Sunday,
Apr. 20, 2003
Ask
American women what disease they're most scared of,
and the vast majority will answer without hesitation:
breast cancer. They may even cite the ominous statistic
that 1 in 8 women will develop breast cancer at some
point in her life. But what most women don't realize
is that they actually have far more to fear from
heart disease, which will strike 1 out of every 3.
More than 500,000 women die in the U.S. each year
of cardiovascular disease, making it, not breast
cancer (40,000 deaths annually), their No. 1 killer.
Women and heart disease? Better believe it. For while most people still think
of cardiovascular trouble as mainly a man's problem, the reality is that heart
disease has never discriminated between the sexes. In fact, for a variety of
complex reasons, the condition is more often fatal in women than in men and is
more likely to leave women severely disabled by a stroke or congestive heart
failure. True, women don't usually start showing signs until their 60s — about
10 years after men first develop symptoms. And hormones seem to play a protective
role in women before menopause. But the common belief that premenopausal women
are immune to heart problems is just plain wrong. Heart attacks strike 9,000
women younger than 45 each year.
The more scientists learn about a woman's heart and what can go wrong with it,
the more they realize that females aren't just small males. There are subtle
but important differences in how women's cardiovascular systems respond to stress,
hormones, excess saturated fat and toxins like tobacco. There are also some pretty
big differences in how aggressively doctors treat women with heart trouble — even
in the emergency room when they are in most desperate need of help.
All those publicity campaigns that have focused attention on breast cancer may
be part of the problem. The pink ribbons, the docudramas and the races for a
cure have inadvertently left women with the impression that breast cancer is
the only thing they need be worried about. So when public-health officials at
the National Heart, Lung and Blood Institute (NHLBI) decided to spread the word
about women's risk of heart disease with a campaign called Heart Truth, they
took a page from the cancer advocates' manual, designed their own lapel pin — in
the shape of a bright red dress — and sought help from some very highly
placed women, starting with the First Lady. "Women take care of all the
people in their family — their children, their husbands — but they
sometimes don't take care of themselves," says Laura Bush. "The goals
of this campaign are just to really make sure that women know that heart disease
is their No. 1 killer and that they can change their lifestyles to prevent it."
The new push couldn't come at a more critical juncture. Many women were stunned
last year when the famous Women's Health Initiative discovered that pills providing
a combination of estrogen and progestin do not protect the hearts of postmenopausal
women. (Tests on estrogen alone are still under way.) Suddenly, what had seemed
to be the simplest, most elegant solution to the aging female heart — replacing
the hormones a woman makes before menopause — had vanished.
After that bombshell, doctors and their female patients had a lot of questions.
If hormones don't prevent heart disease, what does? Is the ailment fundamentally
different in men and women? If not, why do their symptoms seem to differ? And
why do treatments such as bypass surgery and angioplasty, which work so well
for men, often fail for women? In some ways, says Dr. Sharonne Hayes of the Mayo
Clinic in Rochester, Minn., "the findings have allowed us appropriately,
and perhaps belatedly, to refocus our efforts."
It's not as if doctors were starting from scratch. Cholesterol-lowering drugs
like statins and antihypertensive medications like beta-blockers clearly help
both men and women, as do a healthy diet and plenty of exercise. "The vast
majority of heart attacks in women could be prevented with a combination of lifestyle
modifications and medication," says Dr. JoAnn Manson at the Brigham and
Women's Hospital in Boston. "Just making use of existing information could
nearly eradicate the disease."
At the top of the list of risk factors that men and women share is smoking, the
most dangerous killer for both sexes, followed by diabetes, high blood pressure,
high cholesterol levels, excess weight and physical inactivity. Some factors,
however, seem to affect women more severely than men. In fact, smoking and diabetes
completely counteract whatever protective benefits a woman normally enjoys before
menopause. Also, women are more likely to be overweight, less likely to exercise
and appear to be affected more adversely by stress.
Of course, neither men nor women can do anything about their age or the genes
they were born with. (If your father had a heart attack before 55 or your mother
had a heart attack before 65, you should pay special attention to your heart
health.) And it's still unclear why heart disease seems to strike men and women
so differently. Structurally, their hearts and arteries are basically the same;
women's hearts are smaller, but in proportion to their bodies. So doctors are
pretty sure that any differences are matters of degree rather than kind.
Cardiologists are confident that they understand how heart attacks occur in men.
The trouble usually begins when a fatty deposit or plaque, which has taken decades
to build up on the inside of a coronary artery, becomes unstable and bursts,
triggering a clot that blocks a blood vessel. Doctors can see these plaques during
a fairly invasive procedure called an angiogram, in which a catheter is threaded
through an artery in the groin or leg up to the arteries of the heart and a dye
is then released to make any blockages easier to spot.
Although the research is controversial, some evidence suggests that bursting
plaques may not be as important for women as for men. Doctors have long puzzled
over the fact that some of their female heart-attack patients — usually
those who have not yet gone through menopause — show few signs of artery-clogging
plaques on their angiograms. Perhaps their blockages don't occur in the major
arteries of the heart, where angiograms are performed and bypasses are most effective.
Perhaps blood flow is restricted in the smaller vessels that branch off the coronary
arteries. And perhaps the problem isn't plaques at all but the fact that these
smaller blood vessels are somehow more prone to spasm, snapping shut at the slightest
stress or trigger, cutting off the flow of blood to parts of the heart.
Indirect evidence of just such a possibility was published by researchers at
the University of Wisconsin-Madison in the Journal of the American Medical Association
last year. By looking at high-resolution images of the blood vessels of the retina — one
of the few places where doctors can easily examine the body's vascular system
without an invasive test — they found that women with the narrowest arteries
were most likely to have heart disease but that the size of the blood vessels
made no difference in men. The small-vessel theory has some flaws. For example,
certain drugs called vasodilators, which act to keep blood vessels open, do not
appear to prevent heart attacks in women, as you would expect if spasms were
the primary problem. Still, there are enough other ways in which small vessels
may be involved that researchers aren't yet ready to dismiss their role.
It's also possible that plaques — whether in the main coronary arteries
or the smaller vessels — behave differently in women. Unlike men, women
tend to distribute all the "garbage" associated with atherosclerosis — such
as saturated fat and oxidized waste products — more evenly throughout the
arteries. The process is analogous to the way men and women gain weight, says
Dr. Noel Bairey Merz of the Cedars-Sinai Medical Center in Los Angeles. "When
men get fat, it all goes to their belly," she says. "When women get
fat, they tend to get fat all over — fat at the ankles, fat in the sides,
fat in the upper arms." So although women generally avoid the monster plaques
that kill so many men in early middle age, the continuing buildup in women's
arteries may come back to haunt them in their 50s, 60s, 70s and 80s.
Plaques are another reason for women to throw away their cigarettes, as smoking
seems to turn stable plaques into unstable ones. "If you look at the plaque
(of a woman) under a microscope, it doesn't appear to be the kind of plaque that
can become unstable and rupture," says Dr. Robert Bonow of the American
Heart Association. "But the surface has become eroded, exposing the material
beneath the surface to the blood, which causes blood clots. And it turns out
that the women who have this plaque erosion tend to be women who smoked." Those
clots can travel through the bloodstream, wreaking havoc in the heart or the
brain.
Getting to the bottom of why men and women report different cardiac symptoms
is trickier than might be expected. In fact, some researchers think the differences
can be emphasized too much. If a woman doesn't think she can have heart disease,
notes Dr. George Sopko of the NHLBI, she's not going to interpret her symptoms
as heart disease — even if her symptoms are the same as a man's. Truth
is, the classic heart attack made famous onstage and onscreen, where you clutch
your chest and fall to the ground, doesn't tell the whole story. "Half the
time women don't do that," says Cedars-Sinai's Bairey Merz. "But 40%
of the time, men don't have a typical heart attack either." Men, however,
have been conditioned for decades to suspect that they might be suffering a heart
attack even when they feel perfectly healthy. So while women are more likely
to experience the prelude to an attack as shortness of breath, extreme fatigue
or a feeling that they have a bad case of indigestion, they often can't believe
that their symptoms are cardiac in origin. Equally important, their doctors often
don't believe it either. Doctors tend to put off ordering necessary tests for
women having a heart attack or fail to treat them aggressively enough.
Just ask Kathy Kastan, 43, a psychotherapist in Memphis, Tenn., who suffered
both classic and less common symptoms. "I noticed that I would get tired
more quickly," says Kastan, who was and still is very active — biking,
swimming, running, walking. "I would sometimes have to stop because I had
shortness of breath." After a couple of trips to the doctor, who failed
to pick up on her heart problems, she collapsed in the street while on a vacation
in Colorado. "I clutched my chest, had profuse sweating, chest pains from
the front to the back, down my arm, up into my jaw." When the symptoms went
away, she attributed them to the altitude. Finally, after collapsing one more
time, she underwent a more comprehensive and rigorous stress test, which revealed
a blockage that required bypass surgery after earlier treatments ended in failure.
Now when Kastan talks to women's groups about heart disease, she tells them they
need to know their risks and insist that doctors take them seriously.
To be fair, denial isn't the only thing working against women. "More than
men, women have stress-related chest pain and pain when they are resting," says
Dr. Randolph Martin of the Emory University School of Medicine in Atlanta. Sometimes
the pain results from sore chest muscles or monthly variations in a woman's sensitivity.
Also, women frequently have abnormal ECG readings during the classic treadmill
test even when their hearts are functioning normally. But before you decide that
treadmill tests are worthless, consider the latest research from the wise study,
short for Women's Ischemic Syndrome Evaluation. Data from wise suggest that false
positives in women may be not so much an error as an early warning of a problem,
perhaps in the smaller blood vessels, that could become significant in 20 to
30 years, according to Bairey Merz.
To get a better handle on what's going on inside a woman's heart, many cardiologists
perform an echocardiogram during a treadmill test. Echocardiograms can give doctors
a detailed picture of the size, shape and pumping action of the chambers of the
heart and of how well the valves are working. If the pumping action looks stiff,
doctors know the heart is ailing.
Even cholesterol testing is less straightforward in women than in men. Whereas
high levels of ldl, the so-called bad cholesterol, are pretty good at identifying
men at high risk of heart disease, women seem more vulnerable to high levels
of a different fatty substance, called triglycerides. In addition, women with
low levels of HDL, the so-called good cholesterol, are more likely than men to
develop heart disease later on. National guidelines suggest a minimum HDL level
of 40 mg/dL for men and women. "But (low) HDL is a more powerful predictor
of risk in women," says Dr. Lori Mosca of New York-Presbyterian Hospital. "So
in my practice I recommend keeping an HDL of 50 mg/dL for women."
Add up all the caveats and uncertainties, and it's not surprising that when women
finally get to the hospital, it takes longer for doctors and nurses to diagnose
their trouble correctly. Unfortunately, the delay may make female patients too
sick to qualify for certain lifesaving treatments, such as clot-buster drugs
that can stop a heart attack in its tracks. And because most women are older
when they develop heart trouble, they are more likely to suffer from other conditions
that complicate their care.
Fortunately, the medical community is starting to adapt to the new realities
of women and heart disease. Two studies suggest that women may finally be benefiting
as much as men from angioplasty, a procedure in which doctors use catheters and
balloons to open up dangerously narrowed arteries and insert stents to keep the
arteries open. In the past, catheters and stents were all made in one standard
size — to fit men's larger arteries. As a result, women suffered more complications
and a much higher risk of death from angioplasty. Also, until about three years
ago doctors prescribed the same doses of the blood thinner heparin for men and
women, leading to greater internal bleeding in women. Smaller catheters and stents
and lower doses should give women better results.
There's plenty that women — and men — can do to help protect themselves.
There are no guarantees, but adopting a healthier lifestyle, which includes eating
right, getting more exercise and quitting smoking, will tip the odds in their
favor. Probably the hardest thing for women to overcome, however, is the false
sense of security given by the premenopausal years, which to some degree help
delay the start of heart disease about 10 years. Many men would love to have
an extra 10 years in which to make positive changes in their lifestyles. Women
who fail to take advantage of this gift do so at their heart's peril.
Reported
by David Bjerklie, Alice Park and Sora Song / New York
Copyright © 2003
Time Inc.
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