Heart Attacks & Women

Summary

Cardiovascular disease is the leading killer of women in the United States. Every year since 1984, heart disease has claimed more women than men. Currently, an estimated 500,000 women die each year from cardiovascular disease in the United States alone. Cardiovascular disease claims more female lives than breast cancer, accidents and diabetes combined. Worldwide, heart disease is the number one killer of women in developed countries.

According to the National Institutes of Health, women are more likely to have more risk factors for heart attacks than men. Numerous studies have shown that people with more risk factors, such as having diabetes, being overweight, smoking and having high cholesterol, are much more likely to suffer from heart attacks than people with fewer risk factors.

In general, heart attacks are deadlier to women at any age than men. By age 75, cardiovascular disease is more common among women than men. Although the incidence of coronary artery disease is lower for premenopausal women, they are more likely to die from a heart attack and more likely to have a second heart attack within one year.

Furthermore, diagnosing heart attacks can be more difficult in women than men because women tend to have less &typical& symptoms. Women are encouraged to learn all they can about preventing heart attacks and getting the earliest possible treatment if they experience any symptoms of a heart attack.

The American Heart Association estimates that more than 13 million people alive today have a history of coronary artery disease, which is the leading cause of heart attacks. More than half of these are women. In addition, more than 3 million American women have a history of heart attack, and 4.2 million have a history of angina, or chest pain.

About heart attacks in women

Cardiovascular disease (CVD) is the single largest killer of women in the United States, accounting for almost 500,000 deaths every year. Although it can affect women of all ages, it is especially prevalent after menopause. Coronary artery disease rates in women after menopause are 2 to 3 times those of women the same age before menopause. Heart attack is especially dangerous among women. Although women are about as likely as men to have a heart attack, they are more likely to die within a year after their first heart attack. Researchers have proposed a number of possible reasons for this finding, including:

  • Women tend to have &atypical& symptoms that are actually signs of a heart attack. As a result, it may be harder for women to recognize they are having a heart attack and to get treatment immediately. Physicians may also have a harder time diagnosing a heart attack in women because of the atypical symptoms women are more likely to have.

  • Women's heart attacks may be more damaging or associated with more severe medical complications, possibly because of the underreporting and late diagnosis that may result from presenting with atypical symptoms. Consequently, women are more likely than men to become disabled from a heart attack and less likely to be referred for cardiac rehabilitation.

  • Compared with male heart attack patients, women are usually about 10 years older at the time of their first attack. At that age, they are more likely to have medical complications or conditions that could interfere with a full recovery. At the more advanced age, women are more likely to have conditions such as diabetes or high pressure blood (hypertension). They are also more likely to have developed complications from long-term habits such as smoking or excessive alcohol use. It is important to note that, while women are more likely to suffer a heart attack after menopause, younger women can get heart attacks that are just as life-threatening.

  • Women have smaller hearts and coronary arteries than men, which makes some diagnostic and therapeutic procedures more difficult. Non-invasive imaging of the heart may be rendered difficult due to the interference of breast tissues.

Risk factors and causes affecting women

A number of risk factors increase a woman's chance of developing coronary artery disease (CAD) and having a heart attack. Most of these risk factors are the same ones associated with CAD in men. They include:

  • Smoking. A regular smoking habit (including cigars and marijuana) greatly increases the risk of damage to the coronary arteries (more so in women) and dying from heart disease. Chronic exposure to second-hand smoke at work or other places also increases the risk, even in nonsmokers. Smoking is particularly dangerous for women who are taking birth control pills (especially after the age of 35), because the combination has been associated with a significantly increased risk of blood clots. If blood clots either form in, or travel to, the coronary arteries, they then could cause a heart attack.

  • High blood pressure (hypertension). According to the American Heart Association, high blood pressure is more common among men than women until age 55. Between ages 55 and 74, it is slightly more common among women, and over the age of 75, many more women have high blood pressure than men. High blood pressure is a particularly serious problem among black American women, almost 45 percent of whom have elevated blood pressure. Even more serious is poorly controlled high blood pressure, which may be harbinger of an impending heart attack.

  • Cholesterol. Total cholesterol levels should be less than 200, according to the National Cholesterol Education Project, although some organizations have suggested even lower targets. LDL levels should remain below 130. For women who are at &very high risk& of a heart attack, according to the Framingham Risk Calculator, an optimal LDL target of 70 may be pursued.

  • Triglycerides. Women should also carefully monitor their levels of triglycerides, another type of fat in the blood.  The National Cholesterol Education Project recommends that triglyceride levels of less than 150 are considered normal, and up to 199 is borderline high.

  • Low levels of &good& cholesterol (HDL). The American College of Cardiology (ACC) recommends a woman's HDL level be at least 50 milligrams per deciliter (mg/dL), which is 10 mg/dL higher than the level recommended for a man.

  • A diet high in saturated fat. Whereas unsaturated fats (e.g., fish oil and essential fatty acids) are not harmful and are sometimes helpful, saturated and trans fats (usually found in processed and fast foods) cause the liver to produce higher levels of cholesterol and therefore increase the risk of heart disease. In fact, cholesterol levels are much more strongly linked to saturated and trans fats in a person's diet than how much cholesterol the person eats (e.g., from eggs).

  • Obesity (a body mass index [BMI] greater than 30 is considered obese, and a BMI of 20 to 25 is considered normal). Obesity is the second leading cause of preventable death, contributing to serious health problems such as heart disease, diabetes, cancer and stroke. Obese individuals are much more likely to die from a heart attack than those who are not.

  • Lack of regular exercise. Heart disease is twice as likely in inactive woman than in those who get regular exercise – at least 30 minutes three times per week. Studies have shown a correlation between physical fitness and lower levels of C-reactive protein. Elevated levels of C-reactive protein are interpreted as a sign of inflammation in the body and a &marker& of the process of heart disease.

  • Excessive alcohol use. Recent studies have reported that women who have one drink per day are less likely to have a heart attack than a non-drinker. However, the opposite effect has been associated with drinking too much alcohol. Women who drink heavily on a regular basis have higher rates of heart disease (and breast cancer) than either light drinkers or nondrinkers.

  • Family history of heart disease. Women, like men, are more likely to develop heart disease if heart disease runs in their family.

  • Race. African American women have a greater risk of heart disease and heart attack at a young age than white women, largely due to higher average blood pressure levels in African Americans.

  • Diabetes. Regardless of blood sugar control, diabetic women are twice as likely to suffer from heart disease as non-diabetic women, according to the American Heart Association. Similarly, the impact of diabetes on stroke risk is greater for women than men.

  • Polycystic ovaries. A recent study found stiffer and less elastic carotid arteries in women with polycystic ovaries and, to a greater extent, women diagnosed with polycystic ovary syndrome. Polycystic ovaries are enlarged ovaries containing numerous small cysts. In this syndrome’s severe form, both the cysts and size of the ovaries increase further, accompanied by a syndrome of hormonal side effects (chronically absent menstrual periods, infertility, obesity, high blood pressure, excess facial hair and/or type 2 diabetes). Carotid arteries supply blood to the head and neck. Researchers believe that stiffness in these arteries may mean that other arteries in the body are damaged, thereby possibly increasing the risk of coronary artery disease.

  • High blood levels of inflammatory markers. Research has found a link between heart disease risk and high blood levels of inflammatory markers – substances released by the body in response to inflammation. Two such markers are C-reactive protein (CRP) and interleukin-6 (IL-6). Studies show higher levels of both CRP and IL-6 with increasing age, body mass index, blood pressure and exposure to tobacco smoke. High levels of IL-6 alone are associated with excess alcohol intake, diabetes and lack of exercise. High levels of CRP alone have been found in women taking hormone replacement therapy.

Recent studies have explored whether a woman's menstrual cycle plays a role in heart attack risk. One found a higher risk of heart attack at the onset of the menstrual cycle (when estrogen and progesterone levels are at their lowest), compared to the preceding three weeks. Researchers are unsure of the reason, but stress that the risk is very low.

Another study focused on a possible association between irregular periods and heart disease. Spanning 14 years, it followed 82,000 female nurses aged 20 to 35. Compared to those having regular menstrual cycles, the nurses with irregular periods had a higher incidence of heart problems. Researchers conducting the study did not feel that irregular periods by themselves caused heart disease. Rather, it may reflect some other underlying condition that can, in turn, increase the risk for heart disease.

Birth control and heart attack risk

Many studies have investigated the impact of oral contraceptives (birth control pills) on heart attack (and stroke) risk. The newer, &third generation& Pill is a combination of two synthetic hormones, progesterone and low-dose estrogen. Compared to women not taking oral contraceptives, studies show no appreciable increase in risk of heart attack for those on the third-generation Pill. Similar safety has been demonstrated with the newer birth control patch.

Women should be aware of precautions with the Pill, patch and injectable contraceptives. When combined with smoking, the use of &hormonal contraceptives& significantly increases the risk of a heart attack, stroke or other cardiovascular disease – especially in women over 35 years of age. Hormonal contraceptives may not be recommended for those with a prior history of blood clots, cancer, stroke or heart attack (and neither oral nor patch contraception protects against HIV and other sexually transmitted diseases). Women are encouraged to consult with their physicians regarding the benefits and risks of different types of contraception.

Signs and symptoms of heart attack in women

For both men and women, common warning signs of a heart attack include:

  • Chest pain or discomfort (from exertion or not) that is unrelieved by rest or a change in position and often spreads or radiates through the upper body to the arms, neck, shoulders or jaw. The sensation tends to be very intense and unrelieved by medication.

  • Profound fatigue.

  • Chest-area pressure or squeezing sensation that may be either constant or intermittent.

  • Shortness of breath or shallow breathing.

  • Abnormally weak and/or fast pulse.

  • Feeling faint or dizzy.

  • Sweating, often heavy and often cold.

  • Nausea or upset stomach.

In contrast with the common warning signs listed above, some women may have less &typical& symptoms when they are having a heart attack. Women are less likely than men to feel severe chest pain and are more likely to report a feeling of severe heartburn in the upper abdomen or pain in the breast. Unless a woman is familiar with these atypical symptoms, she may delay getting to the hospital. By the time a woman decides to seek medical attention, severe damage to the heart may already have occurred. When in doubt, chew a ®ular& aspirin (not acetaminophen) if you are not allergic or don’t have an ulcer, and call 9-1-1 immediately. Aspirin can greatly reduce the chance of dying from a heart attack.

When meeting with a healthcare professional during an emergency, women should communicate the nature of the apparent health crisis and their need for tests (e.g., blood tests and an EKG) to be run as soon as possible. These may include tests measuring cardiac enzymes and C-reactive protein. Women who are concerned about their heart health are encouraged to seek a second opinion if they are not satisfied with the first.

Treatment and prevention for women

Once a heart attack has been diagnosed, treatment is generally the same for both men and women. It is important that treatment be sought as quickly as possible. Rapid treatment can reduce the muscle damage associated with a heart attack.

For both women and men, the best strategy for preventing heart attacks is to make lifestyle changes that help prevent the main cause of heart attacks: coronary artery disease.

Earlier studies suggested that hormone replacement therapy (HRT) provided an added benefit in postmenopausal women by protecting them against heart disease. Current research has found differently. HRT involves the replacement of estrogen that is lost during menopause. Because natural estrogen protects younger women from heart disease, it was assumed that HRT could also help protect post-menopausal women from heart disease.

A pair of major studies was launched to study the effects of estrogen on heart disease in women. Known as the Women's Health Initiative (WHI), these two studies did not measure the effect of estrogen on side effects of menopause. Instead, they considered only estrogen's effect on the cardiovascular system. The first of the two studies looked at combination estrogen/progestin therapy in 16,000 postmenopausal women aged 50 to 70 who still had their uteruses. The second looked at estrogen-only therapy in 11,000 women who had no uteruses (and therefore did not need to take progestin).

Begun in 1997, the estrogen/progestin arm of the study was terminated on May 31, 2002, (three years before scheduled) when it was shown that the risks of estrogen/progestin outweighed its benefits. Researchers found that estrogen/progestin therapy increased the risks of heart attack, stroke, breast cancer, blood clots and overall cardiovascular disease. These findings overwhelmed the therapy's mild protective effect against fractures and colon cancer. A separate study conducted by British researchers supported these results, adding that, for women in their 50s taking HRT for five years, breast cancer is the greater risk. Those in their 60s have a higher risk of stroke or pulmonary embolism.

The second part of the study, the estrogen-only portion, was discontinued in 2004 for similar reasons. Researchers found that the benefits of estrogen in these women were evenly balanced against its negative effects. Though estrogen-only HRT did protect against fracture and colon cancer, there was a significant increase in the rate of stroke and blood clots. However, there was no statistically significant increase in breast cancer rates.

The reaction to this news was rapid and widespread. Between 1995 and 2001, the percentage of women aged 50 to 74 taking some form of HRT increased from 33 percent to 42 percent. By 2003, after the first of these results had been published, that number dropped to 28 percent. Overall, hormone therapy prescriptions dropped 38 percent in the first year after the study's findings were published. Today, neither estrogen/progestin therapy nor estrogen-only therapy are recommended for the prevention of heart disease, osteoporosis or Alzheimer's disease.

It is important to note, however, that although these figures sound intimidating, they were derived from a large sample. In absolute terms, the level of increased risk to any individual woman on HRT is small. According to WHI researchers, the absolute risk of breast cancer or a cardiovascular complication from combination estrogen/progestin therapy is very low (about 19 events per 10,000 women). It is lower still for younger, postmenopausal women.

Indeed, the U.S. Food and Drug Administration (FDA) recognizes that women may still want to use HRT for a variety of menopausal and postmenopausal symptoms. Consultation with one's physician is essential to weigh the family and person medical history, as well as potential risks and benefits with HRT over the short and long term.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to heart attacks and women:

  1. As a woman, am I at risk of having a heart attack?

  2. Do I have any specific risk factors for having a heart attack?

  3. Do my chances of having a heart attack increase with age?

  4. Are there any lifestyle changes I can make to reduce my chances of having a heart attack?

  5. Would regular exercise decrease my chances of having a heart attack?

  6. Do you recommend any drugs to reduce my heart attack chances?

  7. Could a heart attack have a greater impact on me as I get older?

  8. What are some of the warning signs of a heart attack?

  9. Could hormone replacement therapy help protect me from having a heart attack?
Copyright HLTHO - Healthology
Contact Us