Change Of Heart

Long considered a man’s disease, heart disease is finally achieving recognition as a condition that equally – but sometimes differently – affects women.

Ask a group of women which disease kills more women than any other, and many will likely answer breast cancer. But that’s incorrect. Only half or so – depending on whom you ask – will know the right answer: heart disease.

In a 2012 survey conducted by the American Heart Association, only 56 percent of women knew that heart disease is the most frequent cause of death in women. For African-American and Hispanic women, the percentages were 36 percent and 34 percent respectively.

“When you look at statistics and when you talk to women, the No. 1 thing women fear over many, many years is breast cancer,” says John Spellman, M.D., a cardiologist with Cardiovascular Consultants in Savannah. “But in fact when you look at the numbers, coronary disease is the leading cause of death in women as well as men.”

According to the Centers for Disease Control and Prevention, heart disease is responsible for 1 in every 4 female deaths in the U.S., compared to 1 in 31 for breast cancer.  Roughly the same number of men and women die each year from heart disease, yet many people still tend to think of heart disease as a man’s disease – a perception that the American Heart Association, through its Go Red for Women initiative, and a growing number of cardiologists are working hard to change. 

How Women Are Different

When most people talk about heart disease, or cardiovascular disease, they are referring to a condition in which blood vessels narrowed by plaque lead to chest pain, called angina, or a heart attack.

While women don’t necessarily have more heart disease than men, there are some key differences in women that doctors have recognized or are starting to discover. 

Women have extra risk factors. For the most part, risk factors for women are the same as those for men – a family history of heart disease, smoking, sedentary lifestyle, high blood pressure or total cholesterol. In recent years, however, researchers have identified at least two risk factors – preeclampsia (a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys) and gestational diabetes – that are exclusive to women who have had children.

“When women have these kinds of things happen during pregnancy, that can be a harbinger of events to happen 10 to 20 years after their pregnancy,” Sara Mobasseri, M.D., a cardiologist at Piedmont Heart Institute in Atlanta, says. “Pregnancy is like a stress test in a way, because of all of the adaptations your body makes with fluids and volume – it is a stress test for the heart. So if a woman suddenly develops diabetes or high blood pressure during pregnancy, that tells us something about her physiology. If I find a woman who has had that complication, she is already at risk.”

Another more recently identified risk factor is the presence of an autoimmune disease such as rheumatoid arthritis or systemic lupus erythematosus (lupus). Re-search shows that people who have these diseases, which are characterized by an abnormal inflammatory response by the body to its own tissues, face an increased risk of cardiovascular disease. While that risk exists for both men and women, the diseases themselves tend to be more common in women, particularly lupus, which affects nine times as many women as men.

Women tend to develop heart disease later. “For women it usually lags behind men about 10 years. So while men start having heart disease problems from atherosclerosis after 55, for women it usually happens after 65,” says Gina Price Lundberg, M.D., clinical director of the Emory Women’s Heart Center and assistant professor of medicine at Emory University School of Medicine.

Traditionally, doctors believed that the later onset in women was due to the female hormone estrogen, which women’s ovaries produce in large amounts prior to menopause.

“We always thought there was some type of protection from estrogen for women and that the ovaries protected women from coronary disease, because when women go through menopause they catch up with men very quickly and surpass men after that,” says Dr. Spellman.

Research in recent years, however, has cast doubt on the protective effects of estrogen – at least the synthetic estrogens once given almost routinely after menopause in hopes of staving off some health problems associated with dwindling estrogen levels. Studies have shown that taking hormone replacement after menopause has not only failed to protect women from heart disease, but it has been associated with other side effects, including an increased risk of breast and uterine cancer, says Dr. Lundberg. In fact, some studies have suggested that replacing estrogen after menopause actually increases heart attack risk.

Today, doctors say estrogen replacement is prescribed much more selectively and further research is needed to determine the role of estrogen replacement and heart disease.

Symptoms are more subtle. While women do eventually catch up to men in heart disease prevalence, when they do get it the symptoms may be different.

“While men often complain of pain in the center of their chests, women tend to have more subtle symptoms they describe as shortness of breath or tightness or heaviness in the chest,” says Dr. Lundberg. “Women may have more symptoms of feeling dizzy, palpitations or light headedness. They may have feelings of fatigue or feelings that something is not right, something is just wrong.

“For men, reduced blood flow to the heart due to blockages may cause discomfort that comes on with exertion and is relieved with rest, whereas women may have it with lighter activities like housework or walking up the stairs,” Dr. Lundberg says.

Women may have more severe diseases or complications. Because women present with coronary artery disease when they are older than men, they tend to have more of what doctors call comorbidities, or coinciding health problems, such as diabetes or congestive heart failure.

Also, because women’s symptoms tend to be vague, women may not seek attention until the problem is more advanced, says Dr. Mobasseri. “Now, that being said, time is muscle. If you are not getting attention for angina, or poor blood flow to the heart, you are causing more loss of the heart muscle so there is more damage. So by the time a woman typically comes for help, there are typically more complications or she has a worse outcome because she presented late for medical attention.”

Furthermore, women may also have more extensive involvement of the vessels than men, says Dr. Spellman. “Instead of just being located in one particular place, it seems to be more diffuse than in men.”

A little plaque may also go a long way in women, he says. “Their hearts and arteries are smaller, so if you get just a little plaque build-up in a woman sometimes it can be magnified compared to a big man’s arteries.”

Treatment must be tailored. For women, finding the right treatment can be a challenge, largely because there are few studies to guide those treatment choices. Traditionally, the representation of men in studies of cardiovascular treatment has been as high as 90 percent, says Dr. Lundberg, who encourages her female patients to take part in research when possible.

“If you look at cardiology, cardiology has more research than any other subspecialty in medicine; but if you actually look at the numbers of women in those studies, they are small,” says Allison Dupont, M.D., an interventional cardiologist with Northeast Georgia Heart Center in Gainesville. “So a lot of times we have to kind of extrapolate the information from the studies into women even though they weren’t fairly represented in the studies. Unfortunately, I think that is the case a lot of the time.”

As a result, doctors “really have to work with the woman to find the medication or treatment plan that works best for her and doesn’t have side effects that are unacceptable,” says Dr. Lundberg, who says she has committed her whole career to improving heart disease in women and increasing awareness. “It is not necessarily that we do things differently, but we have to go the extra mile to make sure she gets the right treatment with fewer side effects.

“For example, we have noticed that a lot of women are sensitive to different medications. Sometimes they feel like they are swelling, and sometimes they are feeling like they are feeling foggy or depressed or tired. Particularly with cholesterol medications, a lot of women say they have leg pain or groin pain.”

Women also tend to have more problems with bleeding, says Dr. Dupont. Therefore, the low-dose aspirin (an anticoagulant) routinely prescribed to men is not always an appropriate option for women, she says. “There have been recent data that the benefits of aspirin may not outweigh the risks, depending on what the cardiovascular risk factors are, so we have to administer aspirin on a case-by-case basis – who’s appropriate, who’s not.”

Women’s generally smaller body size is also a factor when prescribing treatment. Because many cardiac medications are based on the patient’s body weight, doctors often need to prescribe lower doses for women. Because their blood vessels are generally smaller than men’s, smaller catheters and stints may also be needed for catheter-based treatments in women, says Dr. Dupont. 

Increasing Awareness, Improving Lives

Dr. Lundberg and others hope a better understanding of treatments for women will emerge as more women get involved in research and the public and health professionals alike become more aware of heart disease differences in men and women – and the simple fact that heart disease can and does affect women as well as men.

Since 2007, Dr. Lundberg has been involved in organizing continuing medical education programs to educate physicians about heart disease in women. Emory’s ninth annual Women and Heart Disease conference, to take place next summer, will attract physicians from throughout the U.S. who have a special interest in women and heart disease, she says.

But much of the education work her group does is targeted at women themselves. “We have worked with garden clubs, book clubs, junior leagues, Daughters of the American Revolution, a million different Bible studies, church groups, embroidery clubs and Kiwanis about the risk factors for heart disease and what you can do to reduce their risk,” she says.

Perhaps the most important thing women can do is to know their numbers, says Dr. Mobasseri. “Whether a woman is having symptoms or not, she should know her numbers – what are her cholesterol numbers? What are her blood pressure numbers? What is her fasting blood sugar number? The other thing is to know her family history – did a first-degree female relative have a heart attack before her mid-60s, or did a first-degree male relative have a heart attack before age 55?”

The next important step is screening. Cardiovascular screening programs such as those offered by Piedmont and Emory Healthcare are not only helping women concerned about heart disease to size up their risk, but more importantly are helping them find effective ways to reduce it.

Eventually, Dr. Lundberg would like to see women take regular heart screening as seriously as they do their mammograms and pap smears. “Heart disease in women is not anywhere near the pink ribbon yet,” says Dr. Lundberg, “but hopefully someday it will be.”

Mending a Broken Heart Valve

Not all heart disease is caused by the build-up of plaque in the arteries or signaled by problems like high blood pressure or high cholesterol – a fact Kyle Young of Sandy Springs knows all too well. When the 61-year-old blogger, artist and advertising exec visited Emory Women’s Heart Center’s comprehensive heart screening, she found that her healthy lifestyle had served her heart and blood vessels well, but something else concerned the center’s clinical director, Gina Price Lundberg, M.D.

The problem, Young says, was a murmur that her doctor had identified but largely dismissed when she was in her 40s. It was caused by a mitral valve that was allowing blood to leak from the heart’s left ventricle to the left atrium. While the condition is generally benign, it can potentially cause serious problems – including heart attack, stroke and sudden death – if the leak is severe. “I never had any problems with it, but it was always in the back of my mind.”

When Dr. Lundberg discovered the leak, she recommended watching it a little bit, Young says. But when Young went back six months later, Dr. Lundberg told her the valve was leakier than it should be and referred her to cardiac surgeon Douglas Murphy, M.D. 

When Young and her husband met with Dr. Murphy, she learned that she was a perfect candidate for robotic surgery, in which small tools attached to a robotic arm are controlled by the surgeon with a computer. 

On Oct. 2, she had the valve repaired in a procedure that required only a few small incisions under her right breast rather than opening her chest, as would have been required just a few short years ago. “Surgery was on a Thursday afternoon, and I was home on Sunday afternoon,” Young says. “Within two weeks, I was feeling normal. I feel so lucky and so blessed to have been able to do it this way.”

Young credits her happy outcome to early screening along with her surgeon’s skill and medical advances. “Going to a cardiologist and having her watch that with me was super helpful, because they could catch it at the right time instead of causing more serious problems later on,” says Young, who has become religious about keeping up with her own checkups after losing her mother to ovarian cancer.

“I think this is just a great example of if you know what is going on with your body, then you can be in partnership with good doctors like this,” Young says. “They will let you know so you can do it at the right time instead of waiting until it is open heart surgery.” – Mary Anne Dunkin

Women and Heart Disease: A Silent Killer

• Heart disease is the No. 1 killer of women and is more deadly than all forms of cancer combined.
• An estimated 43 million women in the U.S. are affected by heart disease.
• Here in Georgia, heart disease and stroke account for 28.2 percent of all female deaths.
• On average, about 27 women die from heart disease and stroke in Georgia each day.
• 154.7 of every 100,000 women die from heart disease in Georgia each year, compared with 143.3 women nationally.
• Ninety percent of women have one or more risk factors for development of heart disease.
• Since 1984, more women than men have died each year from heart disease.
• Only 1 in 5 American women believes that heart disease is her greatest health threat.
• Women comprise only 24 percent of participants in all heart-related studies.

Source: CDC