetes.org

Supports advocacy, research and education on diabetes diagnosis, treatment and management. Offers diabetes-related lifestyle information in a variety of formats.

National Heart, Lung, and Blood Institute

NHLBI Health Information Center

PO Box 30105

Bethesda, MD 20824-0105

301-592-8573

http://www.nhlbi.nih.gov

Plans and coordinates a national program, including clinical trials, in diseases of the heart, blood vessels, lungs and blood, and sleep disorders. Web site offers wide range of information.

WomenHeart:

The National Coalition for Women with Heart Disease

818 18th Street, NW, Suite 730

Washington, DC 20006

202-728-7199

http://www.womenheart.org

National organization founded by women with heart disease; dedicated to reducing death and disability among women living with heart disease.

For more information on women and heart disease, visit: www.healthywomen.org