Sneak Attack:
Women and Heart Disease

 

Jennifer Zeis
Harvard World Health News

(Feb. 13, 2002) -- A greater threat to women's health than cancer, heart disease lurks quietly, biding its time while damage to the cardiovascular system develops. In surveys, women say they think they are more likely to die from cancer than a heart attack. Yet according to the American Heart Association, one in two women's deaths are from cardiovascular disease, including heart disease and stroke, while one in 30 deaths are from breast cancer.

Why is it, then, that women do not understand the severity of heart disease? The same women who are regularly scheduling their children's -- and even their husbands' -- doctor's appointments are missing the biggest threat to their own health.

There are two main reasons why heart disease is seen as less of a risk in women, according to Dr. Francine Welty, a cardiologist at Beth Israel Deaconness Medical Center in Boston and the director of Preventive Cardiology and Nutritional Education at Harvard Medical School.

The first reason, she said, is that women get heart disease later in life than in men. The Framingham Heart Study, a long-term study of cardiovascular disease sponsored by the National Heart, Lung, and Blood Institute, found that heart disease manifests itself 10 to 15 years later in women than men.

The second reason is that their chest pains associated with heart attacks are more likely to appear in women low in the chest, and are often attributed erroneously to indigestion or stress. Symptoms of a heart attack in women also include shortness of breath, pain in their arms or jaw, nausea, fatigue, and dizziness. Because of the variation of symptoms, almost half of women's heart attacks are unrecognized at the time, and are only later discovered when an electrocardiogram shows evidence of heart damage.

Many women, experts say, are living with undiagnosed heart disease that is causing progressive damage to the cardiovascular system. And, of the 40 percent who survive their first attack, 35 percent are likely to have another attack within six years. Experts urge women to prevent heart disease instead of dealing with its repercussions.

A surge of female baby boomers hitting the age when they are susceptible to heart disease has somewhat increased awareness of the problem among women over the last five to 10 years. There is, however, much more work to be done. Dr. Nieca Goldberg, author of the newly published Women Are Not Small Men: Life-Saving Strategies for Preventing and Healing Heart Disease in Women, said doctors must take advantage of any opportunity to talk to women about their risk of heart disease, such as when a young woman visits her gynecologist for oral contraception. It is at this appointment when her blood pressure can be taken and her risks can be reviewed.

Goldberg, who is chief of the Women's Heart Program at New York's Lenox Hill Hospital, recommends that women press their doctors to explain risk factors specific to them. Healthy habits, she said, need to be established years before menopause begins.

There are also groups working to increase awareness of women's heart disease. A leading advocate for this cause is Irene Pollin, a psychiatric social worker by training and a pioneer in helping people cope with chronic illness. Pollin has created a campaign to heighten women's awareness of heart disease through the Sister to Sister, Everyone Has a Heart Foundation. This two-year-old campaign offers heart screenings and information on heart disease in the Washington, D.C. area.

Pollin, who has worked extensively with women facing diseases like breast cancer, lupus, and multiple sclerosis, said she noticed that until recently, heart disease was lumped into the broad category of women's health.

"Breast cancer had a face," she said. "We needed to put a face on heart disease."

The first Women's Heart Day sponsored by Sister to Sister was held in 2001, with a second slated for Feb. 22 in Washington. Heart Day culminates a week of Sister to Sister-sponsored heart screenings -- which measure blood pressure, cholesterol, and glucose levels -- held in different D.C. locations. Along with the screenings, participants complete a risk assessment form and receive counseling about their risks. The campaign plans to expand into Chicago and Philadelphia in 2003.

"Heart disease manifests itself differently than cancer," Pollin said. "It's not as scary. There are things you can do to prevent it, things you can do when you're diagnosed. It's basically an upbeat message."

The National Heart, Lung, and Blood Institute also last year launched the Women's Heart Health Education Initiative. The Initiative aims to educate women about heart disease, as well as improve clinical preventive care and treatment. The Centers for Disease Control and Prevention promote WISEWOMAN, or "Well-Integrated Screening and Evaluation for Women Across the Nation." WISEWOMAN began as a screening program for breast and cervical cancer for low-income and uninsured women, and expanded to include screening for heart disease and its risk factors. Currently serving 11 states, the American Heart Association is urging Congress to institute the program nationwide.

Guidelines on preventing heart disease issued by the National Heart, Lung, and Blood Institute recommend walking, jogging, gardening, bicycling, or any other activity that strengthens the heart and can be done in 30-minute sessions at least three or four times a week or, optimally, daily.

The largest risk factor that can be modified is smoking. One year after quitting, the risk of coronary heart disease decreases by 50 percent, and after 15 years, the risk of dying from heart disease almost matches that of a lifetime non-smoker.

After quitting smoking, the next best thing a woman can do for herself is to eat better. Dr. Walter Willett, a professor of epidemiology and nutrition at the Harvard School of Public Health, recommends that unless a woman is conspicuously underweight or overweight at age 20, she should stay as close as possible to that weight as she goes through life. Even a 10- to 15-pound weight gain increases the risk of heart disease.

Willett, the author of Eat, Drink, and Be Healthy, the Harvard Medical School Guide to Healthy Eating, advises a diet high in whole grains, vegetables, fruit, fish, and chicken, but light in meat, sugars, refined grains, and potatoes. He also recommends taking a daily vitamin which includes heart-helpful folic acid and which "provides a good nutritional safety net."

"By these modest diet and lifestyle changes," he said, "It appears that over 80 percent of coronary heart disease in women could be avoided."

Also recommended is annual monitoring of blood cholesterol levels. It is advised that both men and women keep their cholesterol levels under 200, with anything over 240 considered a risk factor for heart disease. Included in cholesterol readings are measurements of high density lipoprotein (HDL), or "good" cholesterol, and low density lipoprotein (LDL), or "bad" cholesterol. Fortunately for women, they are predisposed to having more "good" cholesterol than men, Welty said, and they need to be aware that this may elevate their total cholesterol level.

A glass or two a day of alcohol has been promoted as a way to stave off heart attacks, but Welty cautioned against using it as a preventative measure for women. Studies have shown that a moderate alcohol intake is most effective for women who have one or more risk factors for heart disease, like a history of smoking, high blood pressure or cholesterol, or diabetes. For women who have no risk factors, alcohol actually increased total mortality, she said.

Any type of alcohol can be consumed, not just red wine. According to Willett, heart benefits are related to the amount of alcohol consumed, not simply the type.

Studies in the past reported that hormone replacement therapy (HRT) reduced the risk of heart disease in women, but the numbers are misleading, Welty said. Women on HRT were likely to be healthier in other respects -- they were seeing their doctor more, for example -- and their heart health was not enhanced because of the HRT.

HRT causes blood clots, especially in women who are susceptible to heart disease, and Welty does not recommend the therapy for these women. She is currently researching the effects of estrogen alternatives, including soy products, for post-menopausal women as an alternative to HRT.

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