HEART
February 1, 2000

Coronary Heart Disease in Women

Two common conditions that can produce chest pain and are frequently confused with angina are esophageal reflux disease and panic attacks.
In February of 1999, yet another report, this time in the New England Journal of Medicine, was published, showing that doctors were less likely to refer women, specifically African American women, who had symptoms suggesting coronary heart disease (CHD) for cardiac testing, when compared with white men.

The purpose of this article was not to "show up" doctors as prejudiced but rather to find ways to improve the diagnosis and treatment of heart disease in women and African Americans.

One explanation for these types of findings is that women get coronary heart disease at a later stage of the disease than men but, in the New England Journal study, everything was the same — age, risk factors, and symptoms — except sex and race. Nevertheless, there was a significant difference between the referral rate of black women compared with black men, white men and white women. Let me assure you that the difference was small, about 7%, and these were model patients, not real patients. Still, it indicates that we in the medical profession must be alert and careful and not make assumptions based on race and sex.

There was a significant difference between the referral rate of black women compared with black men, white men and white women.

As for the public — you, the reader, a Gallup poll, conducted in 1995 by the American Medical Women's Association and the American Heart Association, found that 80% of the women surveyed did not know that heart disease is the leading cause of death in American women. Thirty-two per cent of doctors, in the same poll, did not know it either.

The idea that women don't get heart attacks is deeply ingrained in our society. My purpose, in this article, is not just to correct a mistaken impression about the incidence of coronary heart disease in women. It is also to get both doctors and patients to change the way they act because timely diagnosis translates into lives saved and severe disease avoided.

What Is Coronary Heart Disease?
The three main coronary arteries wrap around the heart and supply heart muscle with oxygen and nutrients. Each artery supplies a particular area of the heart and there is very little overlap. This absence of "collateral" or overlapping circulation means that, if one vessel gets blocked, the neighboring artery cannot take up the slack. The heart muscle supplied by the blocked artery, now deprived of nutrients, will die. We call this tissue death a heart attack ("myocardial infarction").

Coronary heart disease is the leading cause of death in men and women in the United States. It can kill you quickly or slowly. It can kill you instantly or in a few hours by triggering fatal arrhythmias (disturbances in heartbeat) or can cause a profound state of shock (very low blood pressure) that cannot be reversed. In a completed heart attack, in which the clot permanently blocks off the artery, the muscle supplied by the blocked vessel dies. It is irreversibly damaged, will never be restored and, eventually, forms a scar.

Because of this missing muscle, the heart loses power. If you lose a significant portion of muscle or have more than one heart attack, the heart cannot do an adequate job pumping and you will develop "heart failure," characterized by weakness, shortness of breath and swelling of the legs and other parts of the body.

These are the two extremes of what can happen with heart attacks. Most people fall somewhere in the middle, making it through with some damage but not enough to cause heart failure.

Treatments That Can Make a Difference
But changes are occurring rapidly in the approach to coronary heart disease, especially in the last 20 years. Today, emergency therapy is directed to limiting or even reversing the damage to the heart muscle and involves a whole series of measures at the time of a heart attack:

Taking aspirin: Aspirin inhibits blood clotting. It may have the effect of loosening the clot occluding the coronary artery or preventing more clot from forming.

"Clot-buster" drugs: Streptokinase and TPA (tissue plasminogen activator), if given, preferably, within two hours after the onset of the heart attack, can actually dissolve the clot — can make the heart attack go away — and the heart muscle, no longer deprived of blood supply, can recover.

PTCA, Percutaneous Transluminal Coronary Angioplasty: The clot is located by taking a picture of the coronary blood vessels, a procedure called coronary angiography. Then a tube is passed through the blocked area and a balloon or other device is used to remove the obstruction mechanically. Sometimes a stent, a rigid tube, is placed in the narrowed area to keep it open.

CABG, Coronary Artery Bypass Grafting: In this type of cardiac surgery, a piece of blood vessel, taken from another part of the body, is sewn in place to make a detour around the occluded area in the artery.

Both PTCA and CABG can be done on an emergency basis for an acute heart attack or on an elective basis when narrowed arteries are found but a heart attack has not yet occurred.

If these measures are used and successful, it is your responsibility to address all correctable risk factors that caused the heart attack to begin with. That means lowering elevated cholesterol or blood pressure, controlling diabetes and stopping cigarette smoking.3 If you are on hormone replacement therapy, you should continue it because female hormones have beneficial effects on the cholesterol and other blood fats and direct effects on the blood vessels.4

How You Can Prevent Coronary Artery Disease
I have given you a pretty dramatic illustration of all the measures taken in the event of a heart attack. Better yet is preventing the heart attack from occurring in the first place. You can work on two fronts:
  1. prevent coronary heart disease through diet and exercise
  2. take steps to ensure early detection.

Many components of the typical American life style will lead to CHD in both men and women:
  • Our diet: high fat, high cholesterol, low fiber
  • Sedentary lifestyle
  • Obesity, which is increasing in prevalence
  • High blood pressure and diabetes, which are both more common in obesity.

In women, the level of HDL ("the good cholesterol") is the most important consideration. The National Cholesterol Education Project (NCEP II) guidelines define an HDL of less than 35mg/dL as a risk factor for CHD. While appropriate for men, this value is too low for women. A woman should do everything possible to make sure her HDL level stays above 45 mg. The level of HDL cholesterol is genetically determined and difficult to influence. The only lifestyle change that is effective is exercise. Some of the cholesterol lowering medications, the statins and niacin, can increase HDL.

High blood pressure is another factor to which women must pay special attention. It is very common among women, especially as they age and increases dramatically after menopause. Oral contraceptives are associated with an increase in blood pressure, especially higher dose formulations, and are greater risks in women over the age of 35. Women who develop elevated blood pressure while taking oral contraceptives should discontinue them.

A woman should do everything possible to make sure her HDL level stays above 45 mg. The level of HDL cholesterol is genetically determined and difficult to influence.

Though Americans are smoking less than ever, we are not yet smoke free. If you are a smoker, read my article on Tobacco and Women, and get some help to quit. Smoking is a major risk factor for CHD and a precipitator of heart attacks.

One risk factor you can't change is your family history. If there are a lot of heart attacks, especially at an early age, in your family then you have no choice except to develop a really healthy lifestyle to reduce your risk.

Early Detection
For people who don't have the advantage of youth or exemplary health behavior through the years, we have to talk about early detection.

That's where the New England Journal of Medicine article I told you about comes in. The people depicted were not having out-and-out heart attacks. They were having symptoms suggestive of coronary heart disease (CHD). The challenge to the doctors tested was to pick up on those symptoms and order the right tests to detect the CHD, the "heart attack waiting to happen," so to speak. We know that the doctors, for women and African Americans, were less likely to find and react to these subtle symptoms.

Two very common conditions that can produce chest pain and are frequently confused with angina are esophageal reflux disease and panic attacks.

The symptoms the patients had were suggestive of "angina pectoris" (pain of the chest), or angina, a medical term for heart pain due to a decrease in blood supply. In its most typical form, it is in the middle of the chest. It can feel like a pressure, rather than a pain, and it usually occurs with exertion and goes away when you stop the activity and rest. Not everyone has this typical angina. Some folks note pain in the shoulder or the jaw. Others feel profoundly weak or short of breath. Others can develop nausea or abdominal pain. Women often have this "atypical angina," which can be interpreted as something else.

Panic Attacks and Heartburn
Two very common conditions that can produce chest pain and are frequently confused with angina are esophageal reflux disease and panic attacks. In esophageal reflux, the stomach contents rise up into the esophagus (food pipe) and cause pain and also heartburn. Panic attacks are more likely to occur in a younger person, who experiences chest pain and shortness of breath, as well as a great deal of anxiety.

Of course it can work the other way. People with heart pain can be told they are having reflux or a panic attack, when they are really having heart symptoms.

What will happen if your doctor suspects that your chest pain or other symptoms are angina? You would likely be offered a "stress test," a procedure that examines the heart function during and after exertion, looking for clues to poor blood supply. If you had very severe symptoms, but not a heart attack, you would be offered a coronary angiogram, during which a tube is passed through the arterial system to your heart. Dye is injected into coronary arteries and the vessels are "lighted up" and blockages or partial blockages can be seen. If a significant blockage is detected in a critical vessel, you may be advised to have PTCA to clear out the blockage through a tube or to have surgery, CABG, to bypass the obstruction. The net result is that you don't get a heart attack.

If you have experienced any of the early symptoms of possible coronary artery disease — unexplained shortness of breath, pain in the chest, arms, neck or jaw, particularly with exercise, talk to your doctor. Tell the doctor about your risk factors. And, do whatever you can to stop smoking, control your blood pressure, lower cholesterol and control diabetes. Women should have a thorough discussion with their physician about the advisability of taking hormone replacement therapy.
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