Many Women Ignore Greatest Health Risk: Heart Disease

When it comes to women and heart disease, what you don't know can not only hurt you, it can be deadly. Earlier this year, after public health officials at the National Heart, Lung and Blood Institute expressed concern that millions of American women may not know they are at risk for heart disease; they launched a campaign called "The Heart Truth." Its purpose is to convey this urgent message: Heart disease is overwhelmingly our No. 1 killer, accounting for the deaths of nearly one in every three American women. Heart disease can also lead to disability and a significantly decreased quality of life.

When surveyed about their greatest health risk, American women typically mention breast cancer. But the numbers tell a far different story. Every year, more than 500,000 American women die from cardiovascular disease, compared with 40,000 deaths annually from breast cancer. Heart disease actually kills more women than all forms of cancer combined. Yet, according to an article in the April 28, 2003, issue of Time magazine, only 8% of American women are aware of that fact.

Some Physicians Lack Awareness, Too
It's not just women who lack awareness, either. Until recently, cardiac researchers and some primary care physicians regarded heart disease primarily as a men's health concern. To help educate her fellow primary care physicians, Joan M. Bedinghaus, MD, an Associate Professor of Family and Community Medicine at the Medical College of Wisconsin, co-authored a 2001 article in the medical journal American Family Physician titled "Coronary Artery Disease Prevention: What's Different for Women?" More recently, she has seen some increase in awareness: "There have been more articles - both in medical journals and in popular magazines and newspapers - about women and their heart risks," she observes.

Citing information from the National Center for Health Statistics, Dr. Bedinghaus says that during the 1990s, deaths from cardiovascular diseases in women did decline 18%, but men's mortality rates from the same problem during the decade fell 30%. But, she cautions, statistics can be misleading. Men still have a higher incidence of death from heart disease than women do.

"In 1990, the death rate for men was twice that of women. Today, it's down to 1.5 times as high," she notes. Men develop risks for heart disease and suffer heart attacks at an earlier age than women do, she says, adding: "At all ages, men still have heart disease at a higher rate than women do."

But why are death rates for men improving faster than for women? A contributing factor might be that some physicians may still treat women with heart disease differently than men. Gender-specific issues in cardiac care have been incompletely understood, due at least in part to the fact that in the past women were not always included in large research studies. In their American Family Physician article, Dr. Bedinghaus and her co-authors - who included Sabina Diehr, MD, also an Associate Professor of Family and Community Medicine at the Medical College - wrote that men are more likely to be offered treatment to prevent subsequent heart attacks.

Compared with men, women are more likely to be misdiagnosed and are more likely to die of their first heart attack than men are. Also, the number of cardiovascular deaths has decreased in men, but not in women.

Men Develop Heart Problems Earlier
Women, on average, develop heart disease at a later age than men. It is commonly thought the reason for the later onset is that estrogen, the hormone women produce during their childbearing years, provides protection. When estrogen production declines after menopause, women's risks for heart disease do rise rapidly. But other factors could explain the difference, Dr. Bedinghaus says: "It's possible that women's rate is actually the norm, and men's rate is accelerated for some reason."

"Even if the estrogen produced by women's own bodies is protective," she notes, "we can't assume that replacing hormones after menopause will be helpful to the heart. The large national study known as the Women's Health Initiative found that estrogen-progestin combination hormone replacement actually increases the risk for cardiovascular disease. It has not yet found an increased risk with estrogen alone, but the study is continuing."

Not only do women develop heart disease at a later age than men on average, their symptoms may be different, Dr. Bedinghaus and her colleagues wrote. "Although women may recognize that chest pain or pressure can signal a heart attack, they may not realize that neck, jaw or shoulder pain, nausea, fatigue or shortness of breath may be important warning signs as well. In fact, where the chest pain or pressure of typical angina predicts heart disease in 80 to 99 percent of men, it is only predictive in 50 to 60 percent of women."

Women as well as men can help prevent heart disease from starting or progressing by being aware of their risk factors. For both men and women, heredity can play a role: If your father had a heart attack before age 55 or your mother had a heart attack before 65, pay special attention to your heart health. And although symptoms and heart attacks usually don't become apparent until midlife, prevention should start much earlier.

Blood Tests Help Reveal Risk
Because of the cardiac risks posed by high cholesterol and diabetes, Dr. Bedinghaus also recommends that her patients undergo annual blood tests for cholesterol and glucose levels. If either condition has progressed, patients are treated and monitored. She does not recommend routine testing for C-reactive protein (CRP) in the blood, however, which is sometimes used to diagnose risk for coronary artery disease. "Although research is revealing the role of CRP as a risk predictor, much more needs to be done before we know how to use the information to prevent heart attacks," she says. Neither does she recommend CT heart scans, which have become widely advertised recently.

Reducing Your Risk Factors
"For women of any age, smoking is a major risk," Dr. Bedinghaus says. "That's especially true for women using birth control pills. Smoking constricts blood flow, adds carbon monoxide to the blood, decreases the amount of oxygen in the body and accelerates atherosclerosis," commonly called hardening of the arteries. It is the process in which deposits of fatty substances, cholesterol, cellular waste products, calcium and other substances build up in the inner lining of an artery and reduce blood flow.

High cholesterol, as well as high blood pressure (hypertension) and diabetes are also serious risk factors for heart disease. Obesity is often a factor in all these conditions.

The most common risk for heart problems in women is a sedentary lifestyle. In her clinical practice, Dr. Bedinghaus tries to encourage her women patients, regardless of age, to incorporate more physical activity into their lives. "Walking is great - nearly everyone can do it, there's no equipment to buy, no club to join, and you can work it into your daily life. Park farther away in the parking lot, take the stairs instead of using an elevator, take a short walk before or after lunch. Even walking around the block helps. It has so many health benefits - for alleviating depression, stress, preventing osteoporosis, to name a few." If patients are limited in their activities because of conditions like arthritis, she urges them to look into water exercises, which takes stress off joints.

Dr. Bedinghaus also urges her patients of all ages to keep their weight proportionate to their height through a healthful diet that is lower in saturated fat and higher in fiber than typical American diets.

Barbara Abel
HealthLink Contributing Writer

This article includes information from the National Center for Health Statistics.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.