Heart disease remains the leading killer for both men and women in the United States,
but unfortunately, women may not realize this fact. Women worry about breast cancer as they age, perhaps due to the amazing programs related to breast health. Women consider heart disease to be a “man’s disease”, yet every 90 seconds, a woman in this country suffers a heart attack. Women not only miss the symptoms of a heart attack; they also die more frequently from a first heart attack than men. Women may not experience crushing chest pain that brings men to the ER or prompts them to call 9-1-1 for assistance. A heart attack presents differently in women. The symptoms may be ambiguous and may be attributed to a condition such as influenza. Consequently, women may delay seeking assistance, which is why the first heart attack may be far more serious, even fatal for women.3
Women need to learn risk factors for heart disease in order to identify and treat those factors early, particularly as they age. The same number of women die of heart disease as men, and many risks are preventable (or modifiable). While a few risk factors, such as family history, gender, race, familial hypercholesterolemia, genetic history of hyper coagulopathy, menopause, etc. are nonmodifiable and cannot be manipulated, several lifestyle factors can be adapted to lower the risk for heart disease. These factors can be scored by your physician to evaluate the risk for heart disease, utilizing clinical and laboratory data, which will calculate a numerical value called a Framingham Risk Score.3
The Framingham Risk Assessment is used in non-diabetic patients aged 30-79 years old who have not experienced a prior coronary event. The score assesses an individual’s risk for having a cardiac event within the next 10 years. The assessment employs information such as systolic and diastolic BP, (BP values on medication, if treated), age, gender, smoking status, total cholesterol, and HDL cholesterol. There are various Framingham models in use, but the premise of using a risk assessment is to counsel women who score a higher risk for myocardial infarction by encouraging them to actively reduce risk factors while they can!3
The responsibility for assessing cardiac risk in women’s health is twofold. Physicians may passively ignore a woman at high risk for cardiovascular disease, while actively counseling the woman’s husband to cut saturated fat, or to “drop a few pounds”. This phenomenon is not new but has been actively researched and discussed in literature. The Yentl Syndrome, documented very recently by the National Institutes of Health, describes a phenomenon in which women are less likely than men to receive procedures to diagnose or treat heart disease, despite the equality in death rates.5
What is unknown currently, according to NIH statistics, is the following: are men receiving too many procedures, or women too few? What is clear is that thirty years ago, men were in the lead with heart disease. In the interim, women caught up. In 2020, women need to gain equal opportunity in knowledge and proactive decision-making.
Step one is an awareness of risk factors.5
One of the biggest risk factors for heart disease is smoking. While many laypeople believe the worst complication of smoking could be COPD or lung cancer, cigarette smoking will lead to CAD (coronary artery disease) three times faster than the time it takes to produce lung pathology for most. Unfortunately, trying to coax women to quit smoking often leads to the next discussion: weight gain. Many believe they may be trading one risk factor for another. However, studies of ex-smokers demonstrate a median weight gain of ~ 7.5 lbs. during the time spent to achieve smoking cessation. Quitting smoking is an excellent way to reduce cardiac risk.2
Women should know additional modifiable risk factors: BP, weight, cholesterol, and activity. Working on diet modification to replace saturated fats and reduce cholesterol is an excellent plan, as is the introduction of mild exercise, particularly walking. If hypertension is present, medication may be needed to keep systolic and diastolic numbers within normal range. Newer guidelines from the American Heart Association (published in 2017) have established 130/80 as being borderline hypertensive, and 120/80 or below as ideal. Prior to this new standard, BP’s of 140/90 were classified as “borderline”, but these are now considered hypertensive and should be treated. For patients that are clinically Stage I hypertensive (without a prior cardiovascular event), dietary modifications may be recommended: such as the Mediterranean or SALT diets, e.g. cutting out caffeine, salt, saturated fat, excessive sugars.
Understanding the risk of BMI’s greater than 25 and waist measurements greater than 35” (except for pregnancy) are also important for cardiac risk reduction, as is the need to realize the risk for diabetes or pre-diabetes via A1C values. Understanding family risk and patterns is pivotal in understanding what to assess as women age. Did your maternal grandmother die of a myocardial infarction? A sibling? A parent? The more “yes” responses in your family history, the more you need to discuss risk with a family provider.
Once women have discussed their risk of heart disease and understand how to lower or manipulate their modifiable risk factors, it is time for them to learn possible symptoms of a cardiovascular event. Symptoms of a heart “attack’ are quite dissimilar between men and women. While we’ve grown used to seeing men portrayed as clutching their chest, breathing heavily and perspiring, or complaining of severe nausea, these may not be the symptoms to expect with females.4
Women may feel nauseated or experience discomfort in the elbow or jaw, even the upper back. They could experience chest pain, but it could also be absent. They may feel pain in the abdomen or lower chest, or simply feel a sense of pressure in these areas. Women report feeling extreme fatigue, and a sense of fainting, accompanied by shortness of breath, even with minimal activity. They may also experience severe indigestion. Any of these symptoms should be reported promptly for assistance. Women should be encouraged to treat potential symptoms of heart attack seriously. They should understand not to drive themselves to a medical facility. They should also understand the importance of utilizing 9-1-1 and following instructions to take or chew an aspirin (if warranted) until help arrives.1
Women should also realize heart disease may take many forms. Feeling faint or progressively short of breath is a warning sign to discuss with a physician. Irregular or “stuttering” heartbeats should also be promptly reported, especially if these symptoms occur after a sporadic night out with friends, or the occasional cocktail. Missing the onset of atrial fibrillation could lead to an ischemic stroke or pulmonary embolism, both preventable with early detection of irregular rhythms.
In summary, women have come a long way in thirty years with cardiovascular disease, but it is not a place we want to stay. We now equal men in the number of deaths each year due to this preventable killer. We can do much better: we can understand the risks, modify lifestyle factors that may contribute to heart disease, and recognize the symptoms of a heart attack should it occur. We can give this disease the respect and attention it deserves. When we do, we can wear our red dresses with pride, knowing we earned the right to be survivors.
- Activebeat.com “Heart attack red flags for women you should recognize.” Lockhart, E., QOOL media 2020.
- Ajmc.com “5 things to know about women’s heart health.” DiGrande, S., February 1, 2019.
- CDC.gov “Women and heart disease prevention.”, US Department of Health and Human Services, USA.gov, 1-800-232-4636.
- Heart.org “6 things every woman should know about heart health.” American Heart Association News, October 4, 2019.
- Mayoclinic.org “Heart disease in women: Understand symptoms and risk factors.”, Mayo Clinic Staff, October 4, 2019.