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Holly Andersen, MD, is too good-looking to be a cardiologist. I'm sitting in her office wondering who slipped the J.Jill model behind her desk. She keeps two 12-pound barbells on the credenza and does sets in between seeing patients. "Even if I can do it for just 20 or 30 seconds, I've done something for me," she says. As director of education at the Ronald O. Perelman Heart Institute at New York-Presbyterian Hospital, she's big on the idea of women doing something for themselves. She knows that many women have a "family and work first" attitude that puts their own health low on their to-do list.
Personally, I take a certain pride in not going to the doctor. Doctors are for wusses. Also, they always find something wrong -- as my mother, herself a doctor, used to tell me. I hate doctors. Unless they make me look better, in which case I love them. Let's review: Yes to dermatologists, no to virtually everyone else.
So what made me think that perhaps, at 50, I should go to a cardiologist? Well, recently I've been having palpitations and occasional shortness of breath. And a while back I wound up in the emergency room, thinking I was having a heart attack. Many hours later I learned I wasn't. It was actually a panic attack. Gee, could it have to do with any of the following?
1. My dad died. 2. Then my mom died. 3. My husband's a bit of a geezer. 4. My son has Asperger's syndrome. 5 My other son says he hates school. 6. I'm the breadwinner. 7. Nearly everyone in my family drops dead from a stroke or heart attack. Pick one.
Doctors are for wusses. So what made me think that perhaps, at 50, I should go to a cardiologist?
Clearly, stress is not unknown to me. Could this particular cocktail of problems ultimately lead to a genuine heart attack?
Dr. Andersen starts by asking my family health history, but not before she helpfully reminds me that cardiovascular disease is still the top killer of American women, and that those 35 to 54 appear to be dying from it at an increasing rate. Worst of all, nearly half of women say they wouldn't call 911 immediately if they thought they were having a heart attack. "They're so busy, they think, 'I can't be having a heart attack now -- I have to pick up my daughter,'" says Dr. Andersen. "As a result, they tend to come to doctors later than men, are less likely to be diagnosed -- and if they are diagnosed correctly, are less likely to receive lifesaving therapy quickly. That's why we've got to focus on prevention."
So, okay -- on to prevention. Dr. Andersen asks if I take medications (only Synthroid for my low thyroid -- and vodka) and gently prods me to discuss those recent stressors. I mutter something about my aversion to doctors but boast about not being too concerned since there's longevity in my family. "Yes, I had all my grandparents until I was in my 30s," the 49-year-old doctor says, slowly. "I also had a 50-year-old brother who was captain of the football and track teams in high school, exercised, never smoked. Worked like a dog. Probably didn't eat well. Didn't go to the doctor. Dropped dead of a heart attack last Labor Day."
"It's great to have longevity in your family, but that makes it even more important to take care of yourself and stay fit, because if you're going to live a long time, you want to live well," she continues. This I did understand, since in the past year I'd begun, for the first time in my life, to exercise regularly and watch my weight. I'd gone from a size 14 to a size 8 and was spending money on a personal trainer instead of a therapist on the theory that if I were going to feel inadequate anyway, I might as well be inadequate and toned. Did I mention that I don't put much faith in therapists, either?
When I tell Dr. Andersen I sometimes get palpitations, she asks for specifics: Regular or irregular? When do they happen? And do I get shortness of breath? "No, it's usually when I'm having thoughts like, 'Where are the kids and who's picking them up and did I buy a present for Saturday's party and when was that story due and what happens when my husband dies and I'm all alone?'" I say. "You know, the usual. A gimlet usually clears it right up."
"I think you may be self-medicating," she says. I concede that this is true.
We go into Dr. Andersen's examining room and she checks my resting pulse (58 -- not Olympic-athlete level but not bad) and my lying-down blood pressure (128/78). Later she checks it after I've been moving, and it's still only 134/80. This is pretty good but surprising because it's usually about 140/90 when I see a doctor; last time I went it was 160/90. (It was also high when I was pregnant; I was hospitalized for possible preeclampsia.) "Well, you must like me," she says. She's right. I'm more relaxed than usual at a doctor's office. "Resting blood pressure is often taken incorrectly," she continues. "When you're stressed, your blood pressure goes up pretty quickly."
My cholesterol levels look pretty good: My LDL, the bad stuff that goes right into making the plaque that clogs up your arteries, is a decent 106 (under 100 is better); my HDL, the good stuff that can especially protect women's hearts, is a terrific 64 (over 50 is protective); and my triglycerides, which can reveal your recent diet, are quite low at 50 (anything under 100 is good). For the record, my total cholesterol is a respectable 180, though Dr. Andersen says that the HDL and LDL numbers provide more important information.
She then gives me an electrocardiogram, a.k.a. an EKG, where tiny electrodes are attached all over my skin and I lie on a table and breathe. The EKG tests the electrical impulses of the heart. Mine are normal. "If you'd had a previous heart attack -- 25 percent of heart attacks go unnoticed -- this would most likely show you," she says. "And it gives us insight if there are any abnormalities in the chambers of the heart." There aren't. "You have the EKG of a 20-year-old," she says. Thank God something on me still looks 20! "Look over there," she says, shining a light into my eye. "I'm looking at the back of your eye. It's the only place on the body you can directly visualize your arteries. And if there's damage from blood pressure, high cholesterol, or diabetes, we can usually see it. But no -- yours look beautiful."
This day is turning out better than I expected. I begin to wonder if perhaps all the stress in my life is actually keeping me alive. Perhaps without it my pressure and heart rate would be so low I'd be unable to get off the couch.
But really, if everything seems normal, what next? Am I done? Dr. Andersen is quick to say that although things look good now, I shouldn't vanish from medical scrutiny for the next five years, which is essentially what I always do. I should get a blood test for my C-reactive protein level, which is an independent prognosticator of heart attacks in women. I need to cut down on salt, since I put salt on everything, including sugar (mmm, kettle corn). I need to stay active, or what passes for active given my preference for activities that involve lying down. Though then again -- there is a God! -- getting enough sleep and having good sex are pluses on the heart health ledger.
Emergency responders are still more likely to delay heart attack care for women than men. One reason? Symptoms in women can be different and more subtle than what men experience, says Claire Duvernoy, MD, founder of the Women's Heart Program at the University of Michigan Health System. Women often downplay their symptoms, too, and may put off calling for help.
For example, 40 percent of women having a heart attack never feel chest pain, says Dr. Andersen. Instead of an elephant sitting on their chest, women may feel pain in the back, shoulders, neck, or jaw; dizziness or sweatiness; extreme fatigue, and shortness of breath. "Most women having a heart attack also have a nagging feeling that something isn't right," Dr. Andersen says. "So don't wait for chest pain to call 911."
-- Richard Laliberte
Trouble may lurk in smaller blood vessels. In men, a heart attack usually happens when plaque in a large coronary artery forms a blockage or ruptures and causes a clot. But women with symptoms sometimes show no signs of coronary blockage in tests such as an angiogram. "Cardiologists may tell women they're at low cardiovascular risk," says Emily G. Kurtz, MD, director of Preventive Cardiology at Vanderbilt University Medical Center in Nashville. But they might not be. Sometimes the small blood vessels become stiff with plaque and inflammation, causing reduced blood flow to the heart and resulting in chest pain, or angina. It's called microvascular coronary dysfunction, and it's four times more common in women than men. And it can lead to heart attack, stroke, congestive heart failure, and death.
Pregnancy complications can be an early warning. If you had preeclampsia, gestational diabetes, or pregnancy-induced hypertension, you're at higher risk of heart disease, according to the American Heart Association's prevention guidelines for women. "Consider having one of those conditions as equivalent to failing a stress test," Dr. Kurtz says. "Preeclampsia, for example, roughly doubles the risk of heart disease, stroke, and blood clots."
Menopause boosts risks. It's clear from studies that your chance of developing heart disease increases after menopause. Whether it has to do with age, declining estrogen, or something else still isn't clear. Hormone replacement has not been shown to decrease your risks -- and may even raise them.
-- Richard Laliberte
Heart trouble may be difficult to diagnose in women, but the right screenings can help. Read our rundown of the most common ones.
Test: Blood Pressure
When to get it: At least every two years if number is lower than 120/80, yearly if between 120/80 and 139/89, and more often if 140/90 or higher.
When to get it: Every five years starting at age 20; more often if you have high total cholesterol and low HDL, are over 50, or have other risk factors.
Test: Blood Sugar
When to get it: Every three years starting at age 45 -- younger and more often if you're overweight or if the results reveal prediabetes.
Test: Electrocardiogram (Ecg or EKG)
When to get it: Anytime you're evaluated for heart-related symptoms or have a complete physical exam.
When to get it: If your doctor hears a heart murmur or suspects a problem.
Test: Stress Test
When to get it: If your doctor suspects you have impaired blood flow to the heart or other risks.
When to get it: If your doctor suspects you have a blocked or narrowed coronary artery.