Heart Disease

Heart Disease

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You're 40. You've got a high-pressure job that demands intense concentration, a quickgrasp of complex subjects and an obsessive devotion to deadlines. You've also got a propensity for cheesecake, a husband who smokes and an exercise program that stops with taking out the trash.

You know it's not a heart-healthy lifestyle, but so what? You're a woman. And women don't have heart attacks.

Wrong. Nearly one of every two fatal heart attacks happens to a woman. Nearly half a million women die of heart disease every year. After age 45, heart disease affects one woman in nine. By age 65, it affects one in three. It kills twice as many women as all cancers combined and four times as many women as the next three most common causes of death combined.

A Woman's Special Protection

Although the clogged, hardened arteries that set the stage for heart disease begin with the first ice cream cones of early childhood, heart disease doesn't manifest itself in most women until their estrogen levels drop at menopause (unless they have their ovaries removed during a hysterectomy).

Until one of these events occurs, estrogen literally coats a woman's heart with protection. It keeps her arteries supple, increases substances that sweep cholesterol from the bloodstream and enables other substances in the body to actually dilate blood vessels and slow the formation of maverick blood clots that can trigger a heart attack.

But once estrogen's protection is withdrawn, heart disease hits women hard--harder, some doctors say, than it hits men. Women are more likely than men to die from a first heart attack. Even if they survive the first, they are more likely than men to have a second attack within a year. Clot-busting therapy, or thrombolysis, which is commonly used to fight an attack, is more likely to result in stroke for women. And most women who are candidates for such aggressive treatment are less likely to be offered lifesaving interventions like thrombolysis, catheterization or heart bypass surgery because of "gender bias," says Marianne Legato, M.D., associate professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York City and author of The Female Heart. Awareness of such bias among heart disease specialists, however, is bringing significant improvement in the treatment of women, Dr. Legato adds.

Measuring the Odds

What puts women at risk for heart disease? Cigarette smoking, high blood pressure, overweight, abnormal blood fats, a sedentary lifestyle and poor diet, says JoAnn Manson, M.D., co-director of women's health at Brigham and Women's Hospital in Boston and co-principal investigator of the cardiovascular component of Harvard University's Nurses' Health Study. This is a comprehensive, ongoing research project begun in 1976 and involving more than 100,000 women.

But the effects of almost every risk factor can be turned around, she adds.

"I think a key point for younger women to understand is that we largely control our own destiny in terms of heart disease," Dr. Manson says. "We control the most important risk factors such as whether or not we smoke, whether or not we exercise, whether or not we keep our weight under control, whether or not we eat a healthy diet. Except in the very rare person, unchangeable risk factors such as genetics are just not as important." Here's how a woman can prevent heart disease.

Begin by avoiding cigarettes. "Cigarette smoking is, without question in my mind, the number one risk," says Dr. Manson. "Among women in the Nurses' Health Study who were 30 to 55 years old at entry, smoking was the cause of over half of all heart attacks."

Even environmental smoke--in restaurants, workplaces and cars--can be a danger. In a study at the University of California at San Diego, for example, researchers followed 695 nonsmoking women. After ten years, the researchers found that women married at one time or another to smokers were two and a half times more likely to die from heart disease than women who lived in smoke-free homes.

Monitor your blood pressure. High blood pressure beats up your arteries and overworks and weakens your heart. Keep an eye on it, says Dr. Manson, and if it starts creeping up, work with your doctor to get it back down. You can reduce your risk of a heart attack 2 to 3 percent for every point you reduce the bottom or top number of your blood pressure reading. (For tips on reducing blood pressure, see page 276.)

Drop extra pounds. Overweight plays a major but indirect role because it contributes to high blood pressure, diabetes and abnormal blood fats, says Dr. Manson. "It also increases the workload of the heart."

In the Nurses' Health Study, Dr. Manson and her colleagues found that every extra pound weighs on the heart. Even women who were mildly to moderately overweight--15 to 30 pounds or so--had a risk of heart disease 80 percent higher than their leaner counterparts.

Get out the tape measure. How can you tell if your extra pounds are particularly likely to put you at risk?

"The key here is shape," says Michael Miller, M.D., director of preventive cardiology at the University of Maryland Medical Center and assistant professor of medicine at the Johns Hopkins Medical Institutions, both in Baltimore. "Apple-shaped women are more likely to get heart disease than pear-shaped women."

To find out which you are, get out the tape measure and wrap it around your waist, then your hips. Divide the waist measurement by the hip measurement. If the result is 1 or above, you're an apple--and in trouble. If it's 0.8 or below, you're a pear--and probably okay.

This is not just a game of numbers, adds Dr. Miller. Apple shapes seem to metabolize fat and cholesterol differently. For one thing, they're more likely to have high triglycerides--a particularly nasty type of blood fat that can cause heart disease. They also have low levels of HDL cholesterol--the "good" kind that puts a half-nelson on bad, artery-clogging LDL cholesterol and flips it to the liver for disposal.

How are "high" and "low" measured? In a study of 140 women who were tracked over a 15-year period, Dr. Miller and his colleagues found that women who had triglyceride levels of 171 or more were nearly three times more likely to die of heart disease than women who had levels of 115 or less. Women who had HDL levels of less than 45 also had triple the risk.

Apple shapes also seem to have increased resistance to insulin, says Dr. Miller. This can lead to Type II, or non-insulin-dependent, diabetes, which increases the risk of dying from heart disease fourfold.

Together, this clustering of risk factors--apple-shaped obesity, high triglycerides, low HDLs and insulin resistance--has been nicknamed syndrome X.

Move it. "The cornerstone of prevention is exercise," says Dr. Miller. It zaps all four risk factors at once. It can help control weight, lower triglycerides, increase HDLs and prevent the insulin resistance that leads to diabetes. Exercise also decreases your body's ability to form the blood clots that can lead to a heart attack.

Start exercising three times a week at a pace that keeps you moving but is not so strenuous that you can't hold a normal conversation, says Dr. Miller. And whether it's walking, swimming, cycling or some other aerobic sport, keep moving for a good 20 minutes.

A Heart-Healthy Diet

A major factor in reducing the risk of heart disease is learning what you should--and should not--eat.

Load your plate with fruits and veggies. In the Nurses' Health Study, "we found that women who had the highest combined intake of vitamins C and E plus beta-carotene had a 46 percent lower risk of heart disease than women who had the lowest intake," says Dr. Manson.

"I think it's premature to recommend over-the-counter supplements, but I think it would be prudent for everyone to increase their intake of fruits and vegetables," she says.

As a result of her research and that of other investigators, says Dr. Manson, "I try to eat at least five servings a day of fruits and vegetables."

Not only do many fruits and vegetables--such as mangoes, spinach, broccoli and carrots--contain the healthful nutrients that seem to protect the heart, they also form the nucleus of a low-fat, low-cholesterol, high-fiber diet, adds Dr. Manson. And there's plenty of evidence that suggests such a diet can reduce the risk of heart disease.

Skip the meat. A study at Loma Linda University in California found that eating meat as little as three times a week actually increases a woman's risk of death from heart disease by 25 percent. And with every added bite, the risk escalates. "I try to avoid eating any red meat at all," says Dr. Manson.

Garnish with garlic and onions. Substances that are released when raw garlic and onions are cut or crushed seem to make platelets less likely to clump together to form the artery-blocking clots that trigger heart attacks, reports Eric Block, Ph.D., professor of chemistry at the State University of New York at Albany.

An occasional meal heavy on cooked garlic and onions probably won't do very much, he adds. But regularly chopping raw garlic into your salad dressing or slicing an onion into salads probably will.

Add nuts. Researchers at Loma Linda University who are studying 26,000 Seventh-Day Adventists have discovered that eating the equivalent of a handful of nuts five times a week may reduce the risk of heart attack by 50 percent.

Nuts contain a potent relaxing factor that may inhibit spasms in arteries, explains Gary Fraser, M.D., Ph.D., professor of medicine and epidemiology at Loma Linda, who headed the study. They also contain monounsaturated fats, vitamin E, fiber and magnesium--all of which may protect the heart.

Which nut is best? The jury's still out, says Dr. Fraser, but the men and women in his study ate peanuts, almonds and walnuts.

Ditch the stick margarine. Given the artery-clogging fat content of butter, it seemed to make good sense for doctors to suggest that people use margarine instead. But since those suggestions were first made, Dr. Manson and her colleagues have found that women in the Nurses' Health Study who ate even four teaspoons of margarine a day--either as a spread or in baked goods--increased their risk of heart disease by 66 percent.

The culprits, scientists suspect, are the trans-fatty acids that allow vegetable oils to solidify into the stick form that people expect.

"I don't think people should return to using butter," cautions Dr. Manson. "But the research does suggest that people should consider moving more toward olive oil and the softer, tub margarines." Olive oil is free of the trans-fatty acids in stick margarine that sabotage the heart, and tub margarine contains less of them than stick types. Dr. Manson also warns that, along with margarines and baked goods, fast-food french fries are one of the most common sources of trans-fatty acids.

Skip the heavy meals. Scientists have known for years that a high-fat diet will gradually clog the heart's arteries and set the stage for a heart attack. But researchers in London and Chicago have discovered that dietary fat may pose an even more immediate threat--clots.

The problem is a substance called factor VII. When stimulated by an influx of dietary fat, factor VII may lead the body to form the clots that can cause a heart attack. Even a single fatty meal ups the factor VII ante for a short time and puts you at increased risk, researchers report. But a habitually fatty diet sustains that risk.

Drink in moderation. Several studies--including the Nurses' Health Study--have found that consuming a moderate amount of alcohol daily reduces the risk of heart disease. (A moderate amount is considered to be 12 ounces of beer, 5 ounces of wine or a drink with 1 ½ ounces of hard liquor.) In the Nurses' Health Study, the risk declined by 40 percent.

In a study of 81,825 men and women at the Kaiser Permanente Medical Care Program in San Francisco, however, researchers discovered that wine appears to be most beneficial against heart disease and that women who drank white wine had a slightly lower risk of heart disease than women who drank red wine, beer or anything else.

Beat the Sudden Stress Syndrome

Stress is not usually considered a major risk factor for heart disease in women. Yet in a study at Harvard, approximately 40 percent of all heart attacks were preceded within two hours by a psychologically stressful event, says psychologist Sue C. Jacobs, Ph.D., who was a member of the study's research team and is now associate professor of counseling psychology at the University of North Dakota in Grand Forks.

What caused the stress? "For some it was having a son come home from the Gulf War," Dr. Jacobs says. "For others it was winning the lottery." For still others, it was losing a job. It made no difference whether the stressful event was good or bad, says Dr. Jacobs. Either way, the event increased the risk of a heart attack nearly 15-fold.

A stressful event causes the body to secrete "fight or flight" chemicals so we can react quickly in an emergency, explains Dr. Jacobs. The problem is that in addition to giving us fast reactions, these chemicals also trigger substances that can form blood clots.

If you were indeed in a battle, particularly one in which you were wounded, that might be helpful. But for a woman in twentieth-century America, those clot-forming substances are more likely to cause a heart attack than patch a wound.

Here are some ways to deal with stress before it becomes dangerous.

Watch out for signs of stress. Before you can eliminate the stresses that can cause a heart attack, you need to know when your body's actually experiencing stress, says Dr. Jacobs. Watch for sweaty palms, increased heart rate, shallow breathing, headache, muscle aches, stomachache, insomnia and mind chatter that just won't stop.

Develop a relaxation response. When you find yourself reacting this way to a particular event, take a deep breath, exhale and begin to consciously tense and relax muscles all the way from your toes to your head. Or visualize yourself doing something that makes you relax. "I'll picture myself jogging on the beach with my attention focused on the rhythm of my steps," says Dr. Jacobs.

Rethink your roles. A study at the University of Stockholm indicates that the multiple roles women play may increase their risk of a heart attack, says Margaret Chesney, Ph.D., professor at the University of California, San Francisco, School of Medicine.

In a study of managers at the Volvo plant in Sweden, a Swedish researcher found that the levels of stress chemicals increased throughout the day in both male and female managers until 5:00 p.m. At that time, the levels of stress chemicals started to drop in male managers and continued to decline into the evening. But for female managers, the levels either stayed high or continued to rise until 11:00 p.m.

What caused the difference? "We think the men were unwinding. They were home and would relax," says Dr. Chesney. "Women were home and started into their second shift." They didn't sit down. They prepared dinner, cleaned up the kitchen, did the laundry and supervised the kids' homework.

It's not that men weren't helping, she adds. Some were. But what they weren't doing was taking the responsibility for getting things done. As a result, the women's managerial responsibilities never stopped until they dropped.

The key to reducing this type of role-related stress is twofold, says Dr. Chesney. First, women have to learn how to delegate not only chores but the responsibility that goes with them. For example, "I know someone who delegated the dry cleaning to her husband. It became his responsibility, since he had the most to be cleaned anyway. She puts out her clothes that need to be cleaned, then doesn't worry about them."

Women also have to lower their expectations of themselves. "For example, I'm not a good cook," says Dr. Chesney, "so I've given up on entertaining. Instead of four-course meals, we'll go Dutch with another couple to a restaurant. Maybe we'll start out with hors d'oeuvres at our house. Or we'll pick up dessert and go back to our friends' house." But either way, says Dr. Chesney, the only expectation she has of herself is to have a good time.

Estrogen Forever?

Estrogen naturally protects women from heart disease until menopause, when the body stops producing it. Now scientists are finding that estrogen replacement therapy (ERT), in which women take a synthetic form of the hormone to offset the side effects of menopause or of having their ovaries removed, offers some protection. ERT reduces the risk of heart disease by 44 percent, the Nurses' Health Study indicates.

"Women's tissues are estrogen sensitive," explains Trudy Bush, Ph.D., professor at the University of Maryland School of Medicine and adjunct professor of epidemiology at the John Hopkins Medical Institutions, both in Baltimore. "And when estrogen is withdrawn, we're just not as healthy."

ERT is particularly beneficial if you have a number of risk factors for heart disease, she adds. No one is quite sure how it protects the heart, but researchers have discovered that it reduces LDL cholesterol levels while increasing HDL cholesterol (HDL molecules clear LDL cholesterol from the blood). ERT may also prevent arteries from going into spasms, which can choke off blood to the heart or brain.

The effects of oral contraceptives, which also contain estrogen, on heart disease are not quite as clear, according to Dr. Bush. "The old high-estrogen formulations actually promoted blood clots, but the new low-dose estrogen formulations don't.

"My best guess right now is that the new low-dose estrogen pills are safe for women right up to menopause--as long as there are no other risk factors," she says. She cautions, however, that women at any age who smoke should not use oral contraceptives.

But ERT is not without controversy. For one thing, it is not recommended for women at risk for certain cancers.

The Aspirin Advantage

Studies have indicated that as little as 325 milligrams of aspirin (usually one tablet) every other day can help reduce the risk of a heart attack in men. But what about women? "The Nurses' Health Study indicated that one to six aspirin per week was associated with about a 25 to 32 percent reduction in heart attack risk in women," says Dr. Manson. And although more studies are needed to clarify just whom aspirin is most likely to help, women at high risk of heart disease should ask their physician about the benefits and risks of starting aspirin therapy, she says.