Heart Disease
Heart Disease
The Sooner You Act, the Better
There's a myth that says heart disease is a man's problem. A lot of women believe it--and so do many of their doctors. But it couldn't be more wrong.
True, heart attacks usually strike women later in life--an average of seven to ten years later than men. But when they hit, they hit with a vengeance. Heart disease kills more women than any other illness--nearly six times as many as breast cancer and nine times as many as lung cancer.
The Menopause Connection
When it comes to women and heart disease, age is a key factor. The chances of developing heart disease increase steadily after menopause.
The presumed reason: estrogen. Throughout most of a woman's life, this female hormone stands guard over her heart and coronary arteries, defending them against the fatty deposits that can embed themselves in the arterial walls, clogging the bloodstream and making her more vulnerable to heart attack.
"We are now beginning to think that estrogen's protective effect is related to its influence on the HDL (high-density lipoprotein) cholesterol level," says Richard H. Helfant, M.D., vice chairman of medicine and director of the Cardiology Training Program at the University of California, Irvine, Medical Center and author of Women, Take Heart. "There's growing evidence that estrogen increases the amount of this good cholesterol, which we know protects the arteries from infiltration of fatty deposits." At the same time, estrogen may propel your LDL (low-density lipoprotein) cholesterol into a downward spiral, which is just where you want it to head.
After menopause, of course, that protection does a quick retreat. As the natural estrogen produced in your body drops, you're left to fend off the attack of heart disease with one less weapon in your arsenal. At about age 45, your LDL cholesterol level will generally start to climb, along with your total cholesterol count. As it does, so will your risk of heart disease.
It may sound grim. But there's no need to resign yourself to a life of anxiety. True, you can't change your age or keep your natural estrogen flowing, although research indicates that hormone replacement therapy (a combination of estrogen and progestin) given to women at menopause can have a protective effect. Nor can you alter any inherited tendency toward heart disease. But that doesn't mean there are no other risk factors you can alter.
If the Worst Happens
Sometimes even the most conscientious efforts at prevention just aren't enough. If you start to feel the warning signs of a heart attack--such as pressure or squeezing sensations in the chest, pain shooting into the shoulders, arms or neck or shortness of breath and nausea--you need to respond rapidly. Because women tend to think that heart attacks are something that only their husbands, fathers and brothers get, we may not be as quick to react to our own symptoms. But as the American Heart Association warns, "Delay can be deadly!" Clot-dissolving drugs called thrombolytics are administered in the emergency room and can restore blood flow, thus minimizing damage to the heart muscle. But time is crucial. "The later you come in to the emergency room, the less likely a thrombolytic is going to be effective," says Gerald Pohost, M.D., director of the Division of Cardiovascular Disease at the University of Alabama School of Medicine in Birmingham. "The first two hours are the best time, but as time passes, the success of these drugs diminishes." |
Committing to Change
Heart disease doesn't happen overnight. Most heart disease results from a narrowing of the coronary arteries, known as atherosclerosis, over decades. What makes arteries narrow? Largely, it's the way we Americans live our lives. In some other countries, where lifestyles are simpler, arteries are healthy and wide open, even in the very elderly.
The encouraging news is pretty straightforward: Progression of heart disease can be slowed, and in some cases even reversed, without drugs or surgery. But don't think you have to go to extremes or have a will of steel to do so. "Moderate changes go a long way," advises Dr. Helfant. "You don't have to be a fanatic or be perfect to make a difference in your health."
Let's look at some strategies that can keep your heart pumping as though it inherited an extra decade or two of life.
Give up the cigarettes--now. Okay, maybe you've smoked for years and even tried to quit with no luck. But a lot of ex-smokers successfully stopped only after their second, third or even sixth attempts. So don't give up.
Why not? When you smoke, your blood vessels constrict. That places extra strain on your heart. But that isn't all. Cigarette smoke forces your heart to beat more rapidly and raises your blood pressure.
The result is as brutal as it comes: According to the American Heart Association, cigarettes directly cause nearly one-fifth of all deaths from heart disease.
If you smoke and take oral contraceptives, you're asking for trouble. Together, they make you up to 39 times more likely to have a heart attack than a woman who uses neither.
Cut your cholesterol. Everyone needs at least some of this substance in her body for some essential body functions to take place. But the fact is that your own liver produces all the cholesterol your body requires.
If your diet leans too heavily on high-fat, high-cholesterol foods, your total blood cholesterol readings may get up to 240 milligrams per deciliter of blood (mg/dl) or above, a perilous level that will double your chances of heart disease. By making some leaner food choices, however, you can take back control and get yourself on a heart-healthy track--perhaps even reversing atherosclerosis. A total cholesterol of below 200 mg/dl is what you need to shoot for.
When Dean Ornish, M.D., president and director of the Preventive Medicine Research Institute in Sausalito, California, put people on a comprehensive lifestyle program that included a very low fat diet, moderate exercise, smoking cessation and stress management training, 82 percent of them experienced a significant regression of the fatty deposits that had clogged their coronary arteries after one year.
But don't think that to prevent heart disease you need to adopt a deprivation diet that's just a step above a hunger strike. "No one ever got a heart attack from a steak or a piece of pie," says Dr. Helfant. "We're talking about an overall change in lifestyle and not worrying about an occasional slip." The trick is to adhere to recommendations to limit fat intake to no more than 25 percent of calories over the long term.
Tip the triglyceride scale. As if cholesterol weren't enough to worry about, you and your doctor should keep tabs on your triglycerides, too. They are a type of fat in the bloodstream, and though they appear to play a role in heart disease, their exact role in that process is still not as clear as the link between cholesterol and heart problems.
Many experts say that a triglyceride level above 200 mg/dl should serve as a warning flag. What's one of the best ways to temper your triglycerides? Regular exercise, says Peter Wood, Ph.D., professor of medicine emeritus and associate director of the Stanford University Center for Research in Disease Prevention in Palo Alto, California.
Maintain your best weight. In a country that seems obsessed with slogans like "Thin is in," a lot of us could never be mistaken for being undernourished. About 19 million American women are a bit more than pleasantly plump (approximately 20 percent or more over their desirable weights). It's a little like playing Russian roulette with their hearts. In the Nurses' Health Study at Harvard Medical School, 40 percent of heart disease cases were attributed to the buildup of excess pounds.
So whether or not you consider flab to be unattractive, it's clearly hazardous to your heart. "If you're obese, the heart has to work harder to move nutrients to the additional cells in your body," says James Martin, M.D., family physician with the Institute for Urban Family Health at Beth Israel Medical Center in New York City. That extra strain on the heart can be particularly worrisome if you already have other risk factors that can contribute to heart disease, such as high cholesterol or high blood pressure. Set some goals for shedding extra pounds by relying more on low-fat foods and getting more exercise.
Sweat a little. Sure, it's tempting to toss out the exercise shoes, cancel your health club membership and spend every weekend entrenched like Gibraltar in front of the television or camped out on the beach with a best-selling novel. If that's your idea of Shangri-la, you're not alone--but you are paying a price. In fact, almost 60 percent of American women don't get any exercise, a lifestyle choice that greatly increases their risk of heart attack.
Exercise can do more than just get you some fresh air and make you feel more invigorated. "It strengthens the heart muscle," says Dr. Wood. "With regular exercise, the heart becomes a more efficient pump. As a result, the heart rate becomes slower for a given amount of effort." Each beat is more efficient, he says, and so the heart doesn't need to work as hard as it would if you were out of shape.
Exercise is particularly important if you're trying to lose weight. "When women lose weight, their HDL cholesterol levels tend to decrease," cautions Robert Rosenson, M.D., director of the Preventive Cardiology Center at Rush-PresbyterianSt. Luke's Medical Center in Chicago. "To maintain your HDLs at the same level or even produce a slight increase, you need to exercise while you're losing weight through diet."
Deflate your blood pressure. High blood pressure is called the silent killer, quietly doing sinister work that puts so much extra strain on the heart and arteries that it can ultimately provoke a heart attack (not to mention a stroke or kidney failure).
But by pulling the plug on your high blood pressure--which you can do by reducing sodium in your diet, losing weight, exercising and (if necessary) taking one of many available medications--you can give your heart a breather. Here are some comforting statistics: For each one-point decline you can achieve in your diastolic blood pressure (the bottom number), you can cut your risk of a heart attack by 2 to 3 percent. And with proper therapy, it's not uncommon for people with high blood pressure to lower their diastolic readings by 20 points or more.
Consider aspirin. It may not be the Fountain of Youth, but the drug that can keep your heart vital may be as close as the medicine cabinet in your bathroom. Aspirin, the tiny white pill that has been relied on a zillion times to zap headaches and other mild pain problems, appears to be a heart-saver as well.
Again, the Nurses' Health Study has given us the crucial information. Over a six-year period, women who took from one to six aspirin tablets per week had about a 32 percent decreased chance of having a first heart attack compared with women who took no aspirin. Women over age 50 seemed to get the most protection. But particularly if you're prone to bleeding problems, consult your doctor before self-prescribing aspirin, since it's a medication that discourages blood clotting in your body.
Get your vitamins. For decades, mainstream doctors have considered vitamin supplements just a small step away from quackery. But not anymore. A study published in the New England Journal of Medicine involving more than 87,000 women concluded that women who took vitamin E supplements for more than two years had about a 40 percent lower risk of major heart disease than those who did not take supplements.
What's the secret of vitamin E? The vitamin is an antioxidant, meaning that it protects cells from malicious molecules called free radicals that trigger a process called oxidation, which can contribute to the clogging of arteries.
"I'm giving vitamin E to my patients in standard doses that do not pose risks," says Marianne J. Legato, M.D., author of The Female Heart and associate professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York City. Dr. Legato advises supplements of 400 IU of vitamin E, along with 1,500 milligrams of vitamin C and 6 milligrams of beta-carotene, both of which are also antioxidants. She also advises 1,500 milligrams of supplemental calcium, which studies have shown may help prevent heart disease.
Seek hormonal help. Your doctor has the option of prescribing supplemental estrogen in your postmenopausal years, which can empower you to take a bite out of heart disease before it bites you. A study at Harvard University in Cambridge, Massachusetts, of more than 48,000 women found that estrogen replacement therapy could slash the risk of major coronary disease and fatal cardiovascular disease by more than half.
But there's an important caveat to keep in mind: There has been concern that estrogen could increase your risk of cancer of the endometrium (the lining of the uterus) and perhaps of breast cancer. But by prescribing lower doses of estrogen and combining estrogen with progestin (the synthetic form of another hormone called progesterone), your doctor may be able to counteract these threats. You and your doctor need to weigh the pros and cons before deciding whether estrogen alone or in combination with progestin is right for you.
Are You an Apple or a Pear?
In the fruit basket, pears tend to age somewhat faster than apples. But when it comes to your heart--and "pear" and "apple" are describing different body shapes--the pear definitely ages slower. Fortunately, most obese women tend to be shaped like pears (with their extra weight around their hips) rather than apples (with their fat tucked into the midsection). But that isn't always the case, particularly in women after menopause. Studies clearly show that an apple shape creates a higher risk of heart attack (as well as of diabetes, stroke and high blood pressure). Why is a jelly belly so malicious? One theory is that abdominal fat is more easily converted to cholesterol. No matter what the cause turns out to be, make an effort to trim the size of your own "apple" by losing a few of those extra pounds. Here's a guideline for you to keep in mind: To cut your risk, your waist measurement should not be more than 80 percent of your hip measurement. |
A Multitude of Treatments
The good thing about heart disease--surely the only good thing--is that it most often gives you warning signs before striking hard. The most common warning sign is angina, chest pain caused by inadequate blood flow to the heart. Should you experience angina, your doctor might prescribe nitroglycerin to relax the blood vessels and allow the heart to get more blood. Or for chronic angina, she might suggest other medications, such as beta-blockers, calcium channel blockers or ACE (angiotensin-converting enzyme) inhibitors.
"The choice of drugs will depend on your own particular situation," says Dr. Martin. "If you have high blood pressure as well as heart disease, there may be a single drug that can help both of these conditions. If you have heart failure in addition to heart disease--that is, if your heart isn't pumping as efficiently as possible--an ACE inhibitor is a good choice. Some patients do need to be placed on more than one medication. So it's an individualized decision."
If the blockage of your coronary arteries has become severe, then your doctor might recommend an open heart operation (coronary bypass surgery) or angioplasty. Approximately 30 percent of these heart operations are performed on women. Angioplasties and bypass surgery are about equally common.
In angioplasty, a tiny balloon-tipped catheter is guided into the coronary arteries, where the balloon is inflated to flatten the fatty deposits that are causing the obstruction.
Although angioplasty successfully opens the arteries in up to 90 percent of patients, these arteries can become clogged again, sometimes within months of the procedure. At that time, angioplasty needs to be repeated, or the doctor may suggest bypass surgery instead.
In a bypass operation, healthy blood vessels (often transplanted from the leg or the chest) are grafted onto the heart to bypass the obstructed portions of the coronary arteries. Although it is a more major procedure, its benefits tend to last longer. Dr. Legato says that surgery is usually chosen for so-called three-vessel disease, in which three or more of the major coronary arteries are obstructed, severely interfering with blood flow to the heart.
If you wind up opting for either medication or surgery, it is still important--perhaps doubly so--to maintain a healthy, active, low-fat lifestyle.
