Let's
scratch everything you've assumed about heart disease and get something
straight. It's the number-one killer of women (breast cancer is number
three), it affects men and women differently, and it's not limited to senior
citizens. One more thing. It's the choices you make today¾what you
eat whether you smoke, how you handle stress-that determine your risk.
Nicotine patch, anyone?
BY
Lisa Collier Cool (Courtesy of Harper’s Bazar)
On
her 40th birthday, Lori Morray woke with an ache in her chest. Indigestion,
she thought. Too many cigarettes. When that pain persisted into the afternoon,
though, she dropped in to see her doctor, who dismissed it as stress and
sent her on her way. Worse by that evening¾tired, and with a throbbing,
laborlike pain in her chest¾she skipped her birthday festivities
and headed to the emergency room, where doctors hooked her up to an electrocardiogram,
popped nitroglycerin under her tongue and informed her, to her utter amazement,
that she was having a heart attack.
Without
realizing it, Morray was a prime candidate for such a catastrophe, with
a family history of the disease (her mother), a pack-a-day habit, a few
extra pounds to lose and an aversion to exercise. "I just didn't know enough
to pay attention," she says. Neither, apparently, did her doctor. Which
brings us to the crux of the issue: Most of us, physicians included, don't
know much about heart disease in women. (For years, the medical community
simply extrapolated what they knew about the disease in men.) A pity--some
would say an outrage--because heart disease is the leading cause of death
for women, and this is a case in which ignorance can kill.
The
good news for Morray is that she survived her heart attack despite the
obstacles she encountered in getting care (she's since given up cigarettes,
taken up walking and dropped a few pounds). The good news for all women
is that research is beginning to yield surprising new insight into the
vagaries of the female heart, much of which sheds light on the reasons
heart disease is such an unrecognized problem among women, and on what
they can do to reduce their risks and get better treatment. Here, some
of the most unexpected new findings:
Heart
disease is more likely to kill you than breast cancer is.
Some
52 percent of women think they're more likely to die of breast cancer than
of heart disease, according to a 1997 New York Times/CBS News Poll on women's
health issues. The real ratio? Only 3 percent of women are likely to succumb
to breast cancer, while 30 percent are expected to meet their end via heart
disease, says Elsa-Grace Giardina, M.D., director of the Center for Women's
Health at Columbia-Presbyterian Medical Center in New York City. (Breast
cancer is actually the third leading cause of Death in women, the second
being lung cancer.) The perception discrepancy has a lot to do with the
emotional nature of breast cancer and the thoroughness with which breast-cancer
advocates have edu-cated women about the importance of mammograms and self-exams,
say heart researchers. Somehow the word that heart disease is the more
likely killer has been lost in the din.
As
a result women who will nag their cigarette-smoking, fatty-food eating,
sedentary husbands (the stereotypical heart-attack candidates) about changing
their ways aren't necessarily likely to heed their own advice. Thirty-five
percent of adult women in this country are overweight, 24.8 percent smoke,
and 62 percent don't exercise regularly And though the risk of a heart
attack is highest for women after menopause, it's early health habits that
ultimately determine your risk, says Maria Mendelson, M.D., who chaired
the American Heart Association of Chicago's 1997 conference on cardiovascular
disease in women. "Waiting until menopause to do something is way too late."
Chest
pain may not be the first sign of a heart attack.
The
typical symptoms for women tend not to be the classic elephantsitting-on-your-chest,
pain-downyour-left-arm kinds men describe. Instead women tend to experience
a wide range of sensations, including an uneasy feeling in the chest, shortness
of breath, fatigue, dizziness or fainting, fluttering heartbeat, swelling
in the ankles or lower legs and nausea. The tricky aspect of all this,
of course, is that there are a number of reasons you might feel any one
of these symptoms, from a stomach bug to skipping lunch. One indication
that something more serious may be afoot is if your symptoms appear or
get worse with exercise, or anytime the heart's under stress, says Elizabeth
Ross, M.D., a cardiologist at Washington Hospital Center in Washington,
DC, and author of Healing the Female Heart (Simon & Schuster). "I've
seen patients who had warning signs, in that they got 'indigestion' every
time they played tennis or worked out," she says. "They didn't realize
it was cardiac pain."
Your
doctor may know less about your heart than you do.
That's
a slight exaggeration¾but it's not too far off the mark. Only 39
percent of primary-care physicians (the ones you're most likely to call
in a crisis) surveyed in a 1996 Gallup poll said that they were well trained
in the specificities of heart disease in women. About two thirds mistakenly
believed that the warning signs for a heart attack are the same for men
and women, and 90 percent had no idea what the significant female symptoms
might be. Worse yet, only 50 percent knew that the leading health threat
for women is heart disease. Dismal as this sounds, it's an improvement
over the 1995 survey, in which only 11 percent of physicians were considered
well trained.
Basically
there's less than a 50-50 chance that your doctor is up to speed on your
heart, which means that a little medical knowledge on your part might very
well save your life. Consider the case of a 24-year-old emergency medical
technician who, suspecting that the chest pain she was having was heart
related, insisted on a full workup when she went to the emergency room.
It turned out not only that she'd had a heart attack but also that two
of her arteries were so badly clogged that she needed bypass surgery. "If
she hadn't demanded tests, she'd probably have been one of those cases
of sudden cardiac death you read about, where someone drops dead playing
basketball or jogging," say Giardina, who later became the young woman's
doctor.
Most
of us aren't routinely screened for heart risks.
Nearly
60 percent of the women polled for a recent Prevention magazine survey
said their doctors had never discussed heart disease with them, and 50
percent said their cholesterol-the level of which can indicate risk-is
not regularly checked by their doctors. To make sure that you and your
physician are doing everything possible to lower your risk for heart disease,
cardiologists recommend having all three cholesterols (high-density lipoprotein,
low-density lipoprotein and triglycerides) measured; getting your blood
pressure taken (if it's over 140/90, you're at risk); and having your blood
sugar checked. Poorly controlled diabetes-a disorder that's much more prevalent
than people realize is a major risk factor for heart disease in young women.
A
woman's symptoms are often brushed off as psychosomatic.
When
women see their doctors about palpitations, they're frequently told the
problem is in their head, not their heart, according to a new study by
Allegheny University of the Health Sciences, in Philadelphia. Of the 98
people surveyed-all of whom had arrhythmias serious enough, to require
surgery-35 percent of the women, versus 4 percent of the men, said they'd
originally been misdiagnosed with anxiety; half of the misdiagnosed women
had been given powerful antianxiety medication they didn't need. It's a
shame, says Beverly Hills cardiologist Debra R. Judelson, M.D., president
of the American Medical Women's Association, because though not all arrhythmias
need medical attention, some that do may be easily treatable with a new
procedure called radio-frequency ablation, which can be performed under
local anesthesia in a three-hour hospital procedure. "But," says Judelson,
"I continue to see women who have been told by many doctors that their
problem is just anxiety."
The
treadmill stress test isn't effective for women.
Since
the treadmill test is based on the typical male build, heart function and
response to exercise, women's results have to be "translated," which leaves
a lot of room for error. The treadmill test fails to identify as many as
70 percent of women with cardiac disorders, according to a recent study.
On the flip side, up to 40 percent of women with healthy hearts get false-positive
results, which means that they risk being sent for needless and invasive
followup tests. The solution, according to another recent study, appears
to be use of an imaging test (such as echocardiography, in which an ultrasound
is used to visualize the heart in motion) in addition to the treadmill.
The results of the combination have been deemed 80 percent accurate.
Men
may have more heart attacks, but women are more likely to die from them.
Roughly
987,000 men age 29 and over have heart attacks each year, compared with
513,000 women in the same age group, according to estimates from the Framingham
Heart Study The catch is that almost as many women as men (about 250,000)
die from them. Why the deadly gender gap? As in the case of Lori Morray,
women underestimate their risk for heart disease and delay getting medical
treatment for their symptoms; then they're unable to get treatment, because
many of the doctors they consult first don't recognize the problem. By
the time they do go to the hospital, it's often too late for lifesaving
therapies like clot busters, which can stop damage to the heart if given
within a few hours of the attack. What's more, many doctors don't take
women's heart attacks as seriously even when they know what's going on.
Women are only a third as likely to receive balloon angioplasty or bypass
surgery as equally ill men, which might explain why 44 percent of women
but only 27 percent of men die within a year of having a heart attack.
Folic
acid helps keep your heart healthy.
As
if there weren't enough heart hazards to worry about already, researchers
have recently identified a brand-new enemy: the amino acid homocysteine,
a byproduct of protein breakdown. The more of it you have in your bloodstream,
the greater your odds of developing plagued arteries, and thus having a
heart attack. "High homocysteine levels may be responsible for the deaths
from heart disease of up to 35,000 women in the U.S. each year," says Shirley
A.A. Beresford, professor of epidemiology at the University of Washington
in Seattle. The same researchers who identified homocysteine have also
found that the B-vitamin folic acid helps convert it into other, harmless
by-products, and that a deficiency of folic acid ups your risk of high
levels of homocysteine in the blood. You can get the vitamin via supplements
or by eating foods such as citrus fruits, beans or leafy greens. Don't
take more than 400 micrograms, however, since there's concern that very
high levels can mask a vitamin B-12 deficiency.
Anger
is almost as bad for you as smoking and not exercising.
The
stereotype of the driven, hostile, type A personality as the classic heart-attack
candidate is only partly right, according to new research. It turns out
that being ambitious won't kill you, but anger might. "Angry, hostile individuals
tend to have higher blood pressure, which is a major risk factor for a
heart attack," explains Roxanne A. Rodney, M.D., associate director of
nuclear cardiology at Columbia University. "When people get mad, they produce
a surge of catecholamines--stress hormones--that increase heart rate and
blood pressure and, over time, can damage coronary arteries and increase
the likelihood of developing blood clots, precursors to both heart attacks
and strokes." Even if you don't have hypertension to begin with, says Rodney,
flying into a rage on a regular basis can take its toll.
The
fight-or-flight reaction to stress can hurt you.
It's
not stress per se that makes us vulnerable to illness, but how we react
to it. "If stress stimulates you to achieve your goals, it's an extremely
positive force," says Elizabeth Ross. "But if you bottle it up so that
you get anxious, depressed or chronically frustrated, it's dangerous."
In addition to being an emotional drain, these negative emotions can actually
cause blood vessels to constrict, cutting down blood flow to the heart.
Being stressed out doubled the risk that the hearts of a group of patients
(who had clogged arteries to begin with) participating in a recent Duke
University Medical Center study wouldn't get enough blood flow, while chilling
out significantly improved it. One of the key warning signs that stress
may be getting the best of you is something heart experts refer to as vital
exhaustion: feeling mentally and physically depleted first thing in the
morning.
Resources:
For more information or to order the book The Silent Epidemic. The Truth
About Women and Heart Disease, call the American Heart Association at 800-AHA-USA1,
or visit its Web site, http://www.americanheart.org. The National Heart
Lung and Blood Institute offers several low-cost publications, including
the Healthy Heart Handbook for Women (S5.50). To order it or to get a complete
publication list, write to the NHLBI Information Center, P.O. Box 30105,
Bethesda, MD 20824-0105, or call 800-575WELL. You can also read up on the
topic for free via the NHLBI Web site, at http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.
Which
health concerns are more likely to be addressed in research on women's
bodies?
The
gender gap in medical research is closing. It has been since 1990, when
the Office of Research on Women's Health was established at the National
Institutes of Health to address the underrepresentation of women in medical
studies. Since then, women in such investigations have increased not only
in number, but also in diversity. Postmenopausal women, once all but ignored
in scientific investigations, have become the focus of several new projects,
and efforts to include African-American, Asian, and Hispanic women have
expanded. These studies should provide in-formation to guide us in reducing
our risks of heart disease, cancer, osteoporosis, and other degenerative
diseases. They generally take one of two forms--observational or interventional
investigations.
Observational
studies are designed to reveal possible associations between physical characteristics
or health habits and disease. They usually include large numbers of people
who are followed for several years. The participants may answer periodic
questionnaires and may also be tracked through hospital records, tumor
registries or death records
Interventional
studies are designed to determine the effects of specific treatments, diets,
or health practices. Controlled trials are considered the gold standard
of interventional studies, in these investigations, participants are randomly
assigned to groups and each group follows a certain treatment, with at
least one of the groups receiving a placebo or no treatment at all. At
the end of the study, the results in each of the groups are compared.
The
following studies are the first major investigations to deal exclusively
with health issues of women at mid-life and beyond.
*
The Women's Health Initiative The largest study of women to date, the WHI
includes both observational and interventional components. Researchers
at 40 centers around the country are studying 160,000 healthy, postmenopausal
women who were between the ages of 50 and 79 when they enrolled.
In
the Observational Study, 100,000 women will undergo a physical examination
upon entry and again after 3 years. Every year, the participants will complete
questionnaires on their health habits.
The
remaining 60,000 women are being enrolled in one or more of three controlled
trials-the Dietary Modification ONO Study, the Hormone Replacement Therapy
(HRI) Study, or the Calcium and Vitamin D Supplementation (CaD) Study The
DM is designed to determine whether a low-fat diet reduces the risk of
breast and colorectal cancer The CaD study will test the effects of taking
calcium and vitamin D supplements on osteoporosis risk.
The
HRT Study should help to determine whether postmenopausal hormone supplementation
actually lowers the risk of heart disease and osteoporosis and increases
the risk of breast cancer, as some observational studies have indicated.
It may also help to resolve the question of estrogen's effect on mental
acuity and on the risk of developing Alzheimer's disease: women over age
65 will take annual examinations to test memory and reasoning. To enroll
in this study, call 1800-54-WOMEN.
*
The Nurses' Health Study. This ongoing observational study, conducted by
researchers at Brigham and Women's Hospital, Harvard Medical School, and
Harvard School of Public Health, was inaugurated in 1976, when 120,000
women between the ages of 30 and 55 were enrolled. They are asked to fill
out extensive questionnaires about their health and lifestyles every two
years. By changing the questions asked, the researchers are able to examine
the relationship between different lifestyle factors and medical outcomes.
The more than 100 reports emanating from this study have provided the foundation
for additional research into women's health risks. These reports have,
among other things, indicated that there are health benefits in regular
exercise, diets high in fruits and vegetables, and maintaining a lean body
mass. They have suggested that oral contraceptive use does not increase
the risk of cardiovascular disease, that postmenopausal replacement therapy
with estrogen alone is
linked
with an increased risk of endometrial cancer, that drinking alcohol increases
the risk of breast cancer, that the risk of gallstones rises with obesity,
that suntanning increases the likelihood of melanoma, and that aspirin,
estrogen, and exercise may reduce the risk of colon cancer.
The
participants in the Nurses' Study are now between 50 and 75. Not only have
their answers changed with age-more have suffered heart attacks, osteoporosis
or cancer-but the questions have, too. The next round of inquiry is designed
to obtain information on the psychosocial factors, such as stress, anxiety,
social isolation and mood changes, that may influence health and longevity.
*
Study of Women's Health Across the Nation (SWAN). This observational investigation,
sponsored by the National Institute on Aging, is underway at seven medical
centers in the United States. Researchers are selecting 3,200 women between
the ages of 42 and 52, whom they will track for about five years. The project
will focus on the physical and psychological differences among African-
American, Hispanic, Asian- American, and Caucasian women during menopause.
The
researchers will look at body composition, bone density, hormone levels,
cardiovascular function, and menstrual bleeding. They will also consider
psychosocial influences, such as sexuality, interpersonal relationships,
commitment toward work, social values, and attitudes toward aging. Lifestyle
factors--diet, exercise, smoking, and alcohol consumption-will also be
included.