Wednesday, April 11, 2007

Women & Heart Disease - what to know

Heart disease in women: A Mayo Clinic specialist answers questions

When it comes to the prevention, diagnosis and treatment of cardiovascular disease, men have traditionally garnered more attention than women have. You might think this is because men are more susceptible to cardiovascular disease than are women. But in reality, more women than men die of cardiovascular disease each year. Women are six times as likely to die of heart disease as of breast cancer. Heart disease kills more women over 65 than all cancers combined.

Historically, coronary artery disease has been considered primarily a man's disease. But recent statistics have shown that the rate of heart disease has declined in men but not as much in women. This may be due to a combination of biological and social differences.

Cardiologist Sharonne Hayes, M.D., director of the Women's Heart Clinic at Mayo Clinic, Rochester, Minn., and member of the advisory board of WomenHeart: the National Coalition for Women with Heart Disease, shares her insights about women and heart disease.

Isn't heart disease just heart disease, whether it's in a man or a woman?
Not necessarily. We have gaps in our knowledge about the prevention and treatment of heart disease in women. For one thing, women historically haven't been included in scientific research studies to the extent men have.

For example, we now know that just because a woman's arteries appear clear on an angiogram (a picture of the heart), it doesn't mean she's not at risk of heart disease. A study by the National Institutes of Health indicated as many as 3 million women previously diagnosed with healthy arteries could actually have an increased risk of heart attack after all.

This study, called the Women's Ischemia Syndrome Evaluation (WISE), found among other things that the gold standard test for assessing coronary artery disease — the coronary angiogram — may not spot the more diffuse buildup of plaques that often forms in the smaller coronary arteries of women's hearts.

How do heart attack symptoms differ in women and men?
The most common symptom of a heart attack in both men and women is some type of pain, pressure or discomfort in the chest. But it's not always severe or even the most prominent symptom, particularly in women. Women are more likely than men to have signs and symptoms unrelated to chest pain, such as:

* Neck, shoulder, upper back or abdominal discomfort
* Shortness of breath
* Nausea or vomiting
* Sweating
* Lightheadedness or dizziness
* Unusual fatigue

These signs and symptoms are more subtle than the obvious crushing chest pain often associated with heart attacks. This may be due to the smaller arteries involved or because in men, the bulky, unstable plaques tend to burst open whereas in women, plaques erode, exposing the inner layers of the artery.

Differences in symptoms may also relate to a condition called endothelial dysfunction. Endothelial dysfunction — in which the lining of the artery doesn't allow the artery to expand (dilate) properly to boost blood flow during activity — increases the risk of coronary artery spasm and sudden death.

Ultimately, women tend to show up in the emergency rooms after much heart damage has already occurred because their symptoms are not those typically associated with a heart attack. If you experience these symptoms or think you're having a heart attack, call for emergency medical help immediately. Don't drive yourself to the emergency room.

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Are the risk factors different for men and women?
Although the traditional risk factors for coronary artery disease — such as high cholesterol, high blood pressure and obesity — are detrimental to both men and women, certain factors may play a bigger role in the development of heart disease in women. For example:

* Metabolic syndrome — a combination of abdominal obesity, increased blood pressure, elevated blood glucose and triglycerides — has a greater impact on women than on men.
* Mental stress and depression affect women's hearts more than men's.
* Smoking is much worse for women than men.
* Low levels of estrogen before menopause is a significant risk factor for developing cardiovascular disease in smaller blood vessels (microvascular disease).

Is heart disease something only older women should worry about?
No. While heart disease is the leading cause of death for women 65 and older, it's the third-leading cause of death for women 25 to 44 and second-leading cause of death for women 45 to 64. All women, of all ages, should take heart disease seriously.

There seems to be an ethnic disparity in heart disease. Why are black and Hispanic women at higher risk of dying of this disease?
It's complicated. Some of it is socioeconomic. Some of it is also the result of medical disparities. They may get fewer health screenings, or they haven't received ethnic-specific health messages. There are genetic differences to consider, too. Black women are more likely to have high blood pressure and diabetes, but they actually smoke less than white women do. Other ethnic traditions may put a different emphasis on diet and physical activity.

What can women do to reduce their risks of heart disease?
As for the basics: Be active, maintain a normal weight and don't smoke. Women also need to take their prescribed medications appropriately, such as beta blockers, blood thinners and aspirin, and they need to better manage other conditions that are risk factors for heart disease, such as high blood pressure, high cholesterol and diabetes. Some women at high risk may also benefit from the use of supplements, such as omega-3 fatty acids. These are all things you can talk to your doctor about.

Should I take aspirin?
Guidelines from the American Heart Association urge women to be more aggressive about cutting their heart disease and stroke risks. One of the recommendations is for women over 65 years of age to consider daily aspirin therapy.

The aspirin recommendation comes out of the ongoing Women's Health Initiative (WHI) study, the largest study of heart disease risk factors in women. In 2005, the WHI group released a study showing that the most consistent benefit of aspirin for heart attack prevention was observed among women 65 years of age or older. Women in this age group who took aspirin had nearly one-third fewer cardiovascular events (heart attack and stroke) than did women who took a placebo. However, the women taking aspirin had more gastrointestinal bleeding as well.

The key word in these guidelines is "consider." The guidelines recommend that women consider taking aspirin — which means have a discussion with your doctor about the risks and benefits of taking aspirin based on your own individual stroke and heart attack risk. The higher your risk of heart attack or stroke, the more that risk is reduced by taking aspirin, but the higher your risk is of bleeding. So, it's a balance that each woman needs to discuss with her physician.

When you say 'be active,' what do you mean?
Exercise isn't the same as being busy. I have women tell me how busy they are, that they're always running around doing stuff, and they may be tired at the end of the day, but they aren't physically fit. Being active means doing something physical, getting exercise.

In my practice, I give concrete examples of what this means. For instance, it means taking the stairs instead of the elevator, walking, riding bikes with your kids. I tell women to get a pedometer and track their steps. The goal is to log 10,000 steps a day, which is about five miles. Don't be discouraged if you can't jog or join an exercise club, even a 30-minute walk every day results in big benefits for your heart.

Can you give an example of how someone you know made some simple heart-healthy changes?
I know a woman who works on the 11th floor. She was overweight and very out of shape. She started exercising by walking up just a few flights of stairs each morning and then taking the elevator the rest of the way when she got tired. One day, she realized she had walked all the way up to the 14th floor without realizing it or getting winded. Now, she walks up to the 18th floor and then back down to the 11th because it feels good and is a great start to her day. I can tell patients with a completely straight face that soon you'll want to do more exercise because you'll feel better.

What's a normal weight? How much weight should I try and lose?
There is no "normal" weight, but a normal body mass index (BMI) is helpful. This calculation helps you determine if you have a healthy or unhealthy percentage of body fat. BMI numbers of 25 or higher are associated with an increased risk of heart disease. Remember, though, even losing 10 to 15 pounds can help by lowering your blood pressure and helping prevent diabetes — both of which increase your risk of heart disease.

Is the treatment for heart disease different for women?
In some women, plaques accumulate as an evenly spread layer along artery walls, which is not treatable using traditional methods such as angioplasty and stenting designed to flatten the bulky, irregular, not-so-subtle plaques in men's arteries. In women with these more diffuse plaques, drug treatment — rather than angioplasty or stenting — may be a better option.

We also know that men and women respond differently to certain heart medications, such as clot-busting drugs (thrombolytics). There is also a difference between men and women in the effects of aspirin therapy. In women, aspirin therapy seems to reduce the risk of stroke more than in men, while in men it reduces the risk of heart attack more than it reduces strokes.

What these differences suggest is that if we use the same treatment in women that we use in men without understanding those differences, we may actually increase women's risks of complications.

I've heard something about the connection between depression and heart disease in women. What's that about?
Depression is twice as common in women as in men, and it increases the risk of heart disease by two to three times compared with those who aren't depressed. It's estimated that about one in five women who has a heart attack or is hospitalized with heart failure has evidence of depression. We need to better diagnose and address depression because depression makes it difficult to maintain a healthy lifestyle and follow recommended treatment.

What's next in the effort to prevent heart disease in women?
Recent studies, especially those giving results for men and women, have helped us begin to identify gaps in our knowledge and will spur researchers to look for answers that will improve care for women. Doctors are becoming more aware of the different signs to watch for that may indicate a woman is having a heart attack — different than what men may experience.

Women and physicians also need to become better educated about heart disease in women. Knowledge helps women feel empowered to ask questions and learn more about how to prevent heart disease.

And as women become more informed about their risks, they'll be better able to follow through with healthier lifestyle habits.

Original Article:
By Mayo Clinic Staff
Apr 3, 2007
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