Sharonne Hayes
Director, Mayo Clinic Women's Heart Clinic
Tuesday, May 3, 2005
2:00 PM
Sharonne Hayes, M.D., FACC , director of the Mayo Clinic Women's Heart Clinic in Rochester, Minn., was online Tuesday, May 3, at 2 p.m. ET to answer your questions about cardiovascular disease in women and to discuss prevention.
Read Tuesday's article, " Taking the Message to Heart " (Post, May 3)
Hayes is also associate professor of medicine and cardiology at the Mayo Clinic College of Medicine, a fellow of the American College of Cardiology and fellow of the American Society of Echocardiography. She developed the Women's Heart Clinic at Mayo, and has been active at the national, local and institutional level in promotion of cardiovascular health issues in women.
Hayes is chair of the Scientific Advisory Board of WomenHeart: The National Coalition for Women with Heart Disease, and the Women's Health Advisory Group of the American Society of Echocardiography. She co-chaired the Jacob's Institute of Women's Health conference, "Women and Heart Disease: Putting Prevention into Primary Care."
A transcript follows.
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Boston, Mass.: I'm a new nurse working in Boston. I learned in nursing school that heart attacks in women have an "atypical" presentation. Is the "typical" presentation (i.e. left arm numbness, substernal chest pain) actually the most common presentation across genders, or just the typical male presentation. Thanks for your time. Mike
Sharonne Hayes: The symptoms of heart attacks in men AND women can be atypical, so it's not just a gender issue. It's important to remember that the majority of both men and women have some type of chest or upper body discomfort when having a heart attack. The problem is that it is frequently not described a "pain", it may not be "severe", and may actually come and go. It is rarely the "Hollywood heart attack" we see on TV and in the movies where someone clutches their chest, keels over and dies. Symptoms are often much more subtle, and while chest pain may be present, it may not be the most prominent or bothersome symptom. So the patient comes in and says she is short of breath, or nausea or has pain between her shoulder blades that just won't go away. If you ask if she has chest pain, she'll think about it and say "yes" but it wouldn't have been something she would have necessarily volunteered, since since it wasn't the main symptom and because a lot of women still don't ever think they could be having a heart attack, even when they are having "classic" symptoms.
Both men and women should be aware of the wide range of symptoms that can be signs of a heart attack and take prompt action (call 911, don't drive yourself) and get to the Emergency Department.
Here are some of the more common symptoms, but when in doubt, seek medical care.
The most common or "classic" warning signs* of a heart attack are:
Uncomfortable pressure, fullness, squeezing or burning pain in the center of the chest that lasts more than a few minutes, or goes away and comes back.
Pain that spreads to the shoulders, neck or arms.
Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath.
Other warning signs* of heart attack are:
Unusual chest pain, stomach or abdominal pain.Pain between the shoulder blades
Nausea or dizziness (without chest pain).
Shortness of breath and difficulty breathing (without chest pain).
Unexplained anxiety, weakness or extreme fatigue.
Palpitations, cold sweat or paleness.
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Washington, D.C.: Hello,
My father recently died of a sudden heart attack at the relatively young age of 57. He was overweight and had hypertension for years, but good cholesterol numbers - and assurances from his doctors that he was in good health.
My mother, the same age, is trim and fit, but found out that she may have experienced a silent heart attack some time in the past - there's a small area of dead tissue on her heart that was revealed during a routine electocardiogram prior to a surgery.
I am wondering what kind of risk this would indicate for me and what I can do to mitigate it. I am 35, exercise regularly and eat a sound diet. Cholesterol numbers are good, but I've had postpartum hypertension which my doctor is trying to alleviate with thyroid supplementation, which seems to be working, but slowly. Given the family history, should I see a cardiologist? Any other recommendations?
Sharonne Hayes: You don't necessarily need to see a cardiologist, but you do need to have a really good knowledge of your risk factors including your lipid profile (total, LDL (bad), HDL, (good) cholesterols and triglycerides) your blood pressure, your family history, and then take steps to have a really healthy lifestyle.
Since you do have both parents who have had heart disease, you may wish to talk to your doctor about some additional tests such as a lipoprotein a, or C-reactive protein (CRP)which could help better define your risks.
A family history of heart disease doesn't always mean you are at risk, especially if your parents smoked or had other risky health behaviors that you do not share.
There are some early detection tools including special types of CT scans that can see if you have blockages in your heart arteries. You may wish to discuss those tests with your doctor.
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Wheaton, Md.: I filled in the calculator at the NIH web site, and got a risk of 1 percent. However, I think my actual risk is a bit higher, as I am about 80 pounds overweight (on a 5'6" frame). The calculator didn't even ask my weight, much less factor it in. My recent echocardiogram and exercise stress test were entirely normal, but still I am concerned. Where can I find an accurate risk assessment?
Sharonne Hayes: While the Framingham risk score on the NIH Web site is very useful and has been proven in a number of populations, it does tend to underestimate risks in women. The risk score calculates your risk of having a heart attack over the next 10 years. More and more of us are worried about our cardiac risks over a longer time frame. Despite the fact that the risk score didn't ask your weight, it should be relatively accurate in terms of your cardiac risk. It sounds like your doctors are taking your concerns seriously by doing tests to check out your heart. There is no perfect predictor or test to diagnose heart disease so talk to your doctor if you develop any symptoms. Increasing your physical activity even if you remain overweight is one of the best things you can do to lower your risk.
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Washington, D.C.: I am 30, of a normal weight, somewhat active, but I have very high cholesterol -250. My doctor doesn't think I should do anything about it but it seems to me I might need a second opinion. I do have very high HDL - 80, but that was measured when I was more active than I am currently. I guess I'm afraid the moment I stop exercising or eat more poorly I will be in serious trouble.
Sharonne Hayes: Your cholesterol is high but the fact that your HDL (good) cholesterol is also high does cancel out some of that risk. When we make decisions about treating high cholesterol we don't simply look at the numbers. The best way to make a decision about whether or not you need medicine or more aggressive treatment of your high cholesterol is not to look just at the cholesterol numbers but to look at all of your heart disease risks. This is called "a global risk assessment." The "Evidence Based Guidelines for CVD Prevention in Women" were published last year by the American Heart Association and in order to make a decision about whether or not to start a medicine for your high cholesterol we need to take into account your blood pressure, whether or not you are a diabetic, your family history, whether you are a smoker or not, and other factors.
If your high cholesterol is the only risk factor that you have, I would tend to agree with your physician that at your age, the best approach is a healthy lifestyle and continued close monitoring of your cardiovascular risks.
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Queen Anne, Md.: Are shortness of breath, light-headedness and dizziness, upon exertion symptoms of a heart problem?
Sharonne Hayes: The symptoms you describe, especially if they come on with exertion, could certainly indicate a heart problem. If you or someone you know are experiencing these symptoms, you should have them checked out by a healthcare provider.
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Fort Washington, Md.: I have MVP, does that make me a higher risk for heart disease? Should I be worried about anything? My doctors don't think so.
Sharonne Hayes: Mitral valve prolapse (MVP) is an abnormality of the tissue of one of the valves on the left side of the heart. It can sometimes leak or in rare cases develop an infection. However, the fact that you have MVP, does not put you at increased risk for developing blockages in your heart arteries or coronary artery disease.
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Rockville, Md.: I have a 32 yr-old-daughter who has a Mioxoma on the left atrial. How dangerous is this type of tumor? It is necessary for her to have a surgery? Please let me know.
Thank you,
Irma
Sharonne Hayes: A cardiac myxoma is a benign tumor in the heart. Although it is benign, if it gets large or develops in a critical area of the heart it can cause significant symptoms or even a stroke. In general surgical removal is recommended.
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Washington, D.C.: What are the primary risk factors for heart disease for African-American women between the ages of 30 -50
Sharonne Hayes: African-American women have a higher risk of developing heart disease than white women. The risk factors for all races are similar, and include high blood pressure, smoking, family history, high cholesterol, diabetes and obesity. However, some are more prevalent or affect African-Americans more than other races. African-American women tend to have higher rates of high blood pressure and overweight and obesity.
African-American women need to know their risk factors and family history and take extra steps to follow a healthy lifestyle to lower their risks of heart disease. African-American mothers who make these changes set a great example for the rest of their family and especially their children.
Hypertension, in particular, should be screened for and treated effectively to prevent heart disease, stroke and kidney damage.
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Boulder, Colo.: Is there any risk to having a very high HDL level (115) and a low LDL level (85)? I have tested this way twice in 3 yrs.
Sharonne Hayes: Having a high HDL and low LDL is very desirable. This pattern is associated with a lower risk of heart disease than the average woman. You likely have these numbers because of genetic factors. However, you still need to keep up a healthy lifestyle and minimize your other risks.
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Arlington, Va.: I had an interesting argument with a co-worker the other day. We were talking about funding research for heart disease and how almost all of the studies use men as subjects and are directed toward men. He said that since women outlive men by several years, on average, there's no good argument that we spend too little on women's health. I say, at the least, women should get 50 percent of funding, and if men die early, that's too bad. This debate surfaced a few years back in the U.S. Congress, but I haven't heard much recently. Is it still a relevant debate?
Sharonne Hayes: That is an interesting argument! Early cardiovascular research trials included very few or no women. As a result, there are many things we don't know about women and heart disease including how they respond to medications and other treatments, what the best diagnostic tests are and how hormones may affect their heart. Current studies include women but often in insufficient numbers to get definitive answers about women. One reason for this is that women make up only about 25 to 40% of participants in heart attack and heart failure trials and even when adequate numbers of women participate in cardiovascular trials the data are not reported by gender. If data are reported by gender we can tell if a treatment benefits men, women or both.
In a sense, your co-worker is correct that women tend to live longer than men. However, heart disease is the number one killer of women at all ages and has killed more women than men each year since 1994. Also, although there have been significant declines in heart disease deaths over the past 40 years, most of the benefit has been seen in declines in deaths in men but not in women.
So I would argue with you that we need to do more research on women regarding heart disease in order to catch-up and effectively treat women so that their mortality trends improve as well.
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Falls Church, Va.: I have chest wall pains from time to time, usually when I lift something heavy, or am under stress. Typically the pain is more severe when I lay on my back, especially early in the morning, than as the day progresses, the pain goes away.
Does this have anything to do with Heart Disease, or is it un-related.
Sharonne Hayes: Pain in the chest wall that comes on when you are lifting or using the chest muscles and that tends to go away when you change position is less likely to be related to your heart. It may be due to muscle strain, muscle tightness or even arthritis. However, you should mention it to your doctor at your next visit.
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Rockville, Md.: Why is the systolic pressure more important than the diastolic in predicting heart attacks?
Sharonne Hayes: Systolic blood pressure is the upper number in the blood pressure reading and is the pressure in your blood vessels when the heart squeezes. Diastolic blood pressure is the pressure in your blood vessels when the heart is relaxed. In women in particular, the systolic blood pressure seems to predict the risk of heart attack and stroke better than diastolic blood pressure. Ideal blood pressure is less than 120/80 mmHg. Hypertension is defined as a systolic pressure greater than 140 mmHg or a diastolic blood pressure greater than 90 mmHg.
Depending on your level of blood pressure elevation and your other cardiac risks factors you may be advised to make healthy lifestyle changes or go on medications to control the blood pressure levels.
It's important to know your blood pressure numbers. If your doctor tells you that your blood pressure is "okay" ask him or her for the numbers so you can see for yourself how close to "ideal" you are.
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Shoreview, Min.: It's important to stress that not all heart episodes involve pain. When I had my heart episode, there was no "pain." I would describe the symptoms as an "achy and tingly" sensation in the back of my neck, shoulder blades, armpits and finally in a thin string that went down my arm to my little fingers. Nothing in what I considered my chest.
Sharonne Hayes: You are correct. Up to 30% of heart attacks involve no chest pain whatsoever. Any symptoms in your chest or upper body that are new to you, that persist, that make you feel unwell or short of breath, should be evaluated promptly.
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Washington, D.C.: How does family heredity factor into the heart attack equation? My paternal grandfather died of a heart attack (smoker)in his 50s and as his female granddaughter, am I impacted by that risk? Both sides of my family history shows diabetes and forms of lung cancer (overweight smokers/drinkers). I've never thought to fear heart attack, so I appreciate the awareness being shed by heart disease in women.
Sharonne Hayes: Family history and genes are important determinants of your cholesterol levels, your likelihood of developing diabetes, your blood pressure, and heart disease. However, family history doesn't tell the whole story since an unhealthy lifestyle and particularly smoking can overcome a good family history. Alternatively, if your family members with heart disease all had poor lifestyles and you are taking care of yourself, your risk may not be elevated. Type II or "adult-onset" diabetes can be strongly inherited, so with your family history, you should be screened with fasting blood sugars and monitor your other heart disease risks to keep yourself healthy.
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Washington, D.C.: Should a woman nearing 60 have an EKG or stress test done as part of an annual physical examination? I find that male colleagues of mine have had this but they've never been part of my exams.
Sharonne Hayes: There is no perfect test to screen for heart disease in men or women. Although your male colleagues may be having stress tests, in the absence of symptoms these are currently not recommended.
At your age, you should definitely be concerned about your heart disease risk and talk to your physician about the best way to screen for this. This may simply involve a thorough assessment of your risk factors and lifestyle, a test to look at your levels of inflammation such as CRP or imaging such as CT, echo or nuclear scans that can detect blockages. Currently we do not recommend any of these as a screening test for all individuals at a given age.
In general, women are less likely to receive diagnostic tests for heart disease so it's important that you raise your concerns with your healthcare provider.
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Rockville, Md.: I am a 49-year-old healthy woman. My heart beat has always been around 60-65 and I have always had normal blood pressure. Last weekend my heart went into atrial fibrillation. After a day of trying to get it back into sync via meds, the doc had to cardiovert my heart. My heart beat is back to normal, although I am on a lot of meds for awhile. My question, what can I do to keep this from happening again? And what causes it?
Sharonne Hayes: Atrial fibrillation is a common heart rhythm abnormality where the upper chamber of the heart, called the atria, beats fast and irregularly. Although we don't know the cause of atrial fibrillation in most patients, we do know some of the risk factors which include high blood pressure, age, alcohol use and underlying heart disease. Controlling your risk factors, especially your blood pressure, may help prevent future episodes of atrial fibrillation but each patient is different. Maintaining a healthy lifestyle may not prevent another episode of atrial fibrillation but will make you feel better.
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Washington, D.C.: Do you think that campaigns such as The Heart Truth (with the Red Dress symbol) have had an impact in raising awareness levels of heart disease in women?
Sharonne Hayes: The NHLBI's Heart Truth Campaign along with it's national partners, the American Heart Association and WomenHeart, have been very successful at raising awareness about the risk to women of heart disease, their number 1 killer.
The Red Dress seems to have struck a chord with women. It's positive and the NHLBI has found more and more women know about heart disease and their risks as a result of this campaign.
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Kensington, Md.: Thank you for taking my question, I am in my early 50's and last year had chest pain and pain in the upper back that would radiate to my jaw. After cardiac catherization it was found to be vasospasms. Cardiem pretty much kept it under control but my question is how does one with this condition know that they are having a heart attack. The other thing is that my mother at age 58 had a fatal heart attack. Her symptom was nausea and pain in the jaw.
Second part of the question is do the spasms of the arteries in the heart give one a greater risk of heart attack. My cardiologist is vague on this.
Thank you.
Sharonne Hayes: Coronary vasospasm is when one of the heart arteries narrows, not as a result of a blockage inside of the artery, but because the muscles in the artery walls contract, and the spasm closes the artery and blocks flow. Calcium channel blockers and nitroglycerin can relax the spasm. Heart attack symptoms related to spasm are similar to a typical heart attack.
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Springfield, Va.: Hi, I am a young woman, and I was born with some moderate congenital heart defects, including a ventricular septal defect, stenosis of the pulmonary artery, and a little extra loop branching from my aorta back to the heart. These were all fixed by the excellent surgical team at Boston Children's in 1984, and now, at the age of 27, I have no physical restrictions (other than premedicating with antibiotics before dental work or surgeries). I also ran cross country in high school, although I doubt I'll ever run a marathon! I am slim (size 4 at 5'6" tall) and I have a fairly healthy diet with no fast food or junk food. I try to walk a couple times a week but otherwise do not have a regular exercise regime. My last sonogram was at least 4 years ago and was normal. What sort of ongoing health/fitness and medical check-up routine should I undertake to ensure I remain in good heart health for the rest of my life? Do you recommend that I continue to have sonogram appointments at the hospital, and if so, how frequently?
Sharonne Hayes: I am glad your problems were detected and corrected early! Sounds like you are doing great. Since you feel so good, it may be tempting to forget you ever had heart disease, but you should continue to follow up with a cardiologist periodically and you might want to consider seeing what is an important and growing sub-specialty of cardiologists who care fo adults with congenital heart disease. You may especially wish to discuss any plans you have to become pregnant. Although there is no set schedule for echocardiography or doctor visits (it's an individual thing), I think you should probably think about making an appointment, since it's been almost 5 years.
Good luck!
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Clemson, S.C.: Due to back problems, I can no longer, at age 52, jog or even do low-impact aerobics to stay heart-healthy. What form of exercise can you recommend for me? Is walking enough and at what pace?
Sharonne Hayes: Any physical activity is better than nothing. Walking is great. Women who walk 30-45 minutes 4-6 days per week lower their risk of heart disease 30-50%!
If walking on land bothers your back, consider a treadmill, bike riding or walking or exorcising in a pool.
In terms of intensity, use the "talk test". If you can carry on longwinded conversations, you aren't pushing yourself hard enough. If you are panting and can't talk, slow down. You aught to feel a bit breathless while exercising, but be able to converse in short sentences.
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Falls Church, Va.: When is surgery necessary for leaky heart valves? I'm a 42-year-old woman w/MVP, who also has moderate to severe leakages (depending on which doctor you ask) of two valves. I have no pain or arrhythmia or any symptoms and am in good health. Is it ever wise to have surgery to correct these problems when you are not having symptoms?
Sharonne Hayes: The answer is a definite yes. Treatment of leaky mitral valves (mitral regurgitaton-MR) has changed over the last 2 decades. We used to wait for symptoms ot occur, but now we know that waiting for symptoms leads to a worse outcome for patients. Surgical techniques are so much better these days and we can usually repair rather than replace the valve. If you have severe MR, talk to your doctor about the timing and advisability of surgery. And make sure the surgeon you see is committed to repairing instead of replacing your valve. It takes somewhat more technical skill to do a repair and it is not always possible, but patients do much better in the long run.
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Fresno, Calif.: If the information is becoming widespread about the differences in symptoms between men and women, then why are so many women still written off in emergency rooms when the present with the same symptoms as a man?
Sharonne Hayes: There is still a HUGE opportunity for educating health care providers about heart disease in women!
Heart disease is more difficult to diagnose in women than in men, and we lack good research data on many conditions. So we need to raise awareness and knowledge levels among health care providers right along with women patients.
And I always tell women that they have to be their own best advocate. If they don't feel right and are being told they are "fine" they need to speak up and be their own best advocate. I have seen a lot of progress in this area. I am optimistic that improvements in care for women with heart disease are being made.
For more information about heart disease in women, go to www.womenheart.org
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Sharonne Hayes: Thanks for all of the great questions today.
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