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Putting It All Together

New medical research shows how different from men women really are. Take heart disease: female symptoms are more subtle and often get overlooked. What to watch for, what to do

'Sneaky symptoms': Carolyn O'Donnell nearly ignored the mild indicators of her major heart attack

 

By Claudia Kalb and Karen Springen

Newsweek

May 10 issue - Like most women, Kathy Cunningham, 49, a wife, mother and senior VP at a Chicago bank, was well acquainted with the emotional chambers in her heart. Joy, sadness, love. But Cunningham never thought much about her heart as a muscular pump: the size of a fist, weighing less than a can of soda, beating 100,000 times a day. And she certainly didn't think it was vulnerable to disease. The picture of fitness-a nonsmoker, slim, good blood pressure and cholesterol-Cunningham was most concearned about her reproductive health, and she was religious about getting mammograms and Pap smears. But two years ago she was rushed to the ER, sweating, short of breath, in pain. A test revealed a 90 percent blockage in a coronary artery. The diagnosis: heart attack. "We all focus on breast cancer," says Cunningham. "I had no idea women had heart disease."

 

Every year a quarter of a million women die of heart disease-more than the total number killed by breast cancer, diabetes and Alzheimer's combined-making it America's No. 1 killer of women, as well as men. Women who have heart attacks are treated less aggressively, fare worse and die at higher rates than men. And yet the vast majority of women worry more about their husband's dropping dead than they do about the danger lurking in their own blood vessels. A new survey by the American Heart Association found that only 13 percent of women say they consider heart disease their greatest health risk, and barely more than one third have discussed the condition with their doctor.

 

HEALTH FOR LIFE: WOMEN'S BODIES

 

. Maintaining Heart Health: What Tests Can Tell You

. Aspirin and Statins in Women: Heading Off Heart Attack

. Fresh Weapons For an Old Battle

. Have It Your Way: Redesigning Birth

. Fetal Health: Planning for the Future

. An Unspeakable Affliction

. Discomfort: The Mystery of Cystitis

. How to Think About HT

. No Time for Wrinkles

. The More Social Sex

. A Better Sex Life

. Alcohol's Deadly Triple Threat

. Moderation: If You Want to Cut Back

. A Worldwide Gender Gap

. Health for Life M.D.: Our Doctor's Advice

. Women, Cigarettes and Death

 

As the population ages and cardiovascular hazards like diabetes continue to rise, women are more at risk than ever. In response, public-health officials have launched nationwide awareness campaigns to sound the alarm about this "silent killer." Scientists are busy unraveling the unique and sometimes mysterious ways in which coronary disease develops in a woman's body. And doctors in the know are educating their peers, many of whom still operate under the bias that men have a monopoly on matters of the heart. All the attention is starting to pay off, says cardiologist Bernadine Healy, the first female director of the National Institutes of Health, who helped put women and heart disease on the map, "but there's no doubt we have a way to go."

 

From an anatomical point of view, a woman's heart is no different from a man's: four chambers and several ounces of muscle tissue. But the symptoms of heart disease in men and women can appear as different as, well, the colors blue and pink. Men typically experience difficulty breathing and chest pain-still considered the hallmark symptom of a heart attack-which can travel up to the jaw and down the arm. Many women, however, feel no chest sensation at all, and their symptoms are often subtle: an unyielding fatigue, shortness of breath, nausea or indigestion, back or abdominal pain, or just an odd, unwell feeling. Compounding all that is the fact that too many women downplay their own health for the sake of their families, says Dr. Vera Rigolin, of Chicago's Northwestern Memorial Hospital: "They tend to ignore the symptoms because they have to take care of everybody else."

 

Carolyn O'Donnell, 62, remembers feeling "like a wuss" when her husband made her go to the ER. A runner and golfer, O'Donnell is normally an upbeat, high-energy grandmother of four. But on April Fool's Day 2002, she felt a little bit off. She was tired, she had a headache and she noticed an odd sensation near her heart. It was mild, though, no radiating pain, nothing more than "a mouse on my chest," she says, not that elephant everybody worries about. Her self-diagnosis: probably just the flu. But O'Donnell's husband-luckily, a physician-insisted she be checked out. Doctors discovered a piece of plaque clogging a crucial artery and a heart working at half its normal capacity. The "flu" was a full-blown heart attack. Today O'Donnell's health is back to normal. She takes a daily aspirin and an ACE inhibitor, which relaxes the muscles of her blood vessels. And now, more than ever, she's aware of the danger. "The symptoms," she says, "are sneaky."

 

The internal manifestations of women's heart disease can be deceptive as well. Both men and women accumulate plaque, a buildup of fat on vessel walls, which can cause dangerous clogs in blood flow and lead to heart attack or stroke. But women often distribute these deposits in what doctors describe as a more "diffuse" manner than men. Instead of gathering in clumps or bulges, the plaque is spread more evenly along the vessel lining. Women, says Dr. Sujoya Dey of the University of Michigan Cardiovascular Center, "don't always present with one big kink in the garden hose."

 

That distinction may explain some of the striking variations in the way men and women with heart disease tend to be treated. Diagnostic tests look for blockages, says Dr. C. Noel Bairey Merz of Cedars-Sinai Medical Center in Los Angeles, and yet clear-cut clogs don't show up in one third of women who have heart attacks. Instead of diagnosing disease, says Bairey Merz, "the cardiologist says, 'I don't know what's wrong with you'." That, coupled with a woman's tendency to brush off symptoms, can result in catastrophes that should be avoidable, she says. In general, women are less likely to receive medications like cholesterol-lowering drugs or devices like pacemakers or stents (which keep clogged arteries open) after heart disease has been diagnosed. Dey and her Michigan colleagues recently analyzed data from more than 10,000 male and female patients and found that even when men and women had similar severity of disease, women were less often given aspirin, which help dissolve blood clots, and beta-blockers, which prevent future heart attacks.

 

What's your risk for a heart attack?

 

A woman who knows her risk factors may be able to avoid heart disease in the first place. Genes and family history up the odds, and so does plain old aging. Young women are not invulnerable, but heart disease typically strikes women after menopause, starting in their late 50s or their 60s. That's about 10 years later than men, and could account for why women fare worse after heart attacks and die at a higher rate-they're frailer and already suffering from other diseases. Given the average age of onset, if a woman's mother had coronary disease early on-especially below the age of 50-a red flag should go up, says Dr. Erica Jones of Weill Cornell Medical College of New York. "I take that very, very seriously."

 

Most risk factors are gender-blind. Smoking and inactivity are the pillars of bad health, gunking up arteries and depriving the cardiovascular system of the nutrition it needs. Depression and stress can likely trigger heart problems and make existing disease worse. And then there's the cascade of events that starts with unhealthy, high-fat eating: a spike in cholesterol and obesity, which can then trigger the debilitating effects of diabetes. Adults with diabetes are two to four times more likely to develop heart disease than nondiabetics, and yet one third of Americans don't even know they have it. All these risk factors strike particularly hard in minorities: the death rate from heart disease is 69 percent higher in African-American women than in whites. "When we look at the numbers," says Dr. Donna Mendes of New York's St. Luke's-Roosevelt Hospital Center, "we know that something has to be done."

 

Keeping Healthy at Every Age

 

Each stage of life brings its own health concerns. A guide to the tests and vaccines that will keep you on track. These age-based guidelines are for women at average risk of most diseases. Those at higher risk should consult their doctor.

Ages 18 - 39
GENERAL
Full checkup: Ask your doctor
Thyroid test: Start at 35, then every 5 years

EYE/EAR
Vision exam: Once initially between 20 and 39
Hearing test: Starting at 18, then once every 10 years

TEETH
Dental exam: 1-2 times a year

BREASTS
Breast self-exam: Monthly

SEXUAL ORGANS
Pap test/pelvic exam: Every 1-3 years if sexually active or 22+
Chlamydia test: If sexually active, yearly until 25
STD tests: Ask your doctor

HEART
Blood-pressure test: Start at 21, then every 1-2 years

COLON
Rectal exam: Ask your doctor

SKIN
Self-exam for moles: Monthly
Mole exam by doctor: Start at 20, then every 3 years

VACCINES
Influenza: Ask your doctor
Tetanus-diphtheria: Every 10 years

Ages 40 - 49
GENERAL
Full checkup: Ask your doctor
Thyroid test: Every 5 years

EYE/EAR
Vision exam: Every 2-4 years
Hearing test: Every 10 years

TEETH
Dental exam: 1-2 times a year

BREASTS
Breast self-exam: Monthly
Mammogram: Every 1-2 years; ask your doctor

BONES
Bone-density test: Ask your doctor

SEXUAL ORGANS
Pap test/pelvic exam: Every 1-3 years
Chlamydia test: If you are high risk; ask your doctor
STD tests: Ask your doctor

HEART
Blood-pressure test: Every 1-2 years
Cholesterol test: Start at 45, then every 5 years

DIABETES
Blood-sugar test: Start at 45, then every 3 years

COLON
Rectal exam: Ask your doctor

SKIN
Self-exam for moles: Monthly
Mole exam by doctor: Every year

VACCINES
Influenza: Ask your doctor
Tetanus-diphtheria: Every 10 years

Ages 50 - 64
GENERAL
Full checkup: Ask your doctor
Thyroid test: Every 5 years

EYE/EAR
Vision exam: Every 2-4 years
Hearing test: Ask your doctor

TEETH
Dental exam: 1-2 times a year

BREASTS
Breast self-exam: Monthly
Mammogram: Every 1-2 years; ask your doctor

BONES
Bone-density test: Ask your doctor

SEXUAL ORGANS
Pap test/pelvic exam: Every 1-3 years
Chlamydia test: If you are high risk; ask your doctor
STD tests: Ask your doctor

HEART
Blood-pressure test: Every 1-2 years
Cholesterol test: Every 5 years

DIABETES
Blood-sugar test: Every 3 years

COLON
Fecal-occult-blood test: Yearly
Flexible sigmoidoscopy: Every 5 years
Double-contrast barium enema: Every 5-10 years
Colonoscopy: Every 10 years
Rectal exam: Every 5-10 years

SKIN
Self-exam for moles: Monthly
Mole exam by doctor: Every year

VACCINES
Influenza: Yearly
Tetanus-diphtheria: Every 10 years

 

Ages 65+
GENERAL
Full checkup: Ask your doctor
Thyroid test: Every 5 years

EYE/EAR
Vision exam: Every 1-2 years
Hearing test: Ask your doctor

TEETH
Dental exam: 1-2 times a year

BREASTS
Breast self-exam: Monthly
Mammogram: Every 1-2 years; ask your doctor

BONES
Bone-density test: Get a bone-density test

SEXUAL ORGANS
Pap test/pelvic exam: Ask your doctor
Chlamydia test: If you are high risk; ask your doctor
STD tests: Ask your doctor

HEART
Blood-pressure test: Every 1-2 years
Cholesterol test: Every 5 years

DIABETES
Blood-sugar test: Every 3 years

COLON
Fecal-occult-blood test: Yearly
Flexible sigmoidoscopy: Every 5 years
Double-contrast barium enema: Every 5-10 years
Colonoscopy: Every 10 years
Rectal exam: Every 5-10 years

SKIN
Self-exam for moles: Monthly
Mole exam by doctor: Every year

VACCINES
Influenza: Yearly
Pneumococcal: One time only
Tetanus-diphtheria: Every 10 years

 

GUIDELINES ONLY. YOUR HEALTH-CARE PROVIDER WILL PERSONALIZE THE TIMING OF TESTS AND IMMUNIZATIONS TO MEET YOUR INDIVIDUAL NEEDS. SOURCE: THE NATIONAL WOMEN'S HEALTH INFORMATION CENTER

 

The message is beginning to get out. The National Heart, Lung, and Blood Institute is busy raising awareness through The Heart Truth, a nationwide campaign complete with a little pin shaped as a red dress, the new symbol of heart disease in women. The Association of Black Cardiologists has been spreading the word for years through churches. Now it's targeting hair salons, where beauticians are adding a new skill to snipping and styling: measuring their clients' blood pressure. And then there are individuals like Sylvia Woods, 78, who educates hungry customers in her famed Sylvia's Restaurant in New York City. Woods herself underwent an angioplasty for a blocked artery; now she's making soul food more heart-healthy. There's less butter, grilled catfish and no more pork in the collard greens. The rich flavors? "Grandma kicks it up a notch with the spices," says Woods's granddaughter Tren'ness.

No magic pink pill is going to eliminate heart disease in women, but new guidelines from the American Heart Association spell out how to ward it off. Unhealthy habits account for a whopping 82 percent of heart disease in women, which puts lifestyle interventions at the top of the list. It can never be said too many times: stop smoking, get at least 30 minutes of exercise most days of the week, eat lots of fruits and veggies. Blood pressure should be less than 120 over 80. HDL, the "good" cholesterol, should be above 50; LDL, the "bad," below 100.

The AHA guidelines come down firmly on what not to do, as well, starting with hormone-replacement therapy. Researchers long assumed that estrogen was the elixir protecting young women's hearts, which is why HRT was prescribed to postmenopausal women. But the landmark Women's Health Initiative study found that estrogen and progestin actually increased the incidence of heart disease and stroke. And newer data from a trial of estrogen alone have found no heart benefit whatever. "We can now say emphatically that HRT shouldn't be taken for the express purpose of preventing heart disease," says Dr. JoAnn Manson of Harvard's Brigham and Women's Hospital and a WHI investigator.

Doctors will never unlock the emotional mysteries of a woman's heart, but as they continue to unravel its biology, diagnosis and treatment of heart disease should improve. Nothing, however, can replace awareness and vigilance. Women must know their blood pressure and cholesterol levels, calculate their risk factors, pepper their doctors with questions and take symptoms seriously. The beauty is that women are already in touch with their hearts-now they just have to listen to them more carefully.

With Joan Raymond

© 2004 Newsweek, Inc.