Disease & Women:
How High Is Your Risk?
Excerpted from The Planned
Parenthood Women's Health Letter, May
1995, Vol. 2, No. 3
Today Americans know that heart disease
strikes both genders. One in nine women
between ages 45 and 64 and one in three
women after that age have some sort of cardiovascular
(heart and blood vessel) disease, according
to the American Heart Association. But even
though older women and men have equally
high risks, women remain underinformed and
Heart attack is the leading cause of death
in American women, claiming 250,000 female
lives annually, which is more than all forms
of cancer. Yet, when the Survival and Ventricular
Enlargement Study investigating team looked
at more than 2,000 male and female heart
patients at 150 hospitals and clinics throughout
the U.S. and Canada, it found that women
are diagnosed less promptly and referred
for further tests less often than men.
This same study showed that women are
less likely than men to receive life-saving
procedures such as clot-busting drugs and
coronary artery bypass surgery than men.
When women are referred for bypass surgery,
they are sicker and at a more symptomatic,
hard-to-treat stage of the illness, according
to a July 1991 New England Journal of
The most distressing fact of all: Women
who have heart attacks are twice as likely
as men to die -- many within the following
Just why are women on the losing end of
Some Claim Gender Bias Increases Women's
"Until recently, heart disease has
been considered a man's disease," explains
Michael Mil ler, M.D., director of preventive
cardiology at the University of Maryland
Medical Center. Most of the research on
coronary artery disease -- the type of heart
problem that leads to most heart attacks--has
been done on men. Women have been thought
to be exempt from risk.
"The stereotype of the overweight,
stressed-out, middle-aged guy keeling over
from a heart attack at work or while shoveling
snow has been viewed as the typical heart
disease patient," says Miller. "The
fact is, women keel over from shoveling
Unfortunately, women's chest pains and
other symptoms have often been ignored or
misdiagnosed and waved off as psychological
symptoms of depression or anxiety, says
Grace Warner, M.D., attending cardiologist
and codirector of the noninvasive laboratory
of cardiac testing at Arizona Heart Institute,
Ageism May Play a Deadly Role
When women are properly diagnosed and
referred, they are not always treated as
aggressively as men, according to Elsa Grace-Giardina,
M.D., director of the Center for Women's
Health at Columbia Presbyterian Medical
Center, in New York City.
A typical male heart patient is in his
40s or 50s, which are considered prime productive
years, says Grace-Giardina. A woman, on
the other hand, is protected before age
50 against heart disease by estrogen. Once
she reaches menopause and loses estrogen,
however, her risk of heart disease is equivalent
to a man's risk. Indeed, one in three women
after 65 is at risk for coronary heart disease.
But by then, a woman may be viewed as past
her prime and treated less aggressively
than a younger man.
Don't Ignore Symptoms
"Women themselves have not taken
symptoms seriously nor seen themselves at
risk for heart attack," adds Grace-Giardina.
Studies show that more than a third of all
heart attacks in women, versus one in four
in men, go unnoticed or unreported by victims.
The fact is that the typical textbook
symptom -- a heavy pressure on the chest
-- may be typical for men but not for women.
Women's symptoms tend to be more subtle.
"If a woman doesn't recognize these
symptoms as a sign of heart problem, she
may not go to the doctor or emergency room,"
says Grace-Giardina. But for maximum effect,
the clot-busting drugs should be administered
within the first four to six hours. If she
does not receive clot-busting drugs, the
heart attack is greater and her full recovery
Many Experts Claim There Is No Gender
The gender notion has recently been challenged
by a study conducted by Daniel B. Mark,
M.D., assistant professor of medicine, division
of cardiology, Duke University Medical Center,
in Durham, North Carolina. Mark looked at
the attitudes of 15 cardiologists who sent
280 men and 130 women for exercise tests
for suspected heart disease.
As with other studies, the men were substantially
more likely than women to receive follow-up
tests. But the doctors said that differences
in the women's conditions and their advanced
age were the reasons they were not referred
for the cardiac catheterization procedure.
Catheterization is an invasive test that
involves inserting tubes into blood vessels
of the arm and then injecting dye through
the tube so blocked vessels can be seen
on an X-ray. It's considered the gold standard
diagnostic test that determines if surgery
or another treatment is in a patient's future.
To conclude that the poorer outcome of
women with heart disease is due to gender
bias requires looking at men and women of
the same age, Mark states. He goes on to
say in a recent New York Times article that
if you study both men and women who are
otherwise the same with the only difference
being gender, you'll find that the treatments
are very similar.
Standard Tests Aren't Sensitive Enough
Some experts argue that Mark's study is
flawed because the doctors relied on the
standard exercise stress test to diagnose
patients--a test that is notoriously inaccurate
for women. "It's difficult for a 70-year-old
woman to exercise enough on the treadmill
test to get her heart rate up," says
Miller. "As a result, there are a lot
of false positives and false negatives inherent
in this test for women."
Even cardiac catheterization, which is
considered the definitive follow-up test
in heart disease, is not woman-friendly.
In the 1982 Coronary Artery Study, which
looked at more than 8,000 men and women
with chest pain, women were three times
as likely to have "normal" test
results following catheterization.
But a "normal" result does not
necessarily mean a woman is free of heart
disease. Although the test may detect disorders
in the large coronary vessels, it is possible
that this test is unable to detect disorders
of the small blood vessels that may lead
to the heart disease in women, according
to Nanette Wenger, M.D., professor of medicine
in the division of cardiology, Emory University
School of Medicine, in Atlanta.
Women May Need Different Treatments Than
Treatments that may work for men may not
work for women, according to Edward B. Diethrich,
M.D., coauthor of Women and Heart Disease,
and director of the Arizona Heart Institute.
For example, there are no clinical trials
on angioplasty (a procedure that involves
inserting a tiny balloon to break up obstructions
in blocked arteries) in women, Diethrich
says. In the few studies on bypass surgery
in which women were included, he adds, it
appears that women die or suffer serious
complications twice as often as men.
Without dependable research as a guide,
many practitioners proceed with caution.
"If women get aggressive treatment
at all, it is likely to take place under
emergency conditions, when risks are already
greater," writes Diethrich.
Don't Let Gender Equity Become a Buy-In
While doctors are quicker to operate on
mid-life men with heart disease than on
older women with heart disease, it's not
clear if this is due to overtreatment of
men or undertreatment of women, as leading
women's heart disease researcher Elizabeth
Barrett-Connor, M.D., suggested recently.
Before we advocate expensive, risky, and
possibly ineffective aggressive treatments
for women, we need women-based studies that
tell us exactly how best to diagnose and
treat heart disease in females, says Wenger.
The Women's Health Initiative heart disease
study involving 140,000 women, sponsored
by the National Institutes of Health, will
provide answers about hormone replacement
therapy as a treatment option, for example.
That's not enough. We need research on
nondrug, nonmedical therapies like diet
and exercise that will enable older women--who
now survive men but often live out their
days in extremely poor health -- to avoid
being disabled by heart disease, says Diethrich.
How to Get a Reliable Diagnosis
&qu ot;Women need to know that they are
just as likely to be at risk as men,"
says Warner. Although it's less disfiguring
and may strike later in life than the more-dreaded
breast cancer, she says, "heart disease
kills more women than breast cancer, osteoporosis,
domestic violence, and AIDS."
You should seek a complete cardiac work-up
with a doctor who uses an echocardiogram,
if you have symptoms or any of these risk
Diabetes. Increases your
risk of cardiovascular death threefold,
especially when you are aged 35 to 65. The
reason: The protection of estrogen is canceled
out because high sugar levels alter the
artery-clotting "bad" cholesterol
to accelerate hardening of the arteries,
according to Miller.
Family history. The earlier
your parents, brothers, or sisters have
a heart attack or stroke, the higher your
risk, especially if your mother was under
65 or your father was under 55 at the time.
Age. You're at a higher-than-aver
age risk if you are over 51 or in premature
menopause without estrogen replacement.
High blood pressure.
If you have high blood pressure (anything
above 140/90), you're more than three times
as likely to have cardiac disease.
Smoking. Nicotine reduces
estrogen levels and places you at four to
five times greater risk of heart disease
than nonsmokers. If you are over 35, smoke,
and take oral contraceptives, you may have
10 times the risk of heart disease.
Overweight. Even modest
weight gains (about 11 pounds more than
your weight at age 18) are associated with
an important increase in risk of heart disease,
according to a recent Harvard University
study. Also, the bigger your waist in proportion
to your hips, the greater your risk.
HDL levels below 35-45.
The lower your high density lipoproteins
(HDL)--the artery-clearing "good"
cholesterol--the higher your risk of heart
Don't Ignore That Funny Feeling
A woman's first sign of a heart attack
may be a vague fullness or fatigue. Women
are also more prone than men to have sharp
twinges or burning sensations in their mid-chest
that are often thought to be muscle-related
and not heart-disease-related. "Chest
pain related to heart disease is not a pinpoint
pain, but more a general discomfort felt
behind or beneath the sternum," says
Michael Miller, M.D., cardiologist at the
University of Maryland Medical Center. Get
to a doctor or emergency room if you have
any of these other symptoms:
- a vague, uncomfortable pressure, squeezing,
tightness, fullness, or heaviness in the
chest that does not go away in a few minutes
- pain radiating up to the shoulders,
neck, or jaw, or down the arms or back
- dizziness, fainting, sweating, nausea,
new or unusual shortness of breath or
weakness associated with chest discomfort
or when climbing stairs, for example
- chest pain that comes with physical
exertion or emotional stress and eases
- indigestion that does not respond to
- difficult breathing
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