Women and Cardiovascular Disease – An Update
Several past Second Opinion columns have dealt with issues surrounding women and heart disease. Given the increase in heart disease queries resulting from high profile cases like former President Clinton, an update with regard to women and cardiovascular disease is prudent.
A common misperception that may result in catastrophic consequences is that women do not suffer from cardiovascular disease nearly as commonly as men. The reality is that since the early 1980's, careful tracking has demonstrated that heart disease is responsible for more deaths in women than in men; women just get the clinical disease later in life. Women also do not seem to do as well with interventions either. Women do not survive heart attacks at the same rate, and have more complications from angioplasty and open-heart surgery. These observations may be related to more advanced disease at diagnosis, or smaller vessels with less mechanical reserve to tolerate interventions.
All is not bad news, however. Women seem to respond better to prevention strategies than men, regardless of compliance issues. By that I mean that even if you balance out the observation that women are more likely to make the lifestyle changes and take prescribed medications more reliably than men, women seem to have better outcome if they take statins even when compared to compliant men. This translates to lower incidence of first and recurrent events (heart attacks or need for angioplasty or open heart surgery).
These facts reinforce the mantra of the Ventura Heart Institute we have espoused since the mid-1980s: prevention and early detection of heart disease is far better than treating the results of advanced disease. However, as many patients know, insurance companies do not like to pay for a diagnostic test unless there is an acceptable (to the insurer) diagnosis. Also, insurance companies are programmed to pay for procedures, but not prevention. So the focus in American health care (insurers and doctors) has been to wait for a problem, and then treat it. The problem is compounded by recent studies that have documented that a female may present with symptoms other than the classic male symptoms of mid-chest pain going down the left arm.
Doctors have been traditionally trained to recognize the classic symptoms, but the problem is the classic pattern was described for the middle-aged to elderly man, not woman. Women may have symptoms that actually represent cardiovascular disease, but which may not be recognized as such. Some epidemiologists and preventive cardiologists have speculated that this non-recognition has resulted in delayed diagnoses and unnecessary deaths in women.
In a study published late last year in Circulation, a respected peer-review journal sponsored by the American Heart Association, 515 women who survived documented heart attacks were systematically interviewed. It turned out that 95% of these women had symptoms at least a month before their heart attack, but 43% of them never experienced any type of chest pain. Unusual fatigue and sleeplessness were commonly reported. Less commonly, shortness of breath, indigestion and anxiety were reported. If they did report chest discomfort, it was often characterized as achiness or pressure in the upper chest and back.
Consequently, if suspicious symptoms are noted, appropriate diagnostic studies need to be considered. Routine treadmill exercise tests have a higher incidence of false positive studies in women. This means that tests look abnormal when they may not be truly abnormal. For that reason, stress testing may be enhanced by concomitant use of echocardiographic or nuclear perfusion studies that increase their diagnostic accuracy. Increasingly, electron beam computed tomography, or calcium scanning, may play a role in sorting out risk of coronary disease, but not in determining the meaning of a given set of symptoms.
Ultimately, the best strategies involve active prevention. This means awareness of cardiovascular risk factors and then lifestyle and, if necessary, pharmacologic interventions to mitigate them. A family history of premature cardiovascular disease should prompt one to assess her risk factor profile to include knowledge of her LDL-cholesterol (bad cholesterol), HDL-cholesterol (good cholesterol), blood pressure, blood sugar, and in patients with particularly striking family histories of premature disease, a search for novel risk factors. These would include C-reactive protein, lipoprotein (a), homocysteine and lipoprotein phospholipase A2.
Recent evidence that Mediterranean diets rich in whole grains, fruits, vegetables, legumes, nuts, fish and olive oil that also include low amounts of meat, dairy, saturated fats, and moderate alcohol consumption significantly lower cardiovascular risks should prompt everyone to adopt proper nutrition and exercise programs and to also achieve optimal weight. Abnormalities not corrected by lifestyle changes should prompt physician guided drug management to evidence-based goals. Remarkably, even with known coronary risk factors and even after documented heart attacks, women are undertreated compared to men. Consequently, women need to be particularly vigilant to ensure their own health.
Dr. Loh is medical director of the Ventura Heart Institute in Thousand Oaks, CA. His e-mail address is email@example.com . Previous Second Opinion columns are accessible at www.venturaheart.com.