Heart Disease & Women:
How High Is Your Risk?

Excerpted from The Planned Parenthood Women's Health Letter, May 1995, Vol. 2, No. 3

Today Americans know that heart disease strikes both genders. One in nine women between ages 45 and 64 and one in three women after that age have some sort of cardiovascular (heart and blood vessel) disease, according to the American Heart Association. But even though older women and men have equally high risks, women remain underinformed and undertreated.

Heart attack is the leading cause of death in American women, claiming 250,000 female lives annually, which is more than all forms of cancer. Yet, when the Survival and Ventricular Enlargement Study investigating team looked at more than 2,000 male and female heart patients at 150 hospitals and clinics throughout the U.S. and Canada, it found that women are diagnosed less promptly and referred for further tests less often than men.

This same study showed that women are less likely than men to receive life-saving procedures such as clot-busting drugs and coronary artery bypass surgery than men. When women are referred for bypass surgery, they are sicker and at a more symptomatic, hard-to-treat stage of the illness, according to a July 1991 New England Journal of Medicine article.

The most distressing fact of all: Women who have heart attacks are twice as likely as men to die -- many within the following year.

Just why are women on the losing end of heart disease?

Some Claim Gender Bias Increases Women's Risks

"Until recently, heart disease has been considered a man's disease," explains Michael Mil ler, M.D., director of preventive cardiology at the University of Maryland Medical Center. Most of the research on coronary artery disease -- the type of heart problem that leads to most heart attacks--has been done on men. Women have been thought to be exempt from risk.

"The stereotype of the overweight, stressed-out, middle-aged guy keeling over from a heart attack at work or while shoveling snow has been viewed as the typical heart disease patient," says Miller. "The fact is, women keel over from shoveling snow, too."

Unfortunately, women's chest pains and other symptoms have often been ignored or misdiagnosed and waved off as psychological symptoms of depression or anxiety, says Grace Warner, M.D., attending cardiologist and codirector of the noninvasive laboratory of cardiac testing at Arizona Heart Institute, in Phoenix.

Ageism May Play a Deadly Role

When women are properly diagnosed and referred, they are not always treated as aggressively as men, according to Elsa Grace-Giardina, M.D., director of the Center for Women's Health at Columbia Presbyterian Medical Center, in New York City.

A typical male heart patient is in his 40s or 50s, which are considered prime productive years, says Grace-Giardina. A woman, on the other hand, is protected before age 50 against heart disease by estrogen. Once she reaches menopause and loses estrogen, however, her risk of heart disease is equivalent to a man's risk. Indeed, one in three women after 65 is at risk for coronary heart disease. But by then, a woman may be viewed as past her prime and treated less aggressively than a younger man.

Don't Ignore Symptoms

"Women themselves have not taken symptoms seriously nor seen themselves at risk for heart attack," adds Grace-Giardina. Studies show that more than a third of all heart attacks in women, versus one in four in men, go unnoticed or unreported by victims.

The fact is that the typical textbook symptom -- a heavy pressure on the chest -- may be typical for men but not for women. Women's symptoms tend to be more subtle.

"If a woman doesn't recognize these symptoms as a sign of heart problem, she may not go to the doctor or emergency room," says Grace-Giardina. But for maximum effect, the clot-busting drugs should be administered within the first four to six hours. If she does not receive clot-busting drugs, the heart attack is greater and her full recovery less likely.

Many Experts Claim There Is No Gender Bias

The gender notion has recently been challenged by a study conducted by Daniel B. Mark, M.D., assistant professor of medicine, division of cardiology, Duke University Medical Center, in Durham, North Carolina. Mark looked at the attitudes of 15 cardiologists who sent 280 men and 130 women for exercise tests for suspected heart disease.

As with other studies, the men were substantially more likely than women to receive follow-up tests. But the doctors said that differences in the women's conditions and their advanced age were the reasons they were not referred for the cardiac catheterization procedure. Catheterization is an invasive test that involves inserting tubes into blood vessels of the arm and then injecting dye through the tube so blocked vessels can be seen on an X-ray. It's considered the gold standard diagnostic test that determines if surgery or another treatment is in a patient's future.

To conclude that the poorer outcome of women with heart disease is due to gender bias requires looking at men and women of the same age, Mark states. He goes on to say in a recent New York Times article that if you study both men and women who are otherwise the same with the only difference being gender, you'll find that the treatments are very similar.

Standard Tests Aren't Sensitive Enough

Some experts argue that Mark's study is flawed because the doctors relied on the standard exercise stress test to diagnose patients--a test that is notoriously inaccurate for women. "It's difficult for a 70-year-old woman to exercise enough on the treadmill test to get her heart rate up," says Miller. "As a result, there are a lot of false positives and false negatives inherent in this test for women."

Even cardiac catheterization, which is considered the definitive follow-up test in heart disease, is not woman-friendly. In the 1982 Coronary Artery Study, which looked at more than 8,000 men and women with chest pain, women were three times as likely to have "normal" test results following catheterization.

But a "normal" result does not necessarily mean a woman is free of heart disease. Although the test may detect disorders in the large coronary vessels, it is possible that this test is unable to detect disorders of the small blood vessels that may lead to the heart disease in women, according to Nanette Wenger, M.D., professor of medicine in the division of cardiology, Emory University School of Medicine, in Atlanta.

Women May Need Different Treatments Than Men

Treatments that may work for men may not work for women, according to Edward B. Diethrich, M.D., coauthor of Women and Heart Disease, and director of the Arizona Heart Institute. For example, there are no clinical trials on angioplasty (a procedure that involves inserting a tiny balloon to break up obstructions in blocked arteries) in women, Diethrich says. In the few studies on bypass surgery in which women were included, he adds, it appears that women die or suffer serious complications twice as often as men.

Without dependable research as a guide, many practitioners proceed with caution. "If women get aggressive treatment at all, it is likely to take place under emergency conditions, when risks are already greater," writes Diethrich.

Don't Let Gender Equity Become a Buy-In for Overtreatment

While doctors are quicker to operate on mid-life men with heart disease than on older women with heart disease, it's not clear if this is due to overtreatment of men or undertreatment of women, as leading women's heart disease researcher Elizabeth Barrett-Connor, M.D., suggested recently.

Before we advocate expensive, risky, and possibly ineffective aggressive treatments for women, we need women-based studies that tell us exactly how best to diagnose and treat heart disease in females, says Wenger. The Women's Health Initiative heart disease study involving 140,000 women, sponsored by the National Institutes of Health, will provide answers about hormone replacement therapy as a treatment option, for example.

That's not enough. We need research on nondrug, nonmedical therapies like diet and exercise that will enable older women--who now survive men but often live out their days in extremely poor health -- to avoid being disabled by heart disease, says Diethrich.

How to Get a Reliable Diagnosis

&qu ot;Women need to know that they are just as likely to be at risk as men," says Warner. Although it's less disfiguring and may strike later in life than the more-dreaded breast cancer, she says, "heart disease kills more women than breast cancer, osteoporosis, domestic violence, and AIDS."

You should seek a complete cardiac work-up with a doctor who uses an echocardiogram, if you have symptoms or any of these risk factors:

Diabetes. Increases your risk of cardiovascular death threefold, especially when you are aged 35 to 65. The reason: The protection of estrogen is canceled out because high sugar levels alter the artery-clotting "bad" cholesterol to accelerate hardening of the arteries, according to Miller.

Family history. The earlier your parents, brothers, or sisters have a heart attack or stroke, the higher your risk, especially if your mother was under 65 or your father was under 55 at the time.

Age. You're at a higher-than-aver age risk if you are over 51 or in premature menopause without estrogen replacement.

High blood pressure. If you have high blood pressure (anything above 140/90), you're more than three times as likely to have cardiac disease.

Smoking. Nicotine reduces estrogen levels and places you at four to five times greater risk of heart disease than nonsmokers. If you are over 35, smoke, and take oral contraceptives, you may have 10 times the risk of heart disease.

Overweight. Even modest weight gains (about 11 pounds more than your weight at age 18) are associated with an important increase in risk of heart disease, according to a recent Harvard University study. Also, the bigger your waist in proportion to your hips, the greater your risk.

HDL levels below 35-45. The lower your high density lipoproteins (HDL)--the artery-clearing "good" cholesterol--the higher your risk of heart disease.

Don't Ignore That Funny Feeling

A woman's first sign of a heart attack may be a vague fullness or fatigue. Women are also more prone than men to have sharp twinges or burning sensations in their mid-chest that are often thought to be muscle-related and not heart-disease-related. "Chest pain related to heart disease is not a pinpoint pain, but more a general discomfort felt behind or beneath the sternum," says Michael Miller, M.D., cardiologist at the University of Maryland Medical Center. Get to a doctor or emergency room if you have any of these other symptoms:

• a vague, uncomfortable pressure, squeezing, tightness, fullness, or heaviness in the chest that does not go away in a few minutes
• pain radiating up to the shoulders, neck, or jaw, or down the arms or back
• dizziness, fainting, sweating, nausea, new or unusual shortness of breath or weakness associated with chest discomfort or when climbing stairs, for example
• chest pain that comes with physical exertion or emotional stress and eases with rest
• indigestion that does not respond to antacids
• difficult breathing