A Woman's Guide to
Being Heart Smart

Q: What is a woman's biggest health risk?
A: Surprisingly, it's cardiovascular disease. Learn how to protect your body's
most vital organ by understanding what makes it tick.

By Lisa James

February 2005

One January morning, I woke at 8 am and decided to quit smoking. At 4 pm, I had a heart attack.

I’d had chest pains for over a month...and was diagnosed with...acid reflux and asthma....I was told...the chest pain I described was probably a pulled muscle from coughing....Now why would anyone think I was a candidate for heart disease? Well they didn’t, I didn’t, and I was.—Susan (Stories from the Heart, WomenHeart)

   Susan has plenty of company. In the United States, 435,000 women suffer heart attacks every year, and many who have undergone the agony of an attack never saw it coming.

Heart attack is the leading killer of American women; more women than men have died of heart disease, stroke and other cardiovascular woes each year since 1984. Eight million women (equivalent: the population of New York City) are living with heart disease, a sizeable number of them under age 45.

It doesn’t have to be this way for you (or a woman you love). The first step is to recognize a heart attack as it’s happening, starting with the fact that women often don’t have what most people think of as a cardiac crisis.

Subtle Signs of Danger

While both men and women can suffer a “classic” heart attack—clutch at chest, keel over—a woman’s distressed heart is more likely to send out much subtler signs: shortness of breath, dizziness, nausea, sweating, back pain, chest discomfort. Even if such symptoms prompt a visit to the emergency room, the medical response may not be rapid enough.

“Seventy percent of men and women having a heart attack have chest pain or discomfort, but is the woman asked if she has chest discomfort?” says Sharonne Hayes, MD, Director of the Women’s Heart Clinic at the Mayo Clinic in Rochester, Minnesota. “Maybe the nausea is the main symptom, maybe the back pain.” If emergency-room personnel don’t make the connection, treatment may not start until the heart is permanently damaged.

ER professionals aren’t the only ones who can misread the signs. Since most cardiac studies have been done on men, information about the dangers faced by female hearts has been slow in filtering down to GPs and gynecologists, the types of conventional doctors women are mostly likely to see on a regular basis. What’s more, a woman’s smaller blood vessels make standard interventions, such as bypass surgery, trickier.

Women themselves often don’t recognize the danger. Due to the protective effects of estrogen—which helps keep blood vessels flexible—women tend to have their first heart attacks after menopause, roughly ten years after men first run into cardiac trouble. That can lead to an it-can’t-happen-to-me attitude, which can obscure the danger posed by family history (a major risk factor for both genders). As Dr. Hayes puts it, “If a woman’s dad had a heart attack, she figures, ‘It’s because he was a guy.’”

Women can be their own worst enemies when it comes to swift heart-attack action; in one study, it took women 20 minutes longer than men to reach the emergency room. Dr. Hayes explains: “Women often say, ‘I had other things to do,’ ‘I didn’t think it was my heart’ and ‘What will the neighbors say if an ambulance shows up?’”

All this means that “women are behind men in terms of gaining the survival advantages in heart disease we’ve made over the past 40 years,” according to Dr. Hayes. The bottom line: Even if you’re not sure it’s a heart attack—especially if symptoms started recently and aren’t going away—get help fast.

Factoring In Your Risk

Better than knowing when you’re having a heart attack is not having one in the first place. That requires understanding the factors, both physical and emotional, that can tie your heart into knots.

The heart-attack stage is set by coronary artery disease, in which the arteries that feed the heart muscle are narrowed by hardened, cholesterol-laden accretions called plaques. The narrowing itself can result in angina, or chest pain, but doesn’t cause an attack directly; that happens when an obstruction—generally a blood clot—becomes trapped in the constricted opening.

“A common misconception is that you are more likely to have a heart attack if you have a 70% blockage,” says Dr. Hayes. “But it if the blockage is stable, you may have less of a risk than someone with a 30% blockage who has other risk factors, such as smoking.”

In fact, tobacco use is the single biggest controllable risk factor for heart disease. Stop smoking (you’re right, it’s tough) and the risk drops; a decade after that last cigarette, your risk is nearly the same as it would have been had you never smoked at all. Another controllable factor, alcohol usage, is more of a two-edged sword: A little may help (particularly the antioxidants found in red wine) but a lot can do serious harm. If you do indulge, stop after one or, at most, two.

It’s not hard to guess two of the other main physical risk factors—those oft-paired evils, poor diet and lack of exercise. For starters, both are the main causes of obesity, including the belly fat that causes the body to take on an apple shape (versus the pear shape produced by fat that adheres to the bottom and thighs). Abdominal fat poses a greater danger because it “is available and anxious to be converted into cholesterol,” according to Linda Ojeda, PhD, author of Her Healthy Heart (Hunter House).

Unhealthy diet and exercise habits are also linked to increases in blood pressure, cholesterol and sugar. Diabetes, which occurs when the body can no longer properly control blood-sugar levels, is especially dangerous to a woman’s heart; researchers have found that women who bear the twin burdens of diabetes and heart disease run a higher risk of developing heart failure, which reduces the heart’s ability to pump enough blood to meet the body’s needs (Circulation 9/7/04). Too much sugar also plays havoc with the blood-vessel linings.

Affairs of the Heart

Stressful emotions, especially those negative feelings women frequently suppress, can also harm blood vessels—and really put a squeeze on a woman’s overall cardiovascular well-being.

Part of the problem is the burden women put on themselves to be everything to everybody and to meet everybody’s needs except their own. “Throughout history, women have felt they are responsible for all matters of the heart; it’s women who write thank-you notes, women who arrange social calendars,” says Christiane Northrup, MD, women’s health expert and author of Mother-

Daughter Wisdom: Creating a Legacy of Physical and Emotional Health (Bantam). “Over time, if you’re consistently taking on more than your share without support, that can lead to anger, resentment and sadness. That in turn leads to depression, and depression itself is an independent risk factor for heart disease”. Stressful feelings also upset the electrical circuitry that controls heartbeat and lead to cravings for starchy, sugary comfort foods, another cardiac hazard.

“Women carry the emotions for the other half of the population, except for anger, which we’re not allowed to feel,” Dr. Northrup says. “The perception women have is that they’re not as valuable as men.”

This may explain the mixed health benefits that come with marriage: Married men tend to outlive single men whether their marriages are happy or not—for a man, just having someone who cooks decent meals and nags about missed doctor visits is sometimes good enough. But the tension and depression that can ensue from a bad marriage tend to affect a woman’s health more profoundly.

Major changes in a relationship, no matter when they occur, can also have harmful effects; Dr. Northrup knows of a previously healthy 90-year-old woman whose cholesterol levels shot up after she started caring for her 75-year-old husband, whose neglected diabetes caused health complications that he refused to deal with.

Making a Cardiac Stand

Everyone’s different, so assess your own heart-disease risks. “We don’t just say, ‘Her cholesterol is 230, we’ll treat her with this drug,’” says Dr. Sharonne Hayes. “You look at the whole gamut of risk—a cholesterol of 200 might be too high in a diabetic who smokes.”

Find out if heart troubles have previously roosted in your family tree. “If you have a family history of heart disease, be more aggressive,” advises Dr. Hayes. “Know your blood pressure, your lipid levels, what a healthy weight is for you.”

It’s especially important to have regular bloodwork done as you go through menopause to pick up the first signs of possible heart problems; these tests should include a check for C-reactive protein (CRP), a marker of inflammation. What about hormone replacement therapy (HRT), since estrogen helps forestall female heart disease? “I don’t think that estrogen should be thought of as a way to prevent heart disease,” says Dr. Northrup. “Hormone replacement in the form of synthetic hormones isn’t going to help anything.”

Healthy eating is the next item on your heart-smart checklist. The old notion that all fat is bad for the heart has gone by the boards; the latest advice is to make sure the fat you consume is unsaturated (as opposed to saturated fats, such as those found in animal products). Make fish, with its healthy omega-3 fats, a regular item on your menu; ALA, another omega-3 fat found in flaxseeds, has been found to reduce the kind of low-level inflammation that riles up blood vessels (Journal of Nutrition 7/04). For cooking, olive oil is a healthy choice.

“The number-one preventive thing you can do is eat a diet with a low glycemic load,” says Dr. Northrup. “Avoid the white foods—white bread, sugar, mashed potatoes—anything that raises blood sugar fast. Not only will high insulin store excess glucose as fat, it creates what’s called glycemic stress—a rapid progression of free-radical damage in the lining of the blood vessels that affects every blood vessel in the body.” Low-glycemic tomatoes, especially if they’re cooked in a little oil, are a particularly smart food choice; Harvard investigators have found that women who dine on tomato-based foods enjoy a drop in heart risk.

Free radicals can be countered with antioxidants, such as vitamins C and E, because, as Dr. Northrup points out, they really do help with that free-radical damage and inflammation. “Women who are genetically predisposed to high homocysteine [a kind of protein] are predisposed to heart disease, but when you take folic acid and B12, you can prevent that.”

Exercise that muscle: Make the most of your healthy diet by supplementing it with a healthy dose of exercise. “Move more,” says Dr. Hayes. “Exercise prevents heart disease, it prevents cancer and you’ll live longer.” Your goal should be at least 30 minutes of aerobic exercise each day; jogging, biking and spa-based cardio workouts (such as spinning) all qualify. If the idea of breaking a sweat gives you the chills, don't worry—even walking will do the trick, as long as you stick with it.

One thing that exercise does is help burn off stress, as do such practices as meditation and prayer. But one of the best ways to defeat stress—particularly that tied to excess expectations— is to project a new attitude: “Get over the idea that you’re supposed to be the big picker-upper for everyone else’s emotions,” Dr. Northrup advises. “It’s good to reach out and help others, as long as you’re not giving from an empty cup—no martyrdom allowed!”

Your adjusted attitude should include an awareness that heart disease isn’t just a guy thing. “People die of heart disease every day, and many of these deaths need not have not happened,” says Dr. Hayes. “Women have to take ownership of this disease.” Learn all you can, and don’t be shy about advocating for women’s heart-health issues.

Women also need to take ownership of their lives: their work, their relationships, their connections with the deeper spiritual truths that nourish their hungering hearts. As Dr. Northrup puts it: “Live wholeheartedly. You have to find things to appreciate every day—that literally opens the blood vessels.” Living a whole life can help keep your heart whole.

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