How to Prevent a Heart Attack

The Best Heart-Health Checkup

Tremendous strides have been made in diagnosing and treating heart disease over the past decade. But here's the sobering part, if you're female: According to a landmark 2005 study, doctors continue to seriously underestimate women's heart-disease risks.

As a consequence, women still aren't referred as often as men for tests that would uncover problems -- especially those without obvious symptoms -- and so get fewer preventive treatments. Since 64 percent of women who die suddenly of heart disease had no symptoms, this underappreciation of the risks they face is more than just dangerous: It's lethal.

"It's surprising and sad," says Marianne J. Legato, MD, director of the Partnership for Gender-Specific Medicine at Columbia University, in New York City. "Men's death rates from heart disease are diminishing. Women's aren't."

Heart attacks are the number one killer of American women. Heart disease causes six times as many deaths as breast cancer and will kill some 230,000 U.S. women this year.

Part of the problem is that women tend to develop heart disease a decade later than men -- usually in their 60s -- and when they do get it, they're less likely than men to see their problems as severe, according to a new study, and thus they may delay getting care. But plaque formation can begin in your teens. Starting heart-saving strategies early betters your chance of heading off trouble. "Younger women need to realize that they are vulnerable," says Sharonne N. Hayes, MD, director of the Women's Heart Clinic at the Mayo Clinic, in Rochester, Minnesota.

Even if your genes make you a prime candidate, heart attacks are largely preventable. Unhealthy habits -- eating high-fat foods, carrying excess weight, being sedentary, smoking -- cause a staggering 82 percent of heart attacks in women, according to a landmark 2000 New England Journal of Medicine study.

A smart heart-health strategy begins with a complete checkup to evaluate your risk. If you're sent to a cardiologist, use our list of the latest tests to give yourself the best chance of finding and handling any trouble early.

A Thorough Medical and Family History

Your first step in a prevention program is figuring out if you're in good health or whether changes are in order. You can know this for sure by getting a thorough evaluation from your internist or family physician. The risk profile she arrives at will show whether you need to change your habits, use medication, or be referred to a cardiologist. "The tests your doctor gives you, and the treatment plans she devises, will be based on your individual risk factors," says Lori Mosca, MD, director of preventive cardiology at New York-Presbyterian Columbia University Hospital.

When you make your appointment, tell your doctor you want a thorough heart checkup so she'll leave enough time to inventory your habits, do tests, take a family history, and review your current health. Schedule the visit early in the morning -- blood tests are more accurate if you haven't eaten for 10 to 12 hours. Be sure your exam includes the following six elements:

Your doctor should take a detailed medical and family history: If your mother or sister developed heart disease before the age of 65 or your father or brother did before 55, that increases the odds that you will, too. Having had a hysterectomy or having gone through menopause before age 45 also are risk factors. Diabetes -- whether you or a close relative has it -- is another huge red flag. "A diabetic woman has the same heart-attack risk [2.5 times that of a healthy person] as someone who's already had a heart attack," says Nanette K. Wenger, MD, chief of cardiology at Grady Memorial Hospital, in Atlanta. Ills such as the hormone disorder polycystic ovary syndrome and peripheral vascular disease (the narrowing of blood vessels) are also associated with heart disease.

Be honest about your lifestyle. "Don't be embarrassed to answer questions truthfully," says Nieca Goldberg, MD, chief of Women's Cardiac Care at Lenox Hill Hospital, in New York City, and author of Women Are Not Small Men: Life-Saving Strategies for Preventing and Healing Heart Disease in Women.

• Do you -- or did you ever -- smoke? Even one to four cigarettes a day make a woman almost five times as likely to die of heart disease. If you stopped 15 years ago, your risk is the same as a nonsmoker's. Just one year of being smoke-free halves your risk.
• How often do you exercise? Being sedentary is comparable to smoking or having high cholesterol as a risk factor because it contributes to the development of both high blood pressure and diabetes and allows artery-clogging plaque to form in blood vessels.
• How healthy is your diet? Foods that are loaded with high-glycemic carbs and saturated fats up heart-disease risk.
• Are you constantly frazzled? This prompts the release of hormones that can cause inflammation, another heart-risk factor.

A Frank Discussion About Symptoms

Tell your doctor if you're having any symptoms that make you feel less than healthy, even if you think they're not related to your heart. You don't have to feel as though an elephant is sitting on your chest to be having a heart attack.

Women's early warning signs of heart attack -- they may appear without resulting in an attack -- are often subtler than men's: unusual fatigue; back pain; shortness of breath; severe heartburn or stomach pain; sweating or flulike ills, such as nausea, clamminess, or cold sweats; pain or numbness in one or both arms, the shoulders or jaw; sleep disturbance; or heart palpitations. Repeated bouts could be a warning sign that your arteries have dangerously narrowed or that you have a severe blockage. "Even shortness of breath when you're stressed-out or angry shouldn't be ignored," says Jennifer Mieres, MD, assistant professor of medicine at New York University School of Medicine. These can be signs of an actual heart attack or angina (reduced blood flow to the heart). You may even have chest pain, the "male" symptom.

During a routine exam, your physician will take your blood pressure (anything higher than 120/80 is considered risky). She should also weigh and measure you to calculate your body mass index (BMI), a ratio of weight and height that shouldn't be higher than 24.9. Even being moderately overweight -- with a BMI between 25 to 29.9 -- nearly doubles your risk of heart disease; a BMI greater than 30 triples your odds. Why? Carrying extra pounds ups the risk of both high blood pressure (although thin people can suffer from hypertension, too) and diabetes and elevates bad cholesterol (LDL), all of which are major contributors to heart disease. (To calculate your BMI yourself, go to www.lhj.com/bmi.)

Your doctor should also measure your waist and calculate your waist-to-hip ratio. A new study of 27,000 people in 52 countries found that the waist-to-hip ratio (your waist measurement divided by your hip measurement) is an even better predictor of heart at-tack than BMI. A higher risk ratio for women is 0.8 or higher.

A waistline of 35 inches or more is another red flag, regardless of BMI. Apple-shaped women -- those who collect fat around their middles -- are more prone to heart disease because they are likelier to be suffering from metabolic syndrome, which triples the risk of death from heart disease according to a 2004 study. This condition occurs when cells are resistant to insulin, a hormone that helps the body convert sugar into energy (other risk factors for insulin resistance are triglycerides above 150 mg/dL, blood pressure at 130/85 or above, and HDL cholesterol levels below 50 mg/dL).

Three Must-Do Baseline Tests

Because internists and family physicians tend to discount cardiac risks in younger women, you need to proactively ask for tests you want, says Dr. Mosca. Three must-haves:

• A fasting lipid profile test measures levels of three blood fats -- the two types of cholesterol plus triglycerides. LDL (low-density lipoprotein), the so-called bad cholesterol that forms the plaque that sticks to blood-vessel walls, isn't the only fat that boosts risk. Triglycerides transport fatty acids into your blood after eating. If they're too high, they make red blood cells stick together, which ups the risk of a clot. The goal is for overall cholesterol to be 200 or lower, LDL to be below 130, and triglycerides to be below 150. On the positive side, you can offset the heart-health impact of high LDL if your level of HDL (high-density lipoprotein) -- the protective cholesterol that ferries excess cholesterol out of the arteries and dumps it in the liver -- is 50 or more.
• A fasting blood glucose test shows your risk of diabetes, a major contributor to heart disease. Symptoms are vague: fatigue, extreme thirst, frequent urination. Almost a third of the 18 million diabetics in the United States are undiagnosed. A blood-sugar range of 100 to 125 means you are prediabetic -- you'll need a second, more elaborate and accurate blood test.
• A resting ECG (electrocardiogram). This painless test uses electrodes to detect problems in heartbeat and whether you had an attack. Though not recommended under the American Heart Association's routine screening guidelines, women over 40 should get one, says Dr. Mieres. It sets a baseline against which your doctor can diagnose symptoms later on.

Here are two other tests your doctor may order if you have risk factors. They're relatively new and not always covered by insurance.

• C-reactive protein test. If you have a strong family history of heart disease or elevated cholesterol, you may want to ask your doctor for this simple blood test, which can help detail your level of risk, says Dr. Wenger. CRP is a protein secreted by the liver in response to inflammation, including in your blood vessels. We know now that inflammation plays a big role in heart disease, though we don't yet know the most effective medications and ways to treat it. The test can cost $10 to $120 depending on where it's done. Results above 3 mg/dL are considered high risk; 1 to 3, average; below 1 is good. Being sick or overweight (fat cells secrete inflammatory substances) can up inflammation, distorting test results.
• LDL Particle Size Test. There's more to understand about bad cholesterol (LDL) than your overall count: This sophisticated blood test measures risk by whether your LDL is carried in particles that are predominantly small (bad) or large (good). The smaller your particles, the likelier they will burrow into blood-vessel walls, thickening arteries. "The small heavy particles, known as Pattern B [if that size predominates], are the ones that do the damage, while the light and puffy ones, called Pattern A, are relatively innocuous," says Leslie Cho, MD, director of the Women's Cardiovascular Center at the Cleveland Clinic, in Ohio. Another way to gather similar information is to have levels of apoB in your blood analyzed. If you have a low ratio of LDL cholesterol to apoB, you likely have Pattern B, and vice versa-a high ratio suggests Pattern A. The jury's still out on whether particle size is a better marker of risk than routine screening. Studies have shown that having smaller particles can triple heart-disease risk. People with Pattern B should be more aggressive about lowering their LDLs -- optimally below 70 mg/dL, well under the usual 100-mg low-risk level.

Staying Healthy

After reviewing your history, examining you, and seeing the results of your tests, your doctor will probably move in one of three directions:

You may be in fine shape, in which case, you'll probably leave after you settle how soon you need your next checkup. At this point, you should also discuss how to keep your heart as healthy as it is now.

You may have elevated cholesterol or other risk factors that could be lessened by lifestyle changes or other types of therapy. Together, you and your doctor will set up a treatment plan, including follow-up testing to track how well it's working and whether it needs to be adjusted (see "Take Charge of Your Cholesterol," below).

Or your physician may determine that you need further testing and diagnosis.

Use exercise and diet alone or with drugs.

Exercise/stress relief. In the landmark Nurses' Health Study, women who exercised vigorously at least three hours per week cut their heart-disease risk 30 to 40 percent compared with sedentary counterparts. Exercise improves cholesterol levels and prevents plaque buildup, keeps the heart muscle healthy, and combats high blood pressure and diabetes. It also reduces C-reactive protein.

Any activity that adds up to 30 minutes at least of moderate daily exercise counts -- taking the stairs instead of the elevator, gardening, walking the dog.

Counteracting stress helps, too.

Diet. Drop LDL levels by cutting out saturated and trans fats. Substitute unsaturated fats, such as omega-3 fatty acids and monounsaturated fats.

A Mediterranean-style diet can reduce recurrent heart problems as much as 70 percent and reduces inflammation. Focus on fruits, vegetables, poultry, shellfish, and fish; eat little red meat. Switch to nonfat dairy. Eat plenty of fiber, whole grains, beans, and nuts. Moderate alcohol consumption can help.

Drugs that lower bad cholesterol. Statins can lower LDL up to 60 percent, whittle down triglycerides and C-reactive protein, and slightly increase good HDL, cutting heart-attack risk in women nearly 34 percent. They interfere with the liver's overproduction of cholesterol and also help prevent buildup of plaque in artery walls. Rare but serious side effects (liver, muscle, and kidney damage) mean statin users must monitor the liver and watch for muscle soreness.

How low to go? A major 2005 study revealed that people at high risk can significantly cut heart attacks and strokes by lowering LDL to below 80 (the target for low-risk people is 130). Ask your cardiologist which number to use.

Drugs that raise good cholesterol. Prescription niacin can raise HDL 20 to 35 percent. Niacin can cause skin rash, skin flushing, and stomach upset; an extended-release formula can ease symptoms. Fibrates can also increase HDL 10 to 25 percent. Primarily used to cut triglycerides (by 20 to 50 percent), they can also be especially helpful for diabetics: A 2005 study revealed that taking fibrates can reduce the incidence of nonfatal heart attacks by 24 percent in people with type-2 diabetes. Though people with coronary artery disease should be on statins, fibrates must be used carefully in combination with these medications because they can cause muscle and liver damage. "The drug regimen should be managed by a specialist," says Dr. Sharonne Hayes, of the Mayo Clinic.

If You Are Referred to a Cardiologist

Your family doctor will send you to a cardiologist if you have symptoms that haven't been reversed or controlled with medications or lifestyle changes. You may also be referred if you have a strong family history of heart disease or conditions that exacerbate it, such as diabetes, insulin resistance, high blood pressure, or high cholesterol.

It's important to find a cardiologist you feel comfortable working with. "A good cardiologist not only has the credentials but also the ability to be a good listener and the skills to individualize your treatment," says Dr. Mieres. Ask your physician and friends for recommendations. Ask hospitals with heart programs for women for referrals to a physician familiar with women's special needs. (One source: The home page of the National Coalition for Women with Heart Disease, www.womenheart.org, lists both "Women's Heart Centers" and "Best Heart Hospitals" under "Resources.")

You can check cardiologists on Healthgrades.com (education and training, board certification, years in practice, disciplinary actions, hospital privileges, location, health plans accepted, etc.). Cost: $7.95 for initial report, $3.95 for each additional profile.

A cardiologist will prescribe tests of your arteries and heart, including new scan techniques that can yield more reliable information. No single test can tell all; the right combination will help identify the best lifesaving treatments. Below, your options:

What it does: Evaluates heart muscle at rest and peak exercise with a combination of treadmill testing and ultrasound. If you can't exercise, a resting echocardiogram may be used alone. A chemical that raises heart rate can also be injected if you need a stress echocardiogram and can't use the treadmill. This test is more accurate for diagnosing heart disease in women than a stress electrocardiogram (ECG) in part because estrogen can interfere with electrical signals, making results more difficult to interpret. What's more, the ECG stress test is better at detecting problems in the larger arteries, says C. Noel Bairey Merz, MD, a cardiologist and medical director of Women's Health at Cedars-Sinai Medical Center, in Los Angeles, "but women are more likely to have disease in their smaller blood vessels."

Who needs it: The stress echocardiogram will be ordered as a follow-up to the ECG if you have a heart murmur, chest pain, or shortness of breath.

What happens: An ultrasound transducer placed over different areas on your chest emits high-frequency sound waves that create visual images of the heart and indicate the blood flow to different parts of your heart. In the stress echocardiogram, images of the heart are taken while you work out on a treadmill or exercise bike.

What it does: Measures the buildup of calcium, or plaque, within the arterial walls. Calcium collects in the blood vessels when excess cholesterol embedded in artery walls and inflammation prompts some blood cells to calcify. Over time, the calcium stiffens the arteries, which raises blood pressure and forces the heart to work harder.

"This provides additional information after a cholesterol test," says Linda Demer, MD, a cardiologist at UCLA who has studied coronary calcium, "and could help people decide if they need to be taking a statin or can just get away with making lifestyle alterations." A high percentile in someone who doesn't have other symptoms or known heart disease means he or she should be further evaluated, while someone in the moderate range should discuss lifestyle changes with a cardiologist. Insurance companies don't always pay for the $300 to $500 test. "If you're at low risk, or you're already taking statins, you may not need it," says Dr. Demer.

Who needs it: People with several risk factors, such as high cholesterol, elevated blood pressure, or a strong family history of heart disease.

What happens: Doctors use either electron beam computed tomography or a spiral CT scan to identify calcium deposits in artery walls.

What it does: Measures levels of homocysteine, an amino acid used by the body to help build and maintain tissue. Too much homocysteine causes blood platelets to stick together and damages the lining of the arteries, which can lead to heart attacks and strokes. Because measuring homocysteine levels to identify heart-disease risk is relatively new, benchmark values are not yet established. But elevated levels have been linked to increased coronary blockages.

Who needs it: High-risk patients with personal or family history of heart disease. It may also be ordered after a heart attack to help guide treatment. It is not used as a routine screening test for people at low risk.

What happens: A blood sample is taken by needle from a vein in the arm; sometimes a urine sample is also collected. Your doctor may want you to fast for 10 to 12 hours before the test.

More Cardiology Tests

What it does: Detects up to 90 percent of coronary artery disease and measures how well cardiac tissue is being nourished by oxygen-rich blood through a two-part scan.

Who needs it: Patients who have an abnormal resting ECG, who are unable to exercise, or who have already been diagnosed with a problem and need more sensitive and specific information about the condition of their heart, says Dr. Bairey Merz.

What happens: A small amount of a radioactive tracer is injected through an IV into your vein. After you exercise on a treadmill, a scanning camera snaps images of your heart. A few hours later, a second set of images is taken while you're in a resting state and the two sets are compared. If the heart muscle is damaged, it won't absorb the radioactive material. Arteries are blocked or dangerously narrowed if uptake of the radioactive isotope is reduced during exercise but normal when you're resting. If the test detects blockages in multiple areas, you may be referred for an angiogram.

What it does: Produces detailed images of the heart and determines how well the heart is pumping. While MRIs are growing in popularity, says Dr. Cho, "they don't tell you whether your heart is getting enough blood during exercise."

Who needs it: Often those suspected of having damage to the heart structure, such as leaky valves or holes in the heart, or if the sac surrounding the heart, known as the pericardium, is injured.

What happens: A powerful magnetic field generates images of aorta and carotid arteries to evaluate congenital heart disease.

What it does: This X-ray test is invasive and has been around since the late 1950s but is still seen as the gold standard for identifying blood-vessel blockages.

Who needs it: If other tests indicate there is blockage, you need this test to determine whether you require surgery or an angioplasty. It's performed on patients who have abnormal ECGs or blockages or are in the midst of a heart attack.

What happens: In this procedure -- always done in a hospital -- a doctor inserts a thin flexible tube called a catheter into a blood vessel in the groin and then gently maneuvers it into a coronary artery. A dye that is visible by X-ray is injected into the coronary arteries, which makes blockages evident. Angiograms have a slight risk of triggering heart attack, stroke, bleeding, or an arrhythmia.

What it does: This test for blood-vessel blockages will likely reduce the need for angiograms for many patients. X-raying the heart has been hard because it is in constant motion. These newest CT scanners divide the heart into 64 imaginary slices, greatly increasing image resolution and providing a more accurate diagnosis of arterial blockages. While CT scans are less invasive than angiograms and provide much the same data, patients are exposed to high levels of radiation -- about 50 to 80 times that of a chest X-ray -- and insurers may not pay, as they're still considered experimental. Still, "if you don't want an angiogram," says Dr. Hayes, "a CT scan may be helpful."

Who needs it: Same as for angiograms. People with stents or extensive calcium deposits aren't good candidates, because X-rays can't penetrate metal or calcium.

What happens: Dye is injected into the coronary arteries and X-rays image slices of the heart. A computer combines these into a detailed map of arteries and fat-filled plaque.

Stress & Your Heart

It's well established that impatient, angry, hard-driving Type A personalities are likelier to keel over from a heart attack than are pleasant and noncompetitive Type B's. But new evidence links cardio problems to yet another personality type: Type D, the chronically distressed worrier who is uncomfortable in social situations. For cardiac patients, being a Type D personality may be as much of a risk factor for a heart attack as obesity, smoking, and family history.

"Evidence suggests that half the people who have heart attacks don't have high cholesterol," says Edward C. Suarez, PhD, a psychologist at Duke University Medical Center, in Durham, North Carolina. "But we're starting to understand that psychosocial factors and emotional states, like chronic anxiety, depression, and hostility, are major contributors to heart disease."

When we're angry or under pressure, our bodies release stress hormones that spike blood pressure and blood glucose levels so we have the energy and endurance to fend off enemies. This also enhances our ability to form blood clots to heal wounds. Prolonged saturation with stress hormones promotes high blood pressure, harms blood vessels, and contributes to blood clotting that can lead to heart attacks. Meanwhile, the immune system responds by releasing proteins that cause inflammation, harming the heart and letting plaque build up on blood vessel walls.

A 2004 Duke University study found that people who scored high on tests for depression, hostility, and excessive anger had elevated levels of C-reactive protein (CRP), an inflammatory marker linked to increased risk of future cardiovascular disease. "If they had all three traits, CRP levels were double," says Dr. Suarez, who did this research. And a 2005 Israeli study found that women with job-related burnout had higher CRP levels.

The Type D personality describes people who are inhibited socially, are often unable to form close relationships, and have a "generally bleak view of themselves, their future, and the world," says Dr. Goldberg, of Lenox Hill Hospital. "They too risk heart disease due to their tendency to suppress or not deal with anger."

Research shows the importance of a positive outlook. In one 2005 study of women over age 60, the more positive participants felt about their relationships, and the more sense of purpose they felt, the lower their interleukin-6, a potentially harmful protein related to inflammation and heart disease. Another found that depressed men have more interleukin-6 and CRP.

Among proven ways to stay heart healthy: Regular exercise relieves tension and reduces stress hormones. So do yoga and meditation breathing and relaxation techniques. A support network of friends and family helps. And laughter may truly be the best medicine, studies say.

Know Your Heart Scores

This handy guide will help you keep track of good and bad test scores on a variety of tests you may be given.

Blood Pressure
Good score: Less than 120/80

Body Mass Index (BMI)
Good score: 24.9 or less
Moderate risk: 25-29.9
High risk: 30 or more

Waist Circumference
High risk: 35 inches or more

Total Cholesterol
Good score: less than 200 mg/dL
Borderline: 200-239
High risk: 240 or more

LDL
Optimal: Less than 100 mg/dL
Good score: 100-129
Borderline high: 130-159
High risk: 160-189
Very high: 190 or more

LDL Particle Size (ratio of large to small particles in your LDL)
Low risk: Pattern A (more large particles)
High risk: Patter B (more small particles)

HDL
Optimal: 60 or more
Good score: 50 or more
High risk: Less than 50 (women), less than 40 (men)

Triglycerides
Good score: Less than 150 mg/dL
Borderline: 150-199
High risk: 200-499
Very high: 500 or more

Blood Sugar
High risk (prediabetic): 120-125

C-Reactive Protein
Good score: Less than 1 mg/dL
Average: 1-3
High risk: More than 3

Family Medical History
High risk: Father or brother got heart disease before 55; mother or sister before 65

Originally published in Ladies' Home Journal magazine, February 2006.