Letter from the Editor: Heart Facts for Women
Article Outline
Heart disease is the number 1 killer of American women.1 That is the heart truth. The Heart Truth is also a national awareness campaign for women about heart disease sponsored by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health. NHLBI created and launched the Red Dress as the national symbol for women and heart disease awareness during American Heart Month in February 2003.2 National Wear Red Day has become an annual event. A Lifetime Women’s Pulse Poll (released in February 2006) showed that 39% of women recognize the Red Dress as the national symbol for women and heart disease awareness3 and a survey conducted by Harris Interactive® in January 2005 found that 60% of U.S. adult women agree that the Red Dress makes them want to learn more about heart disease.2
Why is there concern regarding women’s awareness of heart disease? One in three American women dies of heart disease.4 The risk of heart disease rises as people age, and men tend to develop it earlier. Specifically, men ages 45 and older are at increased risk of heart disease, while women 55 and older are at increased risk.5 However, it is not something only older women should worry about. Heart disease is the leading cause of death for women 65 and older, the third-leading cause of death for women 25 to 44, and second-leading cause of death for women 45 to 64.6 Only 54% of women correctly identify heart disease as the leading cause of death among women.3 Lack of awareness extends to physicians as well as patients. In one study, fewer than one in five physicians knew that more women than men die each year from cardiovascular disease.7 Nearly 9 in 10 women (84%) admit to having one or more risk factors for heart disease (42% have three or more risk factors), yet only 31% feel that they are personally at risk for heart disease.3 Only 9.7% list heart disease as the disease they fear most, while 22% say they most fear breast cancer.8 While 1 in 3 women die of heart disease, only 1 in 25 will die of breast cancer.9
Too little is known about the diagnosis and treatment of heart disease in women because much of the research on heart disease in the last 20 years has either excluded women or included very few women.9 Women comprise only 24% of participants in all heart-related studies.10 However, there are data showing important differences between men and women when it comes to heart disease. Forty-two percent of women who have heart attacks die within a year compared with 24% of men.9 Since 1984, more women than men have died each year from heart disease and the gap between men and women’s survival continues to widen.10 Under age 50, women’s heart attacks are twice as likely as men’s to be fatal.10 Existing heart disease is undiagnosed in half of women who have a first myocardial infarction.9 Among people with cardiovascular disease, men have their cholesterol measured more often, are treated more aggressively (eg, with statin drugs), and have lower levels of so-called “bad” cholesterol or low-density lipoprotein than women.9 Women are less likely than men to receive aspirin, beta-blockers, ACE inhibitors, intravenous heparin, or nitrate therapies within the first 24 hours of hospital admission for myocardial infarction, therapies known to improve survival.9, 10 This contributes to a higher rate of complications after heart attacks in women, even after adjusting for age. Women are almost twice as likely as men to die after bypass surgery.11
Women’s myocardial infarction symptoms differ from those in men. Women are more likely to have signs and symptoms unrelated to chest pain, such as neck, shoulder, upper back or abdominal discomfort, shortness of breath, nausea or vomiting, sweating, lightheadedness or dizziness, or unusual fatigue.6 Seventy-one percent of women experience early warning signs of myocardial infarction with sudden onset of extreme weakness that feels like the flu—often with no chest pain at all, and nearly two-thirds of the deaths from heart attacks in women occur among those who have no history of chest pain.10
Risk factors differ between men and women.6 For example, the metabolic syndrome (increased blood pressure, elevated blood glucose and triglycerides) has a greater impact on women than on men. Depression is twice as common in women as in men, and it increases the risk of heart disease by two to three times compared with those who are not depressed.
The Women’s Ischemia Syndrome Evaluation found that the gold standard test for assessing coronary artery disease—the coronary angiogram—may not spot the more diffuse buildup of plaques that often forms in the smaller coronary arteries of women’s hearts.6 In some women, plaques accumulate as an evenly spread layer along artery walls, which is not treatable using traditional methods such as angioplasty and stenting designed to flatten the bulky, irregular, not-so-subtle plaques in men’s arteries.6 This results in women’s angiographic studies being misinterpreted as “normal.”
Screening for heart disease differs between men and women. Men can usually use their total cholesterol to tell whether they are at risk. Women, however, should learn their low-density lipoprotein (“bad” cholesterol) and high-density lipoprotein (“good” cholesterol) numbers as well as the total.12 Low levels of high-density lipoprotein are predictive of heart disease in women and appear to be a stronger risk factor for women over 65 than for men over 65. Diabetes increases a woman’s risk of heart disease three to seven times compared with a two- to threefold risk increase in men.12 Treadmills as a screening tool for diagnosing heart disease are accurate in men but not so in women. In one study comparing the accuracy of treadmill tests in women and men, misleading treadmill results occurred in 35% of the women studies.13
It was previously believed that heart disease risk increased when women reached menopause, and that the lack of estrogen was the problem. However, recently released large studies that involved women who have reached menopause cast significant doubt on whether replacing estrogen decreases heart disease risk.14 There is now evidence that atherosclerosis risk determines age at menopause rather than the reverse. Certain risk factors for cardiovascular disease, such as high cholesterol, increasing weight, and the Framingham Risk Score, could lower the age at which women reach menopause. This is a reverse hypothesis to the notion that menopause can increase the risk of cardiovascular disease.
Risk assessment for heart disease has been based on the Framingham Risk Score, first published in 1998, which estimates the risk of developing coronary heart disease within 10 years. Recently, the American Heart Association (AHA) updated its guidelines for preventing heart disease in women. The 2007 Guidelines for Preventing Cardiovascular Disease in Women were published in a special issue of the AHA’s journal Circulation.15 The focus now is on a woman’s lifetime risk for heart disease, not just her short-term risk, as was the case in the 2004 guidelines. Where once women were classified as being at high, intermediate, or low (optimal) risk for heart disease, they are now considered high, at-risk, or optimal. The new stratification incorporates, but does not rely solely on, the conventional Framingham Score. With few exceptions (eg, the use of aspirin for primary prevention of heart disease), recommendations to prevent cardiovascular disease in women do not differ from those for men. The new guidelines emphasize the fact that nearly all women are at risk for cardiovascular disease, underscoring the importance of a heart-healthy lifestyle.
Some of the important recommendations coming from the 2007 AHA panel include the use of aspirin and other therapies. Women age 65 or older should consider daily aspirin therapy if blood pressure is controlled and the benefit for ischemic stroke and myocardial infarction prevention is likely to outweigh the risk of gastrointestinal bleeding and hemorrhagic stroke. Routine use of aspirin in healthy women under age 65 is not recommended to prevent myocardial infarction, as it has been shown only to have a benefit for stroke prevention. Hormone therapy and selective estrogen-receptor modulators should not be used for the primary or secondary prevention of cardiovascular disease. Antioxidant vitamin supplements (eg, vitamin E, vitamin C, and beta-carotene) should not be used for the primary or secondary prevention of cardiovascular disease. Folic acid, with or without B6 and B12 supplementation, should not be used for the primary or secondary prevention of cardiovascular disease. The role that newer cardiovascular risk factors, such as high-sensitivity C-reactive protein, and newer screening technologies, such as coronary calcium scoring, should play in guiding preventive interventions is not yet defined. Further research is needed on added benefits, risks, and costs associated with such strategies before they can be incorporated into guidelines.15
Using data collected from over 24,000 initially healthy American women, researchers from Brigham and Women’s Hospital devised a new Web-based formula called the Reynolds Risk Score, that more accurately predicts risk of myocardial infarction or stroke among women.16 The findings appear in the February 14, 2007 issue of the Journal for the American Medical Association. Compared with existing risk stratification methodologies (eg, the Framingham Score), many women have been found to be at substantially higher risk using the new Reynolds Risk Score. Two new risk factors proved crucial to understanding cardiovascular risk in the women’s studies. The first was a simple blood test for C-reactive protein reflecting inflammation in the artery wall. The second was whether or not a patient’s parents had suffered a myocardial infarction before age 60. The Reynolds Risk Score can be freely accessed at www.ReynoldRiskScore.org. It allows each woman to calculate risk as she ages, demonstrating the impact that risk reduction early in life can have on future events.
Experts say that until Americans change their way of thinking from one of damage control to one of proactive prevention, heart disease will remain the number one killer of men and women in the U.S.5 One study that followed over 84,000 women who participated in the Nurses’ Health Study showed that women who adhered to lifestyle guidelines involving diet, exercise, and abstinence from smoking had a very low risk of coronary heart disease.17 Specifically, women who did not smoke cigarettes, were not overweight, maintained a healthful diet, exercised moderately or vigorously for half an hour a day, and consumed alcohol moderately had an incidence of coronary events that was more than 80% lower than that in the rest of the population.
As the number one killer of both men and women, heart disease is a topic deserving of two full issues in Seminars in Roentgenology. The Guest Editors, Dr. Smita Patel and Dr. Anil Attili, and the many contributing authors have provided us with the latest information available on how imaging plays a role in the diagnosis and treatment of heart disease. They have given us the heart facts. Future research will tell us more about how the role of cardiac imaging may differ between men and women.
References
- . http://www.nhlbi.nih.gov/health/hearttruth/whatis/index.htmAccessed 3-22-07
- . One in four U.S. women recognize the red dress as the national symbol for women and heart disease awareness; nearly half say the symbol would prompt them to talk to or see their doctor. http://www.nhlbi.nih.gov/health/hearttruth/whatis/reddress_recognized.htmAccessed 3-22-07
- . New Lifetime poll shows more than half of women know heart disease is their #1 killer, yet only one in three believe they are personally at risk. http://www.nhlbi.nih.gov/health/hearttruth/press/risk_awareness.htmAccessed 3-22-07
- . Womenshealth.gov http://womenshealth.gov/faq/heartdis.htmAccessed 3-22-07
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- Heart disease in women. a Mayo Clinic specialist answers questions. MayoClinic.com. January 18, 2007 http://www.mayoclinic.com/print/heart-disease/HB00040/METHOD=printAccessed 3-22-07
- National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499–510
- . Women’s fear of heart disease has almost doubled in three years, but breast cancer remains most feared disease. http://www.nhlbi.nih.gov/health/hearttruth/press/fear_doubled.htmAccessed 3-22-07
- . Research on Cardiovascular Disease in Women. AHRQ Pub. No. 06-P016. June 2006 www.ahrq.govAccessed 3-22-07
- . Women and heart disease facts. http://www.womensheartfoundation.org/content/HeartDisease/heart_disease_facts.aspAccessed 3-22-07
- . Women and heart disease fact sheet. http://www.womenheart.org/information/women_and_heart_disease_fact_sheet.aspAccessed 3-22-07
- . Who’s taking your family’s health to heart?. http://www.acc.org/media/patient/heart/family.htmAccessed 3-22-07
- . Gender differences in diagnosis and management of heart disease. http://www.womensheartfoundation.org/content/HeartDisease/gender_differences.aspAccessed 3-22-07
- . Heart disease risk determines menopausal age rather than the reverse. May 16, 2006 http://www.heart.org/presenter.jhtml?identifier=3040745Accessed 3-22-07
- Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115:1481–1501
- . New risk assessment tool more accurately predicts women’s cardiovascular risk. http://www.brighamandwomens.org/Pressreleases/PressRelease.aspx?PageID=226Accessed 3-22-07
- Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343:16–22
PII: S0037-198X(08)00002-3
doi:10.1053/j.ro.2008.01.001
© 2008 Elsevier Inc. All rights reserved.
