Taking the Message to Heart

AHA guidelines for women say that all high-risk women (those with heart disease, diabetes or kidney disease) should be on a cholesterol-lowering drug -- preferably a statin.

What about aspirin for women? Didn't I just read about this?

You did.

A recent study in the New England Journal of Medicine (NEJM) found that aspirin did not lower the risk of heart attack for middle-aged women who haven't had one -- as it appears to do for men. But it did decrease the risk of stroke.

But in women 65 and older, the study found that aspirin lowered the risk of heart attack as well as stroke. For this group, aspirin's benefits seemed to outweigh its risks. Women taking aspirin were 40 percent more likely to develop intestinal bleeding or serious stomach problems than those who took a placebo.

AHA guidelines issued last year advised women with heart disease or diabetes to take 75 to 162 milligrams of aspirin daily. Women with metabolic syndrome, high blood pressure or cholesterol or multiple risk factors were also advised to take it if the benefit was judged likely to outweigh the risk of gastrointestinal side effects. But the NEJM data may call for updated treatment advice.

I've just gone through menopause. Does that increase my risk of heart disease?

Another tough question. The answer used to be a simple "yes."

According to the NHLBI Web site, heart disease rates are two to three times higher for post-menopausal women than for those of the same age who have not gone through menopause. (The risk of heart attack is still very small in either case; in pre-menopausal women ages 50 to 54 it is 2 in 1,000, in post-menopausal women of the same age, it's 3.5 in 1,000.)

But Rossouw, of NHLBI, said the cause and effect is unclear. Once women go through menopause they tend to be less active, gain weight, have less good cholesterol, more bad cholesterol and higher blood pressure.

Whether the greater risk is related to the decrease in estrogen after menopause or an increase in other risk factors is uncertain.

Will hormone therapy increase my risk of heart attack?

Findings from two large studies released in 2002 -- the Women's Health Initiative and the Heart and Estrogen/Progestin Replacement Study -- have frightened women about hormone therapy. With at least some justification.

"I think the major message is that we have no evidence that [hormone therapy] prevents heart disease," said George Washington University's Bennett. "There is some indication that heart disease events may be increased."

However, some cardiologists now say that scientists' and journalists' reports on those studies may have exaggerated the size of the risks found.

"Unfortunately, my feeling is that . . . there was a needless hysteria in back in 2002," Blumenthal said. "Many of us think that, while we doubt that hormone therapy will ever be a viable preventative measure to decrease heart attacks and strokes, if women take it [only] within the first five years of menopause, there's no real evidence that there's an increase in risk."

There's a caveat, though, on which all of our experts agree: Women who have had a heart attack should not be on hormone therapy if at all possible.

So let's say I try to do all this and I still get the big one. How can I improve my odds of surviving it?

In general, heart attacks are deadlier to women than men at any age.

Although incidence of heart disease is lower in pre-menopausal women, they are more likely than men to die from a heart attack and more likely than men to have a second heart attack within a year. Thirty-eight percent of women (25 percent of men) will die within one year of having a heart attack.

This is partially because women are generally older than men when they have heart attacks and partly because they are less likely to get help afterward: A study conducted by the Mayo Clinic found that women were 55 percent less likely than men to participate in cardiac rehabilitation. The good news is that if they do receive prompt treatment followed by coaching and education after a heart attack, they tend to benefit more than men, said Mayo Clinic's Hayes.

"If we only treated women as aggressively as we treated men, they'd be better off," Hayes said. "Rather than comparing men and women, I think a better comparison is women who get the treatment to women who don't." ·

Elizabeth Agnvall recently wrote for the Health section about consulting pharmacists.