The heart of the matter

Heart disease is the number-one killer of women-yet it's misdiagnosed with frightening regularity. Here, a woman's guide to the tests and techniques that can save your life

Nancy Beall had a heart attack in 1996-and didn't know it. "I sat up all night long," says the 57 year old Baltimore administrative assistant. "It was like all the muscles in my body felt tired and weak. All my joints hurt. I thought, 'Gosh, maybe I have rheumatoid arthritis!' I had achiness in my arms. But there was nothing that I would call pain."

Early in the morning, she called the cardiologist who had been caring for her for years. "He just happened to be in his office at 7am-standing by the phone. He told me to go straight to the emergency room. He ordered me to tell the attending doctor that I have atypical symptoms and to consult with him while waiting for the results."

Immediately Beall called an ambulance and went to the hospital. The emergency room doctors did two cardiac enzyme tests, which showed no sign of heart attack. They told her she had a flu and wanted to send her home. "But my daughter kept insisting they do the test again-she kept repeating that my symptoms were 'atypical.'" Sure enough, the third enzyme test showed that she had really had a heart attack.

"It turned out that three of my four heart arteries were 99% occluded." Beall's life was saved by an immediate quadruple bypass.

Like the ER doctors, many people still think of heart attacks as a man's problem. The truth is that heart disease kills more women every year than all forms of cancer, chronic lung disease, pneumonia, diabetes, accidents, and AIDS combined. That's more than half a million women.

And it's not just women who underestimate their risk. Even some doctors still think of heart disease as primarily a man's problem. Studies have found that doctors provide women with less testing, less follow-up, less treatment, and less surgery.

That may partly explain why, once heart disease does strike, it's far deadlier for women. Women are more than 11/2 times as likely to die within a year of their first heart attack than are men.

Sharing the latest information about women and heart disease-and what you can do about it-has become one of our main missions here at Prevention. Here is what women need to know about the risk factors, symptoms, new testing devices, and an important new link between heart disease and depression.

Diagnosing heart disease
Great technology for diagnosing heart disease in men has been around for a long time. One test is the treadmill stress test, when an ECG (electrocardiogram) is performed continuously during exercise. This test works fine for men, but in women it produces false positives (indicating that there is a heart problem when there really isn't) more than a third of the time and false negatives (indicating no problem when there really is one) about a fourth of the time.

"Women's survival was being harmed," says D. Douglas Miller, MD, professor of internal medicine and medical director of the Cardiac Stress Laboratory at St. Louis University. Some women who really didn't have heart disease were sent on for unnecessary and invasive tests. Or, some doctors decided to ignore the stress ECG results that showed a problem, betting that the woman was really fine and the machine was wrong. Studies show that after a positive ECG, women are not as likely as men to be followed up with subsequent testing.

Over the past 5 to 10 years, a great deal of effort has been directed toward gender-equivalent testing. "We're now at a point where equivalence is virtually achieved," says Dr. Miller.

The two most accurate new techniques involve imaging. "Whenever possible, these are the tests that a woman should ask for," says Rita Redberg, MD, associate professor of medicine at the University of California in San Francisco, and a member of the American Heart Association Council on Clinical Cardiology.

The first of these new imaging techniques involves having a patient walk on a treadmill, then injecting a radioactive isotope (known as technetium 99 sestamibi) into the bloodstream, which allows special scanners to track the blood flow through the heart. Another option is the stress echocardiogram test. Cardiologist and Prevention advisor Marianne Legato, MD, prefers it because there's no injection, it's accurate, sensitive, and less expensive, and it doesn't take as long as the technetium test.

Not all imaging tests, however, are as good. A far less accurate option is the thallium 201 radioisotope test, which was developed for men but doesn't work as well in women.

Who should get tested? Our experts agree that the stress echocardiogram or technetium tests are usually not necessary for women before menopause who have no risk factors for heart disease. (See "Reducing Your Risk: What Every Woman Must Know," p 106.)

Women with symptoms or a strong risk factor should get tested, Dr. Legato explains. "I reserve the tests for women who are of some concern for heart disease risk-perhaps they have a new pain, they smoke, they're sedentary, they have a family history of diabetes, or they have diabetes." She recommends testing at least annually for women with symptoms. If you're going to be tested, Dr. Miller says, it's a good idea to find out what kind.

If stress ECG or thallium imaging are your only choices, they're better than nothing-but make sure you follow up with your doctor and ask for retesting if the first test suggests there's a problem.

Women's symptoms: Different, but just as deadly
What does a heart attack feel like?

For men, it's often the classic chest-clutching pain, tightness, or heaviness in the chest, usually accompanied by shortness of breath or sweating.

For women, a heart attack can be competely different. Women may experience little or no chest pain, says cardiologist Roy Ziegelstein, MD, deputy chairman of the department of medicine at the Johns Hopkins Bayview Medical Center in Baltimore. Because the symptoms may be so unlike a typical male heart attack, female symptoms may be described as atypical.

During a heart attack, women often experience shortness of breath or difficulty breathing and may even have pain or weakness in the shoulder, arms, or all over the body. Women are more likely than men to experience what feels like nausea, which is not relieved by antacids or burping. There may even be vomiting. The symptoms are more likely to occur when they're resting, or during mental stress or physical exercise. Women are also likely to experience fatigue. "Not, 'I fall asleep at 5 pm every night' fatigue," Dr. Ziegelstein explains, "but feeling completely wiped out." Dr. Ziegelstein also cites "a general sense of being unwell-that something really wrong is going on."

In women, atypical symptoms may come and go, signifying angina (a temporary lack of oxygen to the heart, which can be a warning sign of a future heart attack). When they occur at the beginning of a heart attack, symptoms usually don't go away-and they can become worse as minutes or hours pass.

Time is muscle: What to do
Assume you're experiencing some of these feelings-say, extreme exhaustion, shoulder and arm pain, fatigue. Something's wrong. Could be flu or a heart attack. How can you tell?

"You can't," says Irving Kron, MD, chief of cardiothoracic surgery at the University of Virginia Medical Center in Charlottesville, and vice chair of the American Heart Association Council on Cardiovascular Surgery. "You have something that gets you nervous? Get it checked out."

And do it fast. "Time is muscle, " says Dr. Miller. Don't delay. Here's what

to do:

Call your doctor. If you can't reach your doctor, make sure you let the person on the other end know that you believe it's a medical emergency.
Take an aspirin. "Chewing a 325-milligram aspirin in the early stages of a heart attack has been shown to improve the rate of survival in men and women," says Dr. Miller.
Head for the emergency room if the symptoms are extreme and have the medical staff or a family member alert your physician.
Don't worry about your potential embarrassment if you're wrong and really do have the flu. Studies show that women tend to delay much longer than men before showing up at a hospital with a heart attack-as much as four hours longer. "Women and men both have to be willing to feel foolish," says Dr. Kron. "Your chances of surviving, if it is a heart attack, are much better if you're at the hospital than if you're at home wondering."

And when you're describing symptoms to any doctor, be as specific as possible, adds Dr. Legato. "Don't say, 'I have a funny feeling.' Say, 'I have chest discomfort when I am upset. It is a burning pain that goes to my neck and shoulders.' "

Depression: Women must pay attention
For both men and women, says Prevention advisor Redford Williams, MD, professor of psychiatry and director of the Behavioral Medicine Research Center at Duke in Durham, NC, the latest studies link three psychosocial risk factors to a higher risk and worse prognosis for heart disease. They are hostility, social isolation, and depression.

As Dr. Williams explains, men are more likely to have hostility and less likely to have social support. Women tend to have more social support and less hostility-but they're twice as likely to experience depression.

Could depression be one factor explaining why heart disease kills as many women as men? Nancy Frasure-Smith, PhD, associate professor of psychiatry and nursing at Montreal University, tracked 613 men and 283 women who'd had heart attacks. "We found that people who were depressed-men or women-were three to four times more likely to die of cardiac causes. That makes depression as dangerous to the heart as traditional risk factors like high blood pressure or smoking."

How might depression harm the heart? Dr. Ziegelstein, who did a similar study of depression and mortality in more than 200 male and female heart attack patients, offers some theories.

"We found that patients who were depressed had lower adherence to a risk-reduction program," says Dr. Ziegelstein. "Depressed people often lose interest in helping themselves." Another possible explanation, says Dr. Ziegelstein, is a link between the heart and the brain. "The damaging processes may be tied to the level of serotonin in the brain, which may make them more apt to develop a fatal rhythm abnormality."

Whatever the cause, our experts agreed, research suggests pervasive sadness after a heart attack should be addressed and treated promptly.

"A lot of people think that very mild depression after a heart attack is perfectly normal and will go away by itself," says Dr. Ziegelstein. "And in many instances, they're correct. But if it doesn't, it should be cause for concern."

In particular, alarms should go off if the depression is very deep or lasts longer than a month. "Even milder forms of sadness that go on for longer than a month after a heart attack need attention," says Dr. Ziegelstein.

He notes that, in some cases, mild depression could be a reaction to medication, and the patient may need the doctor to make an adjustment. (Never stop taking heart medication without consulting your physician.) Or it may be that the person needs additional psychological and emotional help. It's critical to raise the issue with your doctor. "And if the doctor doesn't respond," says Dr. Ziegelstein, " get a new doctor or ask for a referral to a psychiatrist or a psychologist."

What are the best treatments for depression after heart attack? The experts we interviewed all cited one powerful weapon that is available in virtually every hospital in the country: The cardiac rehabilitation group.

Barbara Riegel, DNSc, a cardiovascular researcher and associate professor of nursing at the San Diego State University School of Nursing, notes, "Good cardiac rehabilitation groups include a lot of components: exercise, useful information classes, and emotional support." Some groups offer other healing therapies, she notes. "They may bring in components of meditation, stress reduction, and behavioral psychology."

If a group isn't available, there are other ways, says Dr. Riegel. "Activate your social support system-just be around other people." (There are also some wonderful nationally based support groups for heart patients and for anyone with depression. See "Resources for Heart Healing," p 105.)

Individual counseling and cognitive and behavioral therapy, which are well proven to combat depression in healthy people, may be an appropriate route for heart patients.

Antidepressant medications for heart patients are more controversial. "Some patients would benefit from antidepressant medication," says Dr. Ziegelstein. "But someone who has had a heart attack is on a lot of other medications, and there are concerns about drug interactions, as well as toxicity to damaged hearts. There isn't enough research to be sure." Ideally, a heart patient on antidepressants should be under the care of (or in consultation with) an experienced psychiatrist or psychopharmacologist.

What about depression in women who don't have heart disease? Can dealing with depression reduce their chances of ever getting heart disease? Dr. Legato is convinced that the answer is "yes." "All my patients have reported, 'I was so stressed the month before my heart attack.' My experience is that the kind of emotional pain people who develop heart disease are suffering is the kind for which they have no answer, no possible escape."

To ease the pain, Dr. Legato says, everyone should seek out a confidante, whether it's a doctor, friend, or relative. "Everyone needs someone to whom they can lay out their problems-many times just verbalizing will begin a train of thought that produces a solution."

Resources for Heart Healing
Mended Hearts. A national organization with more than 260 chapters across the US offering information and support for people who have heart disease, as well as families and friends. Find the nearest chapter of Mended Hearts through the American Heart Association toll-free hotline: 800-AHA-USA1 (242-8721). Web site:

Depressed Anonymous. An international 12-step organization inspired by a woman who suffered from heart disease and depression. Offers local support groups for depression. For free information, call 502-569-1989; send a SASE to Depressed Anonymous, PO Box 17471, Louisville, KY 40217; or e-mail:

Emotions Anonymous. An international organization with more than 1,000 chapters. Fellowship for people experiencing emotional difficulties. Uses the 12-step program sharing experience, strength, and hopes, in order to improve emotional health. Correspondence program for those who cannot attend meetings. Contact: Emotions Anonymous, PO Box 4245, St. Paul, MN 55104-0245. Call 612-647-9712.

PHOTO (COLOR): Get heart smart: Know the risk factors, symptoms, and diagnostic tests that are unique to women.

PHOTO (COLOR): First pegged as the flu, Nancy Beall's heart attack was discovered only after she insisted they repeat a key test.


By Cathy Perlmutter with Laura Goldstein

Are you at risk for a heart attack? For most Americans, the answer depends on their sex. Ask a man, and most likely he'll recognize that he's at risk. What about women? Do they know about their risk of heart disease? It doesn't appear so, according to this month's Prevention/NBC Today-Weekend Edition National Survey.*

In fact, women are dangerously underestimating the real risk to their health.

65% of women did not know that heart disease is the #1 killer of US women.
51% of women said it was unlikely they'd ever have a heart attack.
42% of women age 50 and older think their risk of a heart attack is lower than a man's at that same age.
In fact, beginning at menopause, a woman's rate of heart disease slowly increases until age 75, when it's the same as a man's.

In addition, most women still do not realize that heart disease is a much greater threat to their health than breast cancer.

Only 33% know that their risk of dying from a heart attack is greater than their risk of dying from breast cancer. In reality, it's five times greater!

Are women aware that their symptoms of a heart attack are different from men's?

59% of women think the symptoms are the same for men and women.

To find out more about heart disease risk factors-for men and women-turn to page 100.

* Results are based on telephone interviews with a nationally representative sample of 1,001adults age 18 or older, conducted from November 19 to 23, 1997. Margin of error: +\- 3.0 percentage points.


"The risk factors in women are pretty much the same as they are in men," says John C. LaRosa, MD, chancellor, Tulane University Medical Center in New Orleans, and a member of the American Heart Association Risk Factors Task Force. "But there are some subtle differences." It's important to know what they are. Here's a review of the major heart disease risk factors-and what you can do about them.

Risk factor:
Smoking. Women who smoke heavily increase their heart disease risk two to four times.

What to do: Quit. It works. After smoking cessation, risk in both women and men tumbles within months, and within three to five years is as low as the risk for nonsmokers.

High cholesterol. For men or women with total cholesterol below 150, it is very difficult to get heart disease. More than 150, either men or women are more susceptible-and the higher it goes, the more susceptible they are. But important differences between the genders do exist.

Men can generally use their total cholesterol to tell whether they're at risk. But women need to break the total down and learn their HDL and LDL numbers. Then, they should divide the total by the HDL. The result is called the total/HDL ratio. The goal is to be 4.0 or lower. Anything more than that means an elevated risk of heart disease. (For a complete cholesterol worksheet for women see, "Do Your Heart Good," Prevention, February 1997. Men, see "Your Game Plan for Life," Prevention, April 1996.)

What to do: Regular exercise, and a diet that's low in total fat and animal fats can lower bad LDLs and reduce overall cholesterol. Women under 50 with no risk factors and good readings should have their cholesterol checked every four or five years. Older women, or women with less than optimal cholesterol levels, should have their cholesterol checked annually.

Risk factor:
High blood pressure. For both men and women, target blood pressure should be 130 systolic (top), and 85 diastolic (bottom). If either number is higher, it might mean an increased risk of heart disease.

What to do: Have your blood pressure checked at least every 2 1/2 years. If there's a problem, losing weight, reducing salt, limiting alcohol, and increasing exercise can make a difference. Initial research suggests that for women-as well as men-treating and controlling hypertension can reduce heart disease risk significantly.

Risk factor:
Physical inactivity. Physically active women have a 60% to 75% lower risk of heart disease than inactive women. Possible reasons for this? Exercise not only improves cholesterol, but also may keep blood vessels strong, flexible, and clean.

What to do: Walk 2 miles a day or the equivalent in another form of exercise. If you haven't exercised in the last year, begin slowly with your doctor's okay.

Risk factor:
Diabetes. Regardless of her age, a woman with diabetes has the same risk of heart disease as a man and a risk three to seven times higher than a nondiabetic woman.

What to do: Maintain a healthy weight, stay active, and reduce dietary fat intake to help delay and control diabetes. If you are diabetic, work with your doctor to control heart disease risk factors.

Risk factor:
Waist/hip ratio. Both obesity and a high waist/hip ratio are risk factors for heart disease. A high waist/hip ratio usually signifies too much fat on the abdomen. It's a pattern that doctors call "central obesity." The pattern is more common among men, but for both genders, it's strongly linked to an increased risk of heart disease-regardless of whether the person is overweight. How can you tell if you have a good waist/hip ratio? Get out the tape measure. Here's what to measure:

Waist (inches) a.-----inches
Hip (inches at widest part) b.-----inches
Waist/hip ratio a.----(divided by) b.--- = ---
Target 0.8 or below. Above 0.8, research shows that the risk of heart disease rises steeply in women.

What to do: Lose a little weight. The good news is that it's not so hard to change a waist/hip ratio by losing a little weight. Even 5 pounds lost can make the difference.

Risk factor:
High triglycerides. High triglycerides are more powerful predictors of risk in women than men, especially after women reach age 50. "Triglycerides are not cholesterol, but they're a marker for the same carriers that bring cholesterol to the blood vessel wall," explains Dr. LaRosa. "Anything more than 150 begins to accelerate the uptake of cholesterol into the blood vessel wall. The 200 to 400 range is borderline-there may be some increased risk. More than 400, everyone agrees, is too high," says Dr. LaRosa.

What to do: Weight loss-even as little as 15 pounds around the waist-can reduce triglycerides.

Age. Men's risk of heart attack and stroke soars after age 45. In women, the risk rises when they're about 10 years older. Researchers believe that the gradual drop in estrogen after menopause may be partly responsible. Women well past menopause, especially over 60, are at the greatest risk for heart attack. Past age 60, one in four women, as well as one in four men, will die of heart disease.

In premenopausal women without any major risk factors, the risk of coronary disease is pretty low (unless the woman smokes and takes oral contraceptives together, says Dr. LaRosa. "They increase their risk of coronary disease about 30-fold.) A postmenopausal woman's risk for a coronary event is four times the risk of a premenopausal woman of the same age. But don't feel invincible if you're premenopausal. The disease processes that lead to heart disease start young. Regardless of your age, the sooner you start with prevention and detection, the better.

What to do: While there's not much you can do about your age, there is research suggesting that estrogen replacement therapy (HRT) can significantly reduce postmenopausal women's heart disease risk. It may reduce LDL and increase HDL by 10% to 15%. Of course, there is controversy over the use of HRT, and it's a complex decision that women must make with their doctors. Minimizing all the other risk factors that you have control over-like diet and exercise-can make a big difference.

Risk factor:
Family history and race. A family history of heart disease is even more common in women with coronary heart disease than men. Your risk of heart disease or stroke is higher if a close member had any of these diseases. Race makes a difference too: African-Americans have a higher risk than Caucasian Americans, partly because of a tendency to high blood pressure.

What to do: Adopt heart-healthy habits and get regular and complete checkups. African-Americans, and everyone with a family history, should be particularly vigilant.

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