Women and Heart Attacks

"Wow!" thought Danielle Peterson.* "What on earth is going on in my body?" The 49-year-old Manhattan marketing executive was in the middle of a business meeting when -- in her own words "it was as if there was this sudden pressure drop inside me." Soon her left arm began to tingle from numbness and her chest was seized by a gripping pain.

Fearful she was on the verge of a heart attack, she went to see her primary doctor, a pulmonary specialist who had long treated her for asthma. Despite informing him that she was experiencing cardiac symptoms, he kept her waiting an hour and a half while he saw other patients. Then, after monitoring the electrical activity of her heart with an electrocardiogram machine, he brushed off her symptoms as the flu. "Go home and get some rest," he urged.

At 5:45 the following morning Peterson bolted up in bed wracked by pain. "I'm having a heart attack!" she screamed to her husband. He rushed her to the emergency room of a nearby hospital but once again she was greeted by a doctor who didn't believe her. "You've probably got shingles," he tried to convince her. It took nearly half an hour before another physician appeared in the emergency room, instantly recognized the first doctor's error, and raced to administer a clot-busting drug.

Peterson survived -- but the delay in her diagnosis led to irreversible heart damage: Ten percent of the organ's muscle died. The path toward her emotional recovery has also been strewn with obstacles. Terrified of having another heart attack, she sought out a support group of female heart patients who were dealing with the same issues. But neither her cardiologist nor the American Heart Association could track down such a group in all of Manhattan. "Why don't you go to a cancer group?" she was advised.

Peterson's experience would lead one to think heart disease in women is as rare as hen's teeth. In fact, heart disease kills more women than men each year. And everything about Peterson's case -- including her reluctance to be identified by her real name -- is more typical than most women or their doctors realize.

Cardiovascular disease (including strokes) is the number one killer of U.S. women, claiming the lives of nearly 500,000 of them each year -- or more than die from all types of cancer combined, according to the American Heart Association. It's not only women in the U.S. who need to be concerned. A study in the April 7, 2001 issue of the British Medical Journal also reports that women in the United Kingdom also get less heart disease care than men.

Though it's a preventable disease if caught early, that opportunity is all too often lost. The disease's onslaught is invisible, being caused by plaque deposits that silently accumulate in the arteries over a lifetime. Frighteningly, a woman's first clue to the obstruction of her blood vessels may be a full-blown heart attack (or stroke, if the blockage occurs in the brain.). Two-thirds of women who die of a heart attack have no prior symptoms in comparison to only half of men. Though women over 65 are most vulnerable to the disease's encroachment, middle-aged women are scarcely immune. A staggering one in nine U.S. females between 45 and 64 show evidence of coronary artery disease. And make no mistake -- it can fell them in these vital years (though rarely before menopause). Indeed, heart disease kills twice as many woman in that age group as breast cancer -- the disease women dread most.

Black women are especially imperiled. Heart disease is 69 percent more common among them than in white women, and they are more likely to die of a heart attack before menopause. Medical researchers suspect an interplay of genetics and socioeconomic factors contribute to their starkly elevated risk. Yet in spite of these figures, numerous studies show that doctors are less likely to screen women for their risk of heart disease than men, routinely overlook or discount their symptoms, and often treat female patients less aggressively than their male counterparts. Even paramedics have been slow to recognize and treat women in cardiac distress.

When Judy Mindgram, a computer sales representative in Los Angeles, suffered a massive heart attack at age 40, the paramedics who responded to her call hung out in her house for 35 minutes, urging her repeatedly to admit to cocaine use. Then, though she was vomiting and barely conscious, they made her walk to the ambulance. She got to the hospital so late that she went into cardiac arrest and had to twice be jolted back to life.

"We hear these kinds of stories from female patients all the time," bemoans Dr. Nancy Davenport, a cardiologist on the advisory board for women and heart disease at Washington Hospital Center in D.C. "A man with cardiac symptoms is taken seriously -- a woman's likely to be told she's having a panic attack." So how come women aren't up in arms about the disparity in their care? Why aren't they marching on Washington to focus public attention on female heart disease as they have for breast cancer? Why no special ribbons or funding drives for the number one killer of women?

"Very simply, few women see heart disease as part of the spectrum of illnesses they might get," says Dr. Debra Judelson, medical director of the Women's Cardiovascular Institute of Southern California. "Say the words 'heart disease' and most women think of their husbands -- not themselves." Indeed, a 1995 Gallup poll found that four out of five women 45 to 75 were not aware that heart disease is the leading cause of death in their age group. (Most respondents mistakenly thought cancer, notably breast cancer, was more likely to kill them.) Worse, a surprising number of doctors are just as ignorant. In the same Gallup poll, one-third of primary care physicians also did not know that cardiovascular disease was the biggest killer of women. Another survey of primary care doctors, conducted more recently by the Washington Hospital Center in D.C., revealed that 60 percent felt less skilled at diagnosing heart disease in women than men. Indeed, two-thirds of the physicians surveyed erroneously reported that the warning signs and detection of heart disease are the same in both sexes. In reality, women with coronary artery disease vary from men in their symptoms, diagnosis and response to therapy. Yet all too often they are -- in the words of experts on women's heart care -- treated like "little men."

This glaring gap in knowledge is particularly ironic, for although men on average develop heart disease ten years earlier than women, more women now die of it primarily because heart disease is most prevalent in the latter decades of life. Hence women, with their sizable longevity advantage over men, ultimately live long enough to succumb to the disease in greater numbers.

To shatter the myth that cardiovascular disease is largely a male affliction, the American Heart Association launched a major three-year campaign aimed at educating women and their doctors. But so far it lacks the clout and luster of the breast cancer movement because -- in the parlance of Madison Avenue, the issue just isn't "sexy." Explains Dr. Marianne Legato, professor of clinical medicine and director of the Partnership for Women's Health at Columbia University in New York City, "Women value their breasts, beauty and reproductive capacity foremost because society has mainly appreciated them for bearing and raising children. That makes very good sense from an evolutionary perspective but it's crazy in the context of women now spending one third of their life in their menopausal years."

Still another challenge in awakening women to their biggest health threat is that female victims of heart disease may themselves be reluctant to come forward. One reason is that they may feel partly to blame for their illness, since several of its risk factors -- notably smoking, a high-fat diet and a sedentary lifestyle -- are viewed as controllable. The afflicted may also fear that it earmarks them as old and sickly. "It's bad for business," says one middle-aged victim, explaining her desire for anonymity. "When people know you have heart disease they think of you as super-fragile and won't tell you unpleasant news straight up," explains another victim who declined identification. "I don't want to be treated with kid gloves."

Educational efforts have been further thwarted by the lack of a charismatic celebrity spokesperson to draw attention to the issue. While the breast cancer movement can point to such high-visibility victims as Betty Ford, Olivia Newton John, and the late Linda McCartney, the faces of heart disease are nowhere to be seen.

"Believe me they're around," says cardiologist Judelson. "Being based in Beverly Hills, I know of many famous women with heart disease -- but none want to be spokespersons." Why? Due to the perceived age stigma, she reports, and because screen luminaries will literally be uninsurable by the studios. At the astronomical cost of today's movies, Judelson explains, producers want to make sure a star doesn't drop dead of a heart attack before a picture is completed. "It's different for celebrities with breast cancer," she insists. "They're still insurable because they're not likely to die suddenly."

Whatever the reasons for women's blindness to the peril of heart disease, the ignorance of numerous doctors clearly isn't helping matters. Why are so many of them still lagging in their understanding of female heart problems?

Training practices of the past are a big part of the problem, according to Dr. Susan Blumenthal, assistant surgeon general in the federal government's Department of Health and Human Services. "When I went to medical school we only learned about heart disease in the 180- pound male," says Blumenthal. Until recently, she further points out, women were not viewed as appropriate research subjects because they have menstrual cycles and might get pregnant. As a result, drugs and procedures for heart disease were optimized for men. It wasn't until 1993 that Congress set about rectifying this oversight by passing a law requiring women to be included in all clinical trials. Such studies are just now yielding results, bringing to light numerous sex differences in heart disease.

Women have smaller hearts, weighing 50 to 100 grams less than men's. Their hearts also beat faster, and their arteries are finer and more fragile. In addition, the interplay of their anatomy and hormones influences their cardiovascular systems in unique ways. These differences affect virtually all aspects of their care.

One surprise is that women don't always suffer from the classic male symptom of crushing chest pain. About 15 to 20 percent of women having a heart attack specifically complain of pain high in the abdomen, shortness of breath, and profuse sweating. Preceding or during an attack women may also complain of chronic fatigue, indigestion, pain in the back or jaw, and heart palpitations. Such diffuse symptoms can easily masquerade as run-of-the-mill problems like heartburn or a favorite medical culprit -- mental stress.

Sex discrimination -- namely a tendency for doctors to see women as more emotional and less trustworthy barometers of their own health -- may further contribute to misdiagnoses. In this respect, female doctors may be just as guilty as their male colleagues -- or so suggests a study of doctors in training conducted last year by psychologist Gabrielle Chiaramonte of State University of New York, Stonybrook.

In the study, male and female medical students were given case reports of a 48-year-old man and a 58-year-old women (by age, at equal risk for heart disease). Both patients had identical cardiac symptoms and half of each of their profiles mentioned that the patient was experiencing stress from the denial of a job promotion. The addition of anxiety to a case history brought out a strong gender bias in diagnosis. By in large, both male and female medical students referred the anxious male patient to a cardiologist. In contrast, the majority of the medical students sent the anxious female patient with exactly the same symptoms to a psychologist.

Gender also plays an important role in the evaluation of cardiac risk factors. Early menopause, by depriving the body of estrogen's heart protective benefits, is an obvious example of a risk factor unique to women. Other major risk factors -- elevated cholesterol, smoking, high blood pressure, diabetes and obesity -- are shared by the sexes but vary between them in subtle and sometimes dramatic ways. For a woman, total cholesterol is not as strong an indicator of heart disease as for a man. What counts most is the level of her HDL or good type of cholesterol, says Dr. Mary Ann Malloy, a cardiologist at Loyola University Medical Center in Chicago. Yet until recently national guidelines defined an unhealthy HDL level for women as 35 or under. "That's appropriate for a male," say Malloy, "but ideally it should be over 45 for a female -- the higher the better."

Smoking, everyone knows, is bad for the heart - but mounting clinical evidence points to worse consequences for female smokers than male ones. Women who smoke on average suffer heart attacks fifteen years earlier than those who don't, whereas male smokers typically have heart attacks seven years earlier.

Diabetes has also emerged as a much stronger cardiovascular risk factor for women, contributing to as many as one in five post- menopausal heart attacks. And though excess weight has long been linked to heart disease in both sexes, when it accumulates around the waist, females are especially prone to a cluster of conditions that damage the cardiovascular system, warns Dr. Harriette Mogul, director of the menopause program at New York Medical College in Valhalla. This group of conditions includes high blood pressure, low LDL, and insulin resistance (a precursor to diabetes and a contributor to plaque formation).

Clearly, an awareness of predisposing factors holds the key to catching a woman's disease early, before she keels over from a heart attack. But many doctors aren't even screening their female patients for the most salient risk factors, so entrenched is in the view that heart disease is a male problem.

Nancy Loving, a 51-year-old public relations executive in Washington, D.C., learned this the hard way. "No one ever told me I was at risk for heart disease -- not my gynecologist, not my general practitioner, not my internist," she says. Yet she'd been a smoker most of her life, was a couch potato, carried 25 excess pounds, had a family history of heart disease, and as she eventually discovered, her cholesterol was a sky-high 313. Her first warning that she was at risk was a heart attack at age 48. That jolt spurred her into action. Loving joined a health club, lost the excess weight, quit cigarettes and through a combination of drugs and dietary changes has lowered her cholesterol by over 100 points. "I've never felt better," she reports. "But it didn't have to take a heart attack to make me shape up."

Even if a doctor does suspect coronary artery disease in a woman, diagnostic testing is further complicated by gender differences. The cheapest and most widely used screening tool, the treadmill stress test, is less accurate for women. Roughly 25 percent have false positives on the test, as compared to 10 percent of men. Consequently, if the test indicates a woman has heart disease, doctors are often inclined to brush off the result as an error and not pursue it any further, reports Dr. Elizabeth Ross, attending cardiologist at the Washington Hospital Center and author of the book Healing and the Female Heart (1996).

More accurate exams for women, says Ross, are the stress echocardiogram, which uses ultrasound to image the heart, and a thallium scan or nucleolite test, which maps the organ using radioactive particles. Most accurate of all, but also a step up in price, is angiography -- the use of a thin tube that is snaked through the arteries to detect blockages. The American Heart Association holds this test as a gold standard for diagnosing heart disease in both sexes.

Not only do women receive inferior diagnostic care, but they are less likely to be treated aggressively once coronary disease is detected. Fewer women than men get clot busting drugs, bypass surgery or balloon angioplasty -- the three main techniques for restoring blood flow to ailing hearts. The fact that the average woman tends to be older and frailer by the time she develops heart disease is a major factor behind this disparity. The more aged and sickly a patient is, explains Ross, the greater the danger posed by such invasive procedures and the fewer years of life she stands to gain.

But there are other reasons as well why women are undertreated. In the case of clot-busting drugs, women often arrive at an emergency room too late to benefit from these compounds, which must be administered within six to eight hours of a heart attack. Just why women take longer than men to reach a hospital is not clear, but a recent Scottish study published last year in the journal Circulation provides a fascinating clue. Women having heart attacks often prefer to call their physicians first, the researchers reported. Men race straight to the emergency room.

To Ross, this suggests women probably have more trouble putting a finger on what's going on since their symptoms can be less specific and harder to interpret than men's. Also, she adds, women are sensitized to being labeled hypochondriacs or neurotic. "They don't want to appear to be making too big a fuss about something that might turn out to be frivolous."

That concern, justified as it may be, is costing them dearly. Because women arrive later and sicker for treatment, they are more likely than men to need emergency bypass surgery, whose mortality rate is far higher than an operation that has been carefully planned in advance.

Still another reason why women receive less aggressive treatment is that they themselves decline it. "Men take the attitude, 'I'm broken, now fix me," reports Dr. Jay Cohn, a cardiologist at the University of Minnesota Medical School, "whereas women often prefer prescription drugs to avoid surgery. They see it as a gentler approach." Ross concurs, noting that many women will tolerate severely restrictive lives rather than submit to an invasive procedure. But the "gentler" route women chose, she says, may also stem from a failure to appreciate their peril. "They can't believe they'll die of heart disease -- a man yes, but not them."

Owing to all these deficiencies in the diagnosis and treatment of women, their disease prognosis is often worse than a man's. A woman is more likely than a man to die of a heart attack, suffer congestive heart failure, stroke or have a second heart attack.

What can women do to prevent heart disease and improve their care? First, they need to recognize their risk and be alert to the symptoms. Just as important, women should get an annual physical and be thoroughly screened for risk factors by a doctor sensitive to how heart disease affects them. "Don't entrust your heart care to a gynecologist," advises Columbia's Legato. "That's like a man leaving his primary care to his sport's physician." In her opinion, it's best to chose a doctor who is either board certified in internal medicine or family practice. (A general practitioner, she cautions, is not a good choice unless he or she is certified in one of those specialties.)

A proper check up, says Legato, should not only include a complete blood work up (with a woman's cholesterol broken down into HDL, LDL and triglyceride fragments), but her heart's electrical activity should be analyzed with an EKG machine. Though far from a perfect instrument, it's useful at detecting abnormalities that can signal arterial blockages and other heart problems, reports Legato. If her EKG suggests potential heart disease, or if she has two or more risk factors (especially if one of her risk factors is a low-HDL score) a woman should be referred to a cardiologist for further evaluation.

Good heart care should also be proactive, Legato emphasizes. A woman should be exploring with her physician specific steps for lowering her personal danger profile-from exercise and other lifestyle changes to cholesterol-lowering drugs. A 2004 report by the American Heart Association strongly recommends that all women who are at high-risk (more than 20 percent chance) for having a heart attack take cholesterol-lowering drugs, preferably statins, even if their LDL is below 100. To find out if you are at low-, intermediate-, or high-risk for a heart attack, use the American Heart Association's risk assessment tool. Although past research has shown that hormone replacement therapy (HRT) may improve the cholesterol profile of menopausal women, keeping arteries more youthful and supple and preventing new plaque formation, new guidelines issued by the National Heart, Lung, and Blood Institute advise against using HRT as an alternative to cholesterol drugs. In addition, using HRT for as short a period as 5 years has recently been shown to increase a woman's risk of heart disease, stroke, blood clots, and invasive breast cancer. Some alternative treatments offer better news -- encouraging new studies raise the possibility of fortifying women's hearts against coronary artery disease by supplementing their diets with folic acid, omega-3 fatty acids, and soy products.

In short, exciting preventive strategies await women who reach for them -- but that's the hitch. Most women remain too fixated on breast cancer to capitalize on the latest advances. This shortsightedness understandably angers women like Loving, who fretted about breast cancer only to be stricken by heart disease. "Breast cancer advocates have drummed up so much excitement for their issue that they've totally eclipsed heart disease as a valid concern for women," she complains.

So why aren't Loving and others like her spearheading their own campaign to put heart disease in the spotlight? "There's simply no organizational structure to build on," says Loving. "I wouldn't even no how to contact women like myself. For goodness sakes, I couldn't even find a support group." L.A.-based victim Mindgram agrees. "I couldn't even locate a support group on the web," she reports.

Since this article was first written, however, several online support groups have sprung up, as well as the National Coalition for Women with Heart Disease.. The obstacles are great, to be sure, but women concerned about heart disease could learn a few lessons from their more vocal sisters in the breast cancer movement. As these feisty activists have shown, a woman who wants superlative care must educate herself and be a powerful advocate for her own treatment. She and others like her must organize into a coalition both for mutual support and to shake politicians and the medical establishment into better awareness of their unique needs. Above all, they must be prepared to step out of the shadows and be counted.

If numbers speak, women with heart disease will be heard.