Beyond Awareness About Women's Hearts: What About Yours?
By Elizabeth Agnvall
Special to The Washington Post
Tuesday, May 3, 2005
It is safe to assume that the facts about women and cardiovascular disease circulated by massive public awareness campaigns have reached you by now. You know: that heart disease kills more women than anything else, that it's six times more deadly than breast cancer, more deadly for women than it is for men, yet under-recognized, under-studied, under-treated and under-funded.
So it's time to pick up where the awareness leaves off -- with what you can do about any of it. Knowing the statistics is fine, but it's better to know how not to become one. We've culled expert opinions and recent study findings to help you figure out whether you're at risk, what your symptoms might look like and what to do.
Okay, I keep hearing that heart attack symptoms are different for women. Tell me what to look for -- and don't tell me nausea and fatigue. If I went to the hospital every time I had those, I'd have a private suite in the ER.
First, don't forget that many of the symptoms are the same for you as they are for men. If you feel like there's an elephant sitting on your chest, get help fast, lady. The pain may feel like crushing, squeezing, burning or a fullness in the center of the chest. It may radiate to the neck, one or both arms, the shoulders or jaw. It may go away and return. If this happens, chew an aspirin (uncoated, ideally) and get yourself to a hospital. But you also need to look out for the more subtle signs that some women have -- like shortness of breath, back or jaw pain, and . . . yes, nausea or vomiting. Some women think they have the flu or heartburn when they actually are having a heart attack.
So how can I tell the difference?
"You really can't. That's part of the problem in terms of people getting to the hospital on time," said Kathleen King, a professor at the University of Rochester School of Nursing who co-authored a recent study comparing heart attack symptoms in men and women.
She said unless they have chest pain -- and 30 percent of people have heart attacks without any chest pain -- women often attribute heart attacks to something else. (Here's that lack-of-awareness problem hitting home.)
"I would discourage trying to give women a list of symptoms that would cause them to sit at home and self-diagnose. Symptoms of heart attack are more unique than most people realize."
Oh, come on. Of course we're going to self-diagnose. How else are we going to decide whether to call for help?
All right: If you're vomiting profusely, have fever and diarrhea, it's probably not a heart attack, King said: "Most people don't have a lot of vomiting, it's more of a nauseous feeling."
Another important point: Women often describe what they feel during a heart attack as chest discomfort rather than pain. (Having gone through childbirth, many of us have a different reference point for pain than guys do.)
King said throat discomfort is another common symptom in women. It's not a cold-type sore throat, but a "heaviness in your chest that goes up into your throat."
If I had those symptoms, I think I'd know something was really wrong. So why all the talk about women not getting help in time?
Part of the problem is that some women experience no symptoms at all: According to the American Heart Association, 64 percent of women who die suddenly from heart disease had no prior warnings, and 35 percent of heart attacks in women go unnoticed or unreported.
Women often don't think of heart attacks when they feel ill, said Sharonne Hayes, director of the Mayo Clinic Women's Heart Clinic in Rochester, Minn. "Women experience pain differently. They sense the pain differently. Whether the pain is different or whether this is cultural, we don't know," Hayes said.
If women are having heart attacks that are unnoticed and unreported, how do we know they are having them?
When they go for their yearly physical, the doctor hooks them up to an EKG (electrocardiogram), takes a look at the result and asks, "When did you have your heart attack?" King said we used to call these heart attacks "silent," but studies have shown that women usually knew they were sick -- maybe they stayed in bed for a week with what they thought was the flu -- but they didn't know they'd had a heart attack until their doctors told them.
In that case, why don't doctors just screen women more aggressively?
Good idea -- and many heart groups are urging docs to do just that. But getting more women to undergo routine physicals and screening for cardiovascular disease won't solve all the problems.
Why not?
Because simple screens were designed mostly for men, and they often miss heart problems in women. So it's hard for doctors to know which patients to refer for more complex tests.
Consider this. If a man comes in complaining of shortness of breath, the doc hooks him up to an EKG while he exercises on a treadmill and, bingo, he's got an answer.
But exercise stress tests are less reliable in women, said Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. The tests often need to be combined with other diagnostics such as an echocardiogram before and after exercise, and a nuclear scan, in which radioactive material injected into the veins shows how well the blood flows to the heart muscle. Then there's the question of how to interpret data to apply meaningfully to women.
Okay, but don't other ways of predicting risk work in women?
Not very well. The current gold standard for heart attack risk assessment is the Framingham risk calculator, which is based on data generated by a giant epidemiological study in Framingham, Mass., now more than 50 years old.
Drawing from data culled from more than 5,000 adults, the formula predicts an individual's risk of heart attack or death from heart disease in the next 10 years, based on the person's sex, age, cholesterol, blood pressure and smoking history. (To calculate your risk, see http://www.nhlbi.nih.gov/guidelines/cholesterol and click on "10-year risk calculator.")
The calculator identifies people as high-risk, intermediate-risk and low-risk. The problem, said Blumenthal, is that some recent studies have shown that unless a woman is a smoker, it's nearly impossible for her to get to the intermediate-risk zone using the Framingham Risk Score. He said plenty of women at low risk according to Framingham might be heading for a heart attack.
How does he know?
Together with colleagues at Johns Hopkins, Blumenthal ran a study of nearly 2,500 women over age 45 with no signs of heart disease. He found that when the researchers used Framingham, 90 percent of the women tested were ranked as low-risk, having a risk of less than 10 percent.
But when they used calcium scans -- high-tech imaging to detect arterial deposits of calcium and plaque -- 20 percent of the women were shown to have advanced hardening of the arteries, which Blumenthal said would put them at high or intermediate risk of heart attack.
Don't women tend to have their heart attacks when they're older? Does this mean I don't need to worry much until I hit retirement?
In order: Yes, and it depends.
Women are generally 10 years older than men when they have heart attacks -- 80 percent of them are 65 and older.
If you are a 55-year-old nonsmoking woman with normal cholesterol, weight and blood pressure, congratulations, you're in good shape. Start adding those risk factors -- especially smoking -- and risk goes up. And those birthdays really count against you.
Why are women over 65 more vulnerable?
"Age is a powerful risk factor," said Jacques Rossouw, project officer for the Women's Health Initiative at the National Heart, Lung, and Blood Institute (NHLBI). Starting as a teenager, your risk for heart attack doubles every 10 years, he said.
Is there anything I can do to reduce risk?
For starters, don't smoke: Smoking puts women at twice the risk of heart attack that it does for men.
Next, maintain a healthy weight. Overweight (25 to 29 on the Body Mass Index scale) and obesity (over 30) are closely tied to diabetes. And women with diabetes have a 50 percent greater risk of having a heart attack than men with diabetes, according to a study presented in February at an Orlando conference on women and heart disease.
Metabolic syndrome (a pre-diabetic state indicated by large waist circumference, poor cholesterol measures, high blood pressure and a high fasting glucose) is also tied to more arterial plaque and higher heart attack risk for women.
Maintaining a healthful diet pays off, too. Holly Thacker, director of the Women's Health Center and Breast Pavilion at the Cleveland Clinic, advises increasing the good fats (from olive and peanut oil and fatty fish such as salmon) and decreasing the bad (eliminate anything partially hydrogenated). Women who eat more fiber -- especially from cereal -- have a lower risk of heart disease.
Exercise helps keep the weight off and increase HDL, or good cholesterol, which studies have shown is more predictive of cardiovascular health in women than in men.
Can't I just take a cholesterol-lowering drug, the way my husband does?
Yes, but the benefits aren't as well established for women.
It's true the National Cholesterol Education Program (NCEP) recommends a statin for anyone -- man or woman -- with an LDL ("bad" cholesterol) reading of 190 or higher. NCEP also recommends statins for people at high risk of heart disease whose LDL is over 100.
But while statins have been proven to reduce both heart disease and deaths in men, statin use in women is more controversial. Although statins clearly reduce deaths and disease in women with heart disease, for women without heart disease, they've been shown thus far to reduce heart attacks and strokes but not deaths.
Reduce bad events but not deaths? Help me out here.
This is a case where the lack of research in women could compromise women's health. Susan Bennett, director of the Women's Heart Program at George Washington University, said women generally make up only 25 to 30 percent of study trials, and the women in the studies were younger and healthier than women who typically have heart attacks. As more women are studied, she predicts, statins will be shown to reduce deaths.
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." ยท
Elizabeth Agnvall recently wrote for the Health section about consulting pharmacists.