Today, women’s health issues are front and center, but women still lag behind men where heart health is concerned.
Maureen Lowery, M.D., FACC, is acutely aware of this disparity. Dr. Lowery is a cardiologist at the University of Miami Health System and vice-chair of Faculty Development and Diversity for the University of Miami Miller School of Medicine’s Department of Medicine. She championed the Go Red for Women® campaign, designed to educate women that their number one killer is heart disease. She was the first faculty member to lecture on gender differences in heart disease at the Miller School. “When the campaign started in 2004, we polled women and found that most thought they would die from breast cancer and heart disease was a man’s disease.
Ten years later, a follow-up poll found that more women knew heart disease was the number one killer of women, but most still felt a more significant risk from breast cancer. If a woman does not think she might die of heart disease, she will be less motivated to address the risk factors for heart disease, such as little to no exercise, poor diet, smoking, hypertension, and diabetes. Another reason to take this seriously? Women have 55,000 more strokes per year than men,” Dr. Lowery says.
Are the misconceptions killing us?
Grasping the gender differences surrounding heart disease is complicated by several factors. In women, symptoms typically appear 10 years later than in men, and heart attacks generally occur 20 years later in women than in men, Dr. Lowery says. Meanwhile, early warning signs can go undetected even as plaque accumulates in the arteries, eventually leading to atherosclerosis.
Dr. Lowery highlights other obstacles:
- Many women know the risk factors for heart disease but don’t “personalize” them and don’t receive this information from their doctors.
- Most women get their news from the Internet or magazines, not from doctors.
- Women may know their symptoms are different but don’t recognize subtle or classic signs.
Obstacles to a proper diagnosis
Women don’t shoulder all of the responsibility for heart health disparities. A study published in The Journal of the American Medical Association stated that women are less likely to be diagnosed and treated for unstable chest pain (angina), even if they go to the ER. “Studies suggest that coronary artery disease in women is underdiagnosed, misdiagnosed, and undertreated compared to men. Women presenting with chest pain are less likely than men to be referred for diagnostic tests and therapeutic interventions,” Dr. Lowery says. Those interventions include aspirin, beta-blockers, ACE-inhibitors, procedures to restore blood flow, and cardiac rehabilitation. “These have proven benefits in women but are underused, especially in minority women. Physicians should emphasize the use of proven treatments, with particular attention given to underserved populations,” Dr. Lowery says.
Recognize your risk factors
In her research, Dr. Lowery found that health care providers don’t always counsel women about controlling risk factors. Once again, self-advocacy is crucial. Knowing your risks is the first step in protecting your heart. Women with any of the following situations are at increased risk:
- Obesity: a woman’s waistline should not exceed 35 inches; a man’s should not exceed 40 inches
- Tobacco use
- High blood pressure
- High cholesterol
- Physically inactive
- Diabetic: in women, diabetes increases the risk of heart disease 3- to 7-fold compared to a 2- to 3-fold increase in men
- Family history
- Age 65+ or early menopause
Other less commonly known risks include:
- Elevated homocysteine (amino acid) levels
- Elevated lipoprotein(a) (bad cholesterol) levels
- Clotting issues
The estrogen equation
There’s another challenge unique to women. “Arterial plaque increases with estrogen loss; menopause affects cholesterol,” Dr. Lowery says. She cites studies that evaluated the role of estrogen on women’s hearts and its use as a “gender-specific treatment.” The PEPI trial showed that estrogen kept “good” (HDL) cholesterol high and “bad” (LDL) cholesterol low. Unfortunately, it also raised triglyceride levels. In the Heart and Estrogen/progestin Replacement Study (HERS), in which Dr. Lowery was the principal investigator, “We found that there was no statistical benefit to using estrogen/progesterone hormonal replacement as a gender-specific treatment in post-menopausal women with known heart disease. And in the Women’s Health Initiative Trial (WHI), the investigators found no benefit of hormonal replacement in post-menopausal women without heart disease.” Ultimately, this means that doctors should not prescribe estrogen with or without progesterone to prevent or treat heart disease in women.
Some observational studies did show a benefit to taking estrogen, but those were done on younger, perimenopausal women whose atherosclerosis was not advanced. Estrogen stabilized arterial plaque in these women. In research trials involving older, post-menopausal women, “Their plaque was already bad. Adding estrogen made it worse. The age that women start hormone therapy is important in determining the outcome of that therapy since it can have beneficial or adverse effects on atherosclerosis,” says Dr. Lowery.
Unfortunately, our clocks start ticking when menopause begins. As we lose estrogen, the plaque in our arteries increases. Even so, the studies concluded that whether women experience menopause early or later in life, they should not take estrogen for heart health. “Cardiologists cannot prescribe or recommend estrogen to prevent or treat heart disease. Hormone replacement therapy should only be prescribed by gynecologists for menopausal symptoms and osteoporosis.” If you did go through early menopause, tell your doctors so that they factor this into your overall risk profile.
Mixed signals and elusive symptoms
Women’s symptoms may creep in as fatigue or having less stamina for exercise – either of which might be blamed on work, family responsibilities, stress, aging, or other reasons. The message here? Don’t underestimate your symptoms.
Dr. Lowery points to the Framingham Heart Study, which showed that 63% of women
who died suddenly from coronary arterial disease had no previous symptoms.
Some women don’t have chest pains during a heart attack, which might explain why they are sometimes misdiagnosed. Symptoms vary, and some differ from those commonly associated with heart attacks. Women’s warning signs may include:
- Back or shoulder pain
- Stomach pain
- Pain in the neck or jaw
- Pain in one or both arms
- Shortness of breath
- Nausea or vomiting
After being misdiagnosed, former talk show host Rosie O’Donnell created an acronym to help women identify the symptoms that led to her heart attack:
Heat – feeling overheated or flushed
Puke (nausea and vomiting)
Prevent and prevail
Despite the confusion surrounding women’s heart health, the takeaway is simple. “If you don’t take it seriously, you won’t take lifestyle modifications seriously. When patients tell me, ‘I don’t have time for exercise,’ I say, ‘Then you better have time for disease.’”
To keep your heart healthy:
- Get 30 minutes of moderate-to-vigorous exercise 5 days a week; 7 days a week is better
- Eat healthy foods like those in the DASH, Mediterranean, or plant-based diets
- Maintain a healthy weight and a waistline of 35 inches or less
- Manage stress
- Keep your total cholesterol below 200
- Maintain healthy blood pressure at or below 120/80
- Don’t smoke
- If you’re 65+ or you went through menopause early and have other risk factors, ask your doctor about the risks versus benefits of daily aspirin
Get screened in February.
During American Heart Month in February, UHealth offers coronary calcium screenings, a quick, painless test that detects coronary plaque. The tests are regularly $99; in February, they are just $25. Visit UMiamiHealth.org/HeartScreening to learn more.
UHealth also offers a free online HeartAware Risk Assessment.
Nancy Moreland is a contributing writer for UMiami Health News. She has written for several major health care systems and the Centers for Disease Control and Prevention. You can also find her writings in the Chicago Tribune.
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