The prominence of heart attacks in popular culture have increased awareness of their signs and symptoms, but the picture they paint is far from complete.
That’s especially true when it comes to women. Heart problems are depicted as far more commonplace among men than women, and the symptoms shown are generally those experienced by men. But heart disease is still the No. 1 killer among women.
Barb Williams, MD, is part of the Women’s Cardiovascular Center at University Hospitals Harrington Heart & Vascular Institute, and knows all about the true danger cardiovascular disease plays among women – and how that danger can be identified and mitigated.
HealthScene Ohio: Are women more likely than men to overlook the risk of cardiovascular disease?
Dr. Barb Williams: Clinical research has been studying cardiovascular risk in women for more than 25 years. When clinical trials began, only 17 percent of women could identify cardiovascular disease (CVD) as the leading cause of death in women. That number has now increased to 55 percent. This awareness has resulted in a reduction in deaths from CVD in women over the last decade in all categories except for woman under 55. For younger women, death rates are increasing. This result comes from both younger women and the medical system not fully comprehending their risk.
HSO: What, in your experience, accounts for that gap in awareness?
BW: Observational studies in the 1970s and 1980s concluded heart disease was a male disease. Women appeared protected from it. It was concluded that hormones (estrogen) were cardio-protective. This was disproved in the 1990s when clinical trials found that estrogen therapy in post-menopausal woman actually increased the risk of heart disease. Our modern-day guidelines reflect this point. Hormone therapy should never be administered for the primary purpose of reducing cardiovascular risk in post-menopausal women.
HSO: What are some of the more recent developments you’ve encountered in terms of detection and prevention?
BW: Skipping breakfast confers increased CV risk compared to women who ate breakfast. Skipping breakfast has a significant effect on appetite regulation and metabolic efficiency, according to a 2017 study in the Journal of the American College of Cardiology. The body perceives it is in a starvation state when breakfast is skipped. As a result, the body’s metabolic rate is lowered. This makes weight loss difficult.
Early detection of coronary atherosclerosis can be identified with coronary artery calcium scan. This technique uses CT technology to measure coronary calcium. Calcium is a marker for the presence of atherosclerosis. The scan measures the burden of atherosclerosis within the coronary arteries. The score used to risk stratify into low, intermediate and high risk. For low-risk scores (0-99), dietary management and exercise are recommended to keep cardiovascular risk low. For high-risk scores (risk for heart attack is greater than 2 percent per year), acetylsalicylic acid (ASA) and cholesterol medication (statins) are recommended. Intermediate risk needs a personalized approach.
HSO: What are some of the biggest cardiovascular risk factors faced by women?
BW: Traditional risk factors are diabetes, hypertension, high cholesterol, smoking and family history of premature coronary artery disease (CAD), in which a heart attack is suffered by men under 55 or women under 65 years of age. Diabetes carries the greatest risk for developing heart disease; one out of every four women with diabetes will develop CAD.
HSO: How do you go about diagnosing cardiovascular disease? What factors might be caught by early detection?
BW: CVD includes coronary artery disease (the most common), cardiomyopathy (weakness in the heart muscles, pump function is reduced), valvular heart disease and arrhythmias (electrical problems of which atrial fibrillation is the most common). The cardiovascular risk factors that are poorly uncontrolled or undertreated (blood pressure greater than 130/80 mmHg) can progress to the development of CVD, including organ damage from elevated risk or hypertension not well controlled. Research has also identified that women with a history of hypertension or diabetes during pregnancy, as well as women with autoimmune disease (lupus, rheumatoid arthritis, inflammatory bowel disease), have a greater lifetime risk for developing heart disease. This is thought to be from a more prolonged period of inflammation within the blood vessels leading to vessel injury, setting the vessel up for the deposition of cholesterol into the artery wall.
Diagnosis of CVD begins with history, physical examination, electrocardiogram and lab work, including cholesterol, glucose and C reactive protein (CRP). Based on calculated cardiovascular risk, additional testing may include a cardiac stress test, cardiac catheterization or CT angiography. CT angiography is a procedure to image the coronary arteries and is gaining acceptance in individuals without known coronary artery disease.
CRP is a biomarker of inflammation. Clinical trials have shown elevated levels of CRP (inflammation) increase the likelihood of developing CVD. Statin therapy (cholesterol medication) can lower CRP levels.
HSO: How does heart trouble break along ethnic lines in women? What accounts for those differences?
BW: One in three Hispanic and African-American women will develop CVD, while one in four Caucasian women develop it. The increased risk for Hispanic women comes from high rates of diabetes, while, for African-American women, it is from higher rates of hypertension.
HSO: What do survival rates look like for heart attack and heart disease? Are there significant differences in survivability between women and men?
BW: Rates of death from CVD have declined in the last decade by 31 percent. However, CVD still remains the leading cause of death for both men and women. CVD accounts for approximately one of every three deaths. Coronary artery disease alone caused one out of every six deaths.
Women do not fare as well as men when it comes to surviving a heart attack. On average, women are 10 years older than men at the time of their heart attack. Women generally have more cardiovascular risk factors at the time of their heart attacks, such as hypertension, high cholesterol and diabetes. The increase in cardiovascular factors occurs most frequently after menopause. It is important for patients to present to the hospital early when they are experiencing a heart attack. Woman have comparable success rates for target vessel revascularization (percutaneous coronary intervention) as men. Symptoms of a heart attack in women include chest pressure, squeezing or tightness. This discomfort may involve any area of the torso from the lower jaw to the waistline. This includes the neck, upper back, right chest and arm, as well as the stomach area. Shortness of breath with or without chest pain is another symptom of coronary artery disease. Heart attacks can be associated with nausea and cold sweats.
HSO: Are there conditions to which women are more naturally susceptible, such as heart failure?
BW: Women have higher rates of hypertension. Hypertension is a risk factor for congestive heart failure, atrial fibrillation, and strokes. Three conditions more frequently are seen in women, especially as they age.
HSO: What are some of the procedures available for treating cardiovascular disease?
BW: A woman suffering a heart attack will undergo cardiac catheterization, the insertion of a hollow tube into the large blood vessel leading to the heart to measure pressure and blood flow. If a severe disease is found in the major arteries, a coronary angioplasty will be performed. Women who have survived a heart attack but whose left ventricular ejection fraction (a measurement of how much blood is being pumped out of the heart’s left ventricle) remains less than 35 percent – normal being 55 percent or above – are eligible for a defibrillator to reduce their risk of sudden cardiac death.
Women with a history of hypertension who develop atrial fibrillation can be offered an ablation. This is a procedure performed by a cardiac electrophysiologist. The electrophysiologist maps the interior heart, locates the site from which the atrial fibrillation is originating and then uses a tool that places a small burn in the heart muscle, disrupting the conduction of the atrial fibrillation. This stops the arrhythmia, resulting in restoration of the natural rhythm of the heart.
HSO: How significant a role do symptoms play?
BW: Symptoms of CVD should always be evaluated by a doctor. I instruct women that, when the pattern to which they are accustomed changes, it’s time to be evaluated. For example, if vacuuming the living room is now resulting in shortness of breath and this was not occurring three months ago, it is time to be evaluated. The same is true for a highly conditioned woman. She may be able to run for one hour, but now, five to 10 minutes into her exercise, she must slow her pace down because of vague chest discomfort or new fatigue. That means it’s time to be evaluated.
HSO: Is a woman at risk for heart disease likely to see warning signs, or are there early signals that are only likely to be detected by a doctor?
BW: Women need to be aware, the first time they experience chest pain, it could be from a heart attack. Some women never have warning signs; their first episode of chest discomfort is from a heart attack. That is why women should not wait to see a doctor. If symptoms are lasting more than five minutes, they should seek immediate medical attention. I would rather tell a woman her symptoms of chest pain or indigestion have been evaluated and we are not finding a cardiac problem than to have her at home, suffering from a heart attack. The longer one waits to be evaluated during a heart attack, the more cardiac muscle damage results. The more damage, the greater the risk for other cardiac complications including congestive heart failure and sudden cardiac death.
HSO: What efforts are being undertaken at University Hospitals, and in Ohio in general, to raise awareness and advance research?
BW: University Hospitals is a proud supporter of the American Heart Association’s Go Red for Women campaign. This program offers free blood pressure, cholesterol and carotid artery screenings, and also calculates participants’ 10-year cardiovascular risk. In addition, there are cooking and fitness demonstrations. University Hospitals also offers Community Health Promotion programs throughout the year focusing on people at younger ages, working at the family and community level to change health behaviors to prevent cardiovascular disease.
Garth Bishop is a contributing writer. Feedback welcome at feedback@cityscenemediagroup.com.
About the Expert
Barb Williams, MD, of University Hospitals, is board certified in internal and cardiovascular medicine. She completed medical school at the Case Western Reserve University School of Medicine in 1994, her residency in internal medicine at Cleveland Clinic in 1997 and her fellowship in cardiovascular disease at Yale-New Haven Hospital in 2000. Her areas of expertise include women’s cardiovascular health, diagnostic imaging, valve repair, preventive cardiovascular medicine and coronary artery disease. She is a clinical instructor in medicine at the Case Western Reserve University School of Medicine.
