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Heart disease has a brand-new face. It's young, mostly fit, and definitely female. The problem is that women -- and many doctors -- are only beginning to recognize it. Last November, paging through the Journal of the American College of Cardiology, Jooyoung Julia Shin, MD, an attending cardiologist at Montefiore Medical School in New York City, read in a report that heart-disease deaths in women under 45 inched up 1.3 percent each year between 1997 and 2002. So, deaths in women under 45 are increasing by the thousands every year, while cardiac mortality is dropping in all other segments of our population. "I was shocked," Dr. Shin recalls. "I mean, I'm female, I'm in the demographic -- and I'm a doctor! I had no idea. It was a wake-up call to me as a doctor and a woman."
Why is this happening? Historically, the typical cardiac patient has been male and middle-aged or older -- that, say experts, is at the heart of the female heart problem. Although awareness campaigns for breast cancer, which kills 1 in 35 women, abound, relatively few organizations educate young women about heart disease, which kills 1 in 3. "The fact is, most support networks just don't target people like me," says Robin Levy, 35, who had her third open-heart surgery in 2007 and now wears a pacemaker. In the past, females were left out of heart-disease research studies, which may have led to a perception that it's not a problem for women, says Lori Mosca, MD, PhD, director of prevention cardiology at New York-Presbyterian Hospital in New York City and a FITNESS advisory board member. Indeed, recent research shows that among people who have relatives with heart disease, young women in particular are more likely to smoke and be overweight -- two big risk factors -- than individuals without a family history of the disease. And while 21 percent of men with a family history are sedentary, that number rises to 40 percent in women, despite the proven cardiovascular benefits of exercise.
Just as young women seem to be in the dark about preventing heart problems, they often don't realize it when they do have one. Female-oriented conditions such as microvascular disease (a stiffening of the smaller blood vessels, often affecting otherwise healthy premenopausal women) and pregnancy-related heart trouble are less understood than coronary-artery disease, the buildup of fatty deposits that triggers most attacks in men. Meanwhile, 4 in 10 women don't recognize heart disease's most dramatic, life-threatening sign: an attack.
Not every woman who has heart disease will undergo an attack, which occurs when the heart is deprived of blood and oxygen, usually from a blockage in the artery. But women who do suffer one are more likely than men to die of it, in part because women don't always have the easily recognizable, chest-grabbing, arm-clutching symptoms. That may be why it takes a woman having a heart attack a full 20 minutes longer than a man to get to the ER; once there, she may not get the prompt care she needs. In a 2004 study, women receiving an emergency procedure to reopen clogged vessels had to wait an average of 118 minutes before being treated; men waited approximately 105 minutes.
Ongoing research on more than 1,500 female heart-attack victims by Jean McSweeney, RN, PhD, of the University of Arkansas for Medical Sciences, is giving us a clearer picture of their key symptoms. Instead of the left-sided chest and arm pain that men describe, generalized discomfort in the chest, breast, back, shoulders, neck, or throat may be more likely to affect some women, says McSweeney. "The most common heart-attack warning sign among our subjects is unusual fatigue," she says. "We had one woman who told us that she had to sit down and rest between making the left and right sides of her bed." Shortness of breath, anxiety, and nausea were other common symptoms for McSweeney's subjects; in recent research done at Yale University, jaw pain also afflicted many women. Finally, in the days leading up to an attack, many women report sleep disturbances and severe indigestion.
Some women suffer these symptoms, especially fatigue, for months before a full-blown heart attack, says McSweeney. Sometimes doctor oversight is to blame. For a long time, physicians were taught to envision a heart-attack victim as either a man clutching his chest or as an elderly woman, says Suzanne R. Steinbaum, DO, director of women and heart disease at the Heart and Vascular Institute of Lenox Hill Hospital in New York City. For a year and a half before her heart attack 12 months ago, Judi Roach had been seeing her internist for breathlessness, exhaustion, and a racing pulse, which were attributed to her allergy medication, fatigue, and stress. "It never entered her mind that a 34-year-old could be having heart-related problems," says Roach, who, ironically, wrote herself a note to "call a cardiologist" for a second opinion two weeks before the event.
Other women survive an attack and don't even know it. Nadine Jenkins was 34 when she mentioned to a nurse at the hospital where she worked as an administrator that her heart had been "skipping a beat." Her friend hooked her up to an EKG machine, which revealed atrial fibrillation, a relatively common condition in which the heart's two small upper chambers quiver instead of beating effectively. When she followed up with a cardiologist, the doctor did additional scans to investigate further. "At one point, she peered at the screen, raised her eyebrows at her assistant and then said to me, 'Do you realize you've had a heart attack?'" says Jenkins. "The scarring revealed it, but I couldn't tell her when it had happened." Jenkins was diagnosed with an enlarged heart and ventricular tachycardia, which can cause the heart to fall suddenly into a "deadly rhythm." She now wears a defibrillator, which shocks her heart back into the appropriate beating pattern whenever it gets out of sync. "I don't smoke, I don't drink, I'm of average weight -- people can't believe I have heart disease, and I guess I couldn't either. Who knows what would've happened had I not said something to a coworker who knew enough to look into it?"
The most frustrating situation is when a woman thinks she's having a heart attack but can't convince her caregivers. When 26-year-old Belinda Jenkins awoke one morning with severe indigestion and shortness of breath, followed by vomiting, she called 911 and said that she thought she was having a heart attack. "The dispatcher kept asking me, 'Are you sure?,'" she recalls. Once in the ER, she waited nearly 40 minutes before any cardiac testing was done. "The nurses and the doctors kept asking me if I'd been using drugs, saying that an admission would help me get medical attention more quickly," says Jenkins. At last, she convinced a doctor to give her an EKG, which revealed that she had indeed suffered a heart attack.
Why aren't doctors making the connection between suspicious symptoms and a significant cardiac event? Studies show that gender does influence diagnosis, even in seasoned physicians. In a 2006 study, Dr. Mosca presented 800 doctors with patient profiles in which the heart-risk levels were identical, but the genders differed. "Even when a woman's risk was the same as a man's, doctors were more likely to classify her case as significantly lower risk," explains Dr. Mosca. Other research reveals that fewer than one in five practicing physicians knows that more women than men die of heart disease each year.
Women not only experience a distinct kind of heart-attack pain, they also use different words to describe their situation. When they have chest pain, for instance, men use dramatic, attention-grabbing words like "crushing" or "viselike"; women typically complain of "tiredness" in their chest, says Nieca Goldberg, MD, of the Women's Heart Program at New York University and author of Dr. Nieca Goldberg's Complete Guide to Women's Health. (In her study, McSweeney found that women also labeled their discomfort as heaviness or burning.) Women can help their cause by being as direct and detailed as possible about what they're feeling, says McSweeney. "Don't just mention that you feel tired. Say, 'I can't walk to the mailbox.' Your doctor will be better able to evaluate you as a potential heart-attack patient."
Beyond misinformation and miscommunication, inadequate diagnostics may also undermine young women's heart health, say experts. At 29, Tara Jacques had been seeing a cardiologist regularly and had a cardiac stress test to measure her heart's reaction to physical exertion -- which she passed. Nonetheless, she went on to have a heart attack. "I had three blocked arteries," she recalls. "Why didn't the test show that?"
It may be because women develop a different type of heart disease than men, says Dr. Steinbaum. "We're just now beginning to understand that microvascular disease, which strikes the heart's small arteries, is a significant problem in women, more so than in men," she says. While men may develop a single large plaque that clearly blocks an artery, in women the thickening is more diffuse and affects the entire inner, or endothelial, lining. "It narrows and stiffens the vessel throughout, so it's hard to pick up with conventional testing," explains Dr. Steinbaum. A calcium score test may help diagnose this problem. And if a seemingly fit woman is having trouble climbing a flight of stairs, it may indicate significant blockage. "It's the smaller arterioles -- the ones involved in microvascular disease -- that contract or relax in order to direct blood flow to working muscles," says C. Noel Bairey Merz, MD, director of the Women's Heart Center at Cedars-Sinai Medical Center in Los Angeles. "When the arteries become stiff, they lose the ability to increase blood flow and pump oxygen to the heart during exertion." If plaque is also present, the combination is a classic recipe for an attack.
Additionally, notes Dr. Goldberg, "the connection between the reproductive organs and heart health has been under-recognized." Unpredictable menstrual cycles may be due to obesity, which is a risk factor that can increase your chances of developing heart trouble. "If you have abnormal periods, your body may be producing less estrogen, a hormone that helps to keep coronary vessels elastic," explains Dr. Goldberg. "Stiff arteries are more susceptible to heart disease and heart attack."
Pregnancy can also be a trigger, since it leads to increased blood clotting, which ups heart-attack risk. In her second trimester, Julie Venables, 40, started having chest pain and difficulty breathing. She had to spend the last two months of her pregnancy hospitalized and was eventually diagnosed with mitral-valve stenosis, a narrowing of one of the valves in the heart that affects three times more women than men. Doctors believe that Venables probably developed the disease during an earlier bout of rheumatic fever, but it didn't cause problems until her heart was forced to help nourish an additional life. Other pregnancy complications, such as high blood pressure, preeclampsia (high blood pressure and swelling), eclampsia (high blood pressure with seizures or coma), and gestational diabetes, can also make you more vulnerable to future cardiac issues. "Doctors used to tell women that these conditions were pregnancy-specific and resolved once you gave birth," says Dr. Goldberg. "New research shows that they can have an impact years after the pregnancy and can increase your risk for early heart disease."
"If there's anything that I could tell women out there, it would be, 'Don't let anyone talk you out of your symptoms,'" says Roach. "In hindsight, I wish that I had pushed a little bit harder. I should have told my doctor, 'Okay, so the test came back clear -- I still need to get to the bottom of my symptoms,'" she says. "If I had only done that, then I wouldn't be sitting here telling you the story of my heart breaking -- literally."
Don't wait: Find out if you have heart disease now. Here are the steps for figuring out what screenings you need, and when.By age 30, get your blood pressure, cholesterol, triglycerides, and blood sugar checked annually.
You should also have your cholesterol levels evaluated both before and a few months after going on the pill, because it can increase your levels of triglycerides and LDL (bad) cholesterol. And ask about a blood test for C-reactive protein (CRP) -- high levels can indicate increased risk even when LDL cholesterol levels are normal.Assess your total risk.
Based on your numbers, many doctors use online tools to assess your chances of a heart attack and to determine what future tests you need. Consider the female-focused Reynolds Risk Score (www.reynoldsriskscore.org), which, like the older, male-centric Framingham risk score, accounts for high blood pressure and smoking but also considers factors that can be particularly troubling in women, such as inflammatory markers and certain cholesterol types.If you have multiple risk factors, such as a family history of heart disease or obesity, and no symptoms, ask about the following:
For women 45 and under, these are the biggest predictors of heart disease and attack.
Originally published in FITNESS magazine, July 2008.