Heart disease myth: Women at low risk
Fact: It’s their greatest health danger
Patients, providers fear cancer while heart trouble takes highest death toll
The myths about women and heart disease take a tragic toll in preventable death and disability. While we might like to credit the misunderstandings solely to our patients, a good many women’s health providers are also in the dark. It’s this double-sided ignorance that allows heart attacks to damage or claim a shocking number of lives. (To picture the magnitude of feminine coronary problems, please see the graph "Age-adjusted Death Rates From Selected Causes for Women, by Race and Ethnicity, 1993," on p. 150.)
The seriousness of the problem is gradually seeping into the public’s awareness as disturbing studies come to light. Recent investigations offer frank evidence that women receive less aggressive care after heart attacks than men. While the national media equate less aggressive care with second-rate care, Lisa Schwartz, MD, lead author of one often-cited report,1 contends that it’s too soon to go that far. Women do receive less diagnostic testing, angioplasty, and bypass procedures, concedes Schwartz, general internist at Veterans Affairs Medical Center in White River Junction, VT. "But we don’t know the long-term outcomes of either diagnostic and treatment course," she cautions, adding, "Just because there’s a difference doesn’t mean either course is the right one. We need to study the outcomes on both sides."
The gender-specific treatment outcomes indeed warrant study, confirms Olivia V. Adair, MD, a Littleton, CO-based cardiologist specializing in women and heart disease. Adair, who works with Western Cardiology Associates, notes that 18% of women die in the hospital after a heart attack, compared with a 12% male death rate.1 Among the survivors, she continues, 45% of women and 10% of men develop complications during the first year.1
While Schwartz and colleagues write that the women in their study "experienced a more rapid decline in physical health status" after heart attacks than men, she reasons the finding could reflect an older, more frail condition when crisis strikes. Another unsettling discovery in Schwartz’s investigation is the significant under-use of aspirin among female survivors. Only 55% used it, compared with a 70% use rate on the male side.
"Aspirin is cheap, it’s simple, and it has a high potential for preventing another attack, Schwartz asserts. "Our study doesn’t tell us the reasons why women underuse it. Maybe their providers didn’t tell them to take it. Maybe providers didn’t stress the benefits enough. Or maybe the women just didn’t take it for other reasons."
Women fear the wrong disease
Women and their health providers might be looking for danger in the wrong place, suggests Elsa-Grace Giardina, MD, director of the Center for Women’s Health at New York City’s Columbia Presbyterian Medical Center. The Dallas-based American Heart Association’s figures underscore her point: Cardiovascular disease claims the lives of 500,387 women every year. Compare that with all forms of cancer, which kill 250,529 annually.
"It’s a terrible problem," Giardina explains, "because women have not begun to personalize the cardiac disease risk. They’re convinced they’ll probably die of breast or uterine cancer."
Providers share the responsibility for the misunderstanding, she contends.
"Cardiologists haven’t gotten down and dirty in personalizing the risk for their female patients," Giardina says.
Risk reduction key to winning battle
While it could take medical scientists years to figure out the best heart attack treatment protocols, we already know how to stop many of those heart attacks from happening in the first place. It’s all about risk factors. Although estrogen protects us before menopause, women are sitting ducks after they hit midlife. From then on, "our risk factors are the same as men’s," Adair explains. "The only one we can’t change is our family history."
Two culprits, high cholesterol and smoking, are obvious targets. The American Heart Association recommends total cholesterol levels below 200 mg/dL, and HDL at 35 mg/dL or higher. Through regular exercise and weight management, many women could prevent borderline diabetes, another precursor to heart problems.
"We know that taking estrogen supplements is a positive way to maintain heart health," Adair says, "but not enough women are taking them."
Margaret Ryan, MD, of Women’s Health Specialists in Denver, encourages her patients who have a family history of cardiac disease to take one baby aspirin (81 mg) every day along with 400 IU of vitamin E. According to Ryan, the baby aspirin dosage thins the blood enough and reduces the stomach irritation caused by the adult 500 mg pills. (For a fast take on women’s risk factors, see the consumer information insert in this issue, "Women and Heart Disease.")
Teaching heart health
Several of the women’s health providers who spoke with Women’s Health Center Management describe fatal knowledge gaps among the female public. If women knew more, they could prevent many early deaths or lives marred by chronic disability, the providers say.
Elaine E. Hanks, RN, staff nurse for the Women’s Resource Centers of St. Joseph’s Health System of Humboldt County in Fortuna, CA, sees women who ignore the early but subtle signs of cardiac trouble because they don’t know any better. Consider mild nausea or chest discomfort, for example. "Maybe she’ll change the way she lies in bed and, if the pain goes away, she’ll forget about it and she won’t get treatment until she has advanced heart disease and something drastic happens," she says. "Women don’t always have the classic chest pains that we associate with heart problems."
Most women don’t have the advantage of regular intergenerational communication, Hanks continues, "so they don’t know, for example, that grandma had the same symptoms [mild nausea or chest discomfort] before she died of a heart attack at 55."
It’s up to women’s health providers to teach young women that they’re at risk for cardiac disease, Hanks urges.
"If you start managing risk at age 50, it’s OK," she concedes, but some women can’t afford to wait that long. "We need to teach them to ask questions and pay attention to their family histories as soon as they enter the health care setting."
The chart "Rank of Selected Causes of Death for Women, by Age Group, 1993" on p. 151 confirms Hanks’ point. Heart disease is among the top three causes of death for 25- to 44-year-old women.
Another vital component of education, notes Giardina, is coaching women to discuss risk factors when their providers don’t. If a woman knows that cardiovascular disease or diabetes runs in her family, she should insist on regular blood pressure, cholesterol, and glucose monitoring.
Ryan instructs her patients to report any of the following signs of possible heart problems:
• decreased exercise endurance;
• any new arm or jaw pain;
• any pain or discomfort in the chest that comes on with exercise and lets up when you stop.
Take notes from breast cancer advocates
Prevention of cardiac disease-related disability and death is the next women’s health education frontier, says Giardina.
"Every night, I could go out and give a talk to a different women’s group and not begin to fill the knowledge gap," she comments.
Kaye Bennett, RN-C, MS, women’s health nurse practitioner at the University of Wisconsin in Madison, says, "Women aren’t nearly as frightened of heart disease as they ought to be."
Women’s health providers need to learn from breast cancer advocates, Giardina adds.
"They have done a wonderful job of getting the word out in the media," she says. "We have a breast cancer awareness month, but every month ought to be heart disease month because more women die of it."
Reference
1. Maynard C, Litwin PE, Martin JS, et al. Gender differences in the treatment and outcome of acute myocardial infarction: Results from the myocardial infarction triage and intervention registry. Arch Intern Med 1992; 152:972-976.
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