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When Sue Bullers began to feel ill on October 22, 2002, she wasn't overly worried. Her shoulder ached, and she felt nauseated and exhausted, so the 39-year-old single mom from Grinnell, Iowa, went to bed early, figuring she'd feel better after a good night's sleep. When she woke up in the middle of the night with a feeling of heaviness in her chest, she wrote it off as one of her usual bouts of heartburn. But the next morning, she vomited and felt dizzy. She called her doctor, and a nurse advised her that if she was feeling "really bad," she should go to the emergency room.
That sounded extreme to Bullers, who at this point thought she might have gotten the flu, so she decided just to stay home from her job as an instructor at a group home for mentally impaired adults. A few hours later, as she was making a sandwich for her 4-year-old daughter, Taylor, she felt dizzy again and suddenly passed out on the floor. Taylor threw herself on top of her mother and started slapping her face, screaming, "Wake up, Mommy!" That almost certainly saved Bullers' life, since she revived enough to crawl to the phone and call for help.
At the hospital, doctors discovered that the young woman was having a heart attack. "I was terrified and thought, 'Oh my God, I'm going to die,'" says Bullers, who turned out to have 99 percent blockage of her right coronary artery. She was catheterized and treated with a stent -- a tiny mesh tube threaded up through a vein in the leg and used to open a clogged vessel -- plus several medications, including a beta blocker (which blocks the effects of adrenaline on the heart) and an ACE inhibitor (which lowers blood pressure, thereby reducing the heart's workload). She was in the hospital nine days. (Her parents took care of Taylor.)
She recovered with only minimal damage to her heart and is now back at work, yet Bullers is still shocked -- and scared. Although she had several risk factors, including smoking, type 2 diabetes, and being overweight, she just wasn't aware what a dangerous combination they were. "I never thought I'd have a heart attack at 39!" she says.
That thought had never occurred to Andrea Lachowyn, 42, either. But when she got home from work on September 6, 2002, she suddenly felt so profoundly exhausted that she had to lie down. At the same time, the sales manager from Dublin, Ohio, started having severe pain in her arm, chest, and back. She thought she might be having a reaction to a prescription medication and was frightened enough to call 911.
When paramedics arrived, however, they didn't seem to take her symptoms seriously. "I got the impression that they thought it was just anxiety," says Lachowyn, a divorced mother of three children ages 5 to 15. "They didn't even take my blood pressure right away." Still, the paramedics took her to the emergency room, where she was given an electrocardiogram (EKG) and told that her heart function looked fine. Four hours later, she was sent home with a prescription for Valium.
Lachowyn slept for a few hours, but the next day her pain was even worse. She called a neighbor who was a doctor, and he examined her at his home office. Her blood pressure was very high, so he drove her to an urgent care center, where doctors dispatched her to the same ER she'd been to the night before. By now Lachowyn was in such agony she could barely move, so she was given a shot of morphine. Her father, who had made it to the hospital to be with her, didn't think that was enough. "Did you check her heart?" he demanded. That prompted doctors to do a blood test to check her level of cardiac enzymes (an EKG alone can miss 60 percent of heart attacks). The test revealed that Lachowyn, a former 15-cigarette-a-day smoker who worked long, stressful hours as an automobile sales manager, had suffered a heart attack the day before. "I couldn't believe it," she says. "And I was angry that my symptoms had been ignored. If I were a man, I wouldn't have been sent home with Valium."
Lachowyn was treated two days later with balloon angioplasty (insertion of a balloon-tipped catheter) to reopen an artery that was about 50 percent blocked, plus several medications, including aspirin and beta blockers, which reduce stress on the heart. She was lucky: Her doctor says she suffered very little heart-muscle damage. She was back at work in about a month, but ever since, instead of working 65 or more hours a week, she has cut back to about 45.
What happened to Bullers and Lachowyn is, unfortunately, not that unusual. Many doctors still consider coronary artery disease (CAD, essentially a narrowing of heart arteries due to buildup of fatty deposits called plaques) mostly a concern for men. Yet it's the No. 1 cause of death for Americans of both sexes, eventually afflicting one-third of women and nearly half of men, and killing in similar numbers (255,000 American women lose their lives to CAD each year, compared with 261,000 men). In many cases, heart attack is the first symptom of heart disease that's been developing for decades.
Yet symptoms in women are still poorly understood and often go unrecognized and untreated. "Women's symptoms are definitely more likely to be missed or misinterpreted than those of men," says Marianne Legato, MD, professor of clinical medicine at Columbia University College of Physicians & Surgeons and the founder and director of the Partnership for Gender-Specific Medicine at Columbia University, in New York City.
"Significant numbers of physicians still believe women are more likely to die of breast cancer than cardiovascular illness and consider heart disease a man's province."
The typical woman is no more enlightened. Only 9 percent of women ages 45 to 64 name heart disease as the condition they most fear -- while 61 percent consider breast cancer the most dangerous threat to their health, according to a September 2002 report from the National Institutes of Health. In reality, heart attacks kill six times as many women as breast cancer does. And a woman's chances of dying of cardiovascular disease (CVD) -- disorders of the heart (including CAD), or blood vessels, including heart attack and stroke -- are even greater. CVD kills 1 in 2.4 women, compared with 1 in 29 for breast cancer. Indeed, CVD claims more women's lives each year than all forms of cancer combined.
Why don't women get better cardiac care? First of all, the warning signs may be missed because heart disease symptoms are subtler in women than in men. A 2002 study at the University of California, San Francisco, found that of 721 men and women treated in the ER for heart attack, 58 percent of the men had chest, arm, shoulder, neck, or jaw pain, while only 41 percent of women had any pain at all. Other research shows that during a heart attack, women have a higher rate of so-called atypical symptoms, such as nausea, unusual fatigue or weakness, dizziness, heart palpitations, a cold sweat, or indigestion or gas-like pain.
Women's symptoms may also be missed because so many doctors still perceive heart disease as a man's illness, 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 (Ballantine, 2003). "Even though I know better, when I think of a heart attack, I see the picture they showed us in medical school: a middle-aged businessman sweating and clutching his chest," says Dr. Goldberg. "Until several years ago, that's what young doctors were always taught, so even if they see a woman with obvious symptoms and risk factors, they may not think they're looking at heart disease. I recently treated a 42-year-old mom who was overweight and a heavy smoker, and who had consulted two doctors about her chest pain. Neither of them did any heart tests: One said she was stressed out and needed a vacation, and the other prescribed Valium. Actually, she had a 99 percent blockage of a coronary artery and was at high risk for a heart attack."
Research shows that women with heart disease also are less likely to receive potentially life-saving treatments. "After a heart attack, they're less likely to be sent to cardiac rehabilitation, or to get medications like beta blockers, ACE inhibitors, or even aspirin to reduce the risk of a second heart attack," says Dr. Legato. Although nearly equal numbers of men and women get heart disease, women receive only 33 percent of angioplasties (insertion of a balloon-tipped catheter to reopen blocked vessels), stents (mesh tubes used to hold clogged vessels open), and bypass surgeries. All this may explain another deadly disparity: 38 percent of women die within a year of their first heart attack, compared with just 25 percent of men.
Until recently, doctors didn't know much about women's heart disease or the best treatments because, in the past, most major research studies were conducted on men. Indeed, women comprise only 25 percent of participants in all heart-related studies done to date, reports the National Coalition for Women with Heart Disease. "There's a Catch-22: Doctors don't use interventions like angioplasty or bypass surgery as aggressively for women as they do for men, because the effectiveness in women hasn't been studied as extensively," says JoAnn Manson, MD, chief of preventive medicine at Harvard's Brigham and Women's Hospital, in Boston. "As a result, women with heart disease sometimes end up being deprived of treatments that have already been shown to be beneficial in men."
However, now that more women are being enrolled in randomized clinical trials -- the gold standard of research -- physicians are finally starting to get answers about what works and what doesn't. Although doctors used to think ACE inhibitors weren't as effective for women, in October 2002, the Heart Outcomes Prevention Evaluation (HOPE) Study of 2,480 women who had heart disease or were at high risk of getting it showed that the medication has the same life-saving effects for women as it does for men. The women who received it were 38 percent less likely to die from cardiovascular disease. Another large 2002 study at Cardiac Centers of Louisiana found that beta blockers increase survival in women just as much as they do in men.
Of the 435,000 American women who have heart attacks each year, 2 percent are under age 45, and 19 percent are younger than 65. The average age for a first heart attack in women is 70.4, compared with 65.8 for men. (But if you smoke, here's another good reason to quit: Women smokers risk having a heart attack 19 years earlier than nonsmokers do.) Yet most women aren't focused on keeping their heart healthy because they're just not aware of their risks. And doctors aren't doing much to warn women of the danger. When the American Heart Association surveyed more than 1,000 women in 2000, 62 percent said their doctor had never discussed heart disease with them. That's alarming, because recent surveys conducted by several hospitals around the country show that about 80 percent of women age 40 and up have at least one risk factor for heart disease -- and more than half have two. (Dr. Goldberg says the percentage is about the same for men.)
While the most serious heart hazards are the same for men and women, some affect women more. For example, type 2 diabetes and HDL of less than 40 mg/dL are particularly risky for women, says Dr. Legato. Other risk factors include high blood pressure, high cholesterol, diabetes, smoking, high stress levels, being overweight (especially having fat around the abdomen), leading a sedentary lifestyle (sitting 16 hours or more a day raises risk by 70 percent, according to a study in the New England Journal of Medicine) or having a family history of heart disease (especially a parent who died of it before age 55). New research shows that the immune system's inflammatory response also contributes to clogged arteries. Inflammation may be caused by bacterial or viral infections, smoking, diabetes, high blood pressure, and high cholesterol. Women's risk also doubles or triples after menopause, due to the lack of the protective effects of estrogen. The more of these factors you have, the greater your danger.
The real key to saving lives, therefore, regardless of gender, is prevention. "Heart disease is not inevitable," says Dr. Goldberg. "Most risk factors can be reduced, or even eliminated, by lifestyle changes." In fact, Dr. Manson says that more than 80 percent of heart attacks could be prevented by lifestyle factors such as not smoking, being physically active, maintaining a healthy weight, eating a heart-healthy diet, and drinking alcohol in moderation. And the earlier you start taking steps to protect your heart, the safer you'll be, since plaque buildup can begin even when a woman is in her 20s or 30s -- though it usually takes decades before clogging gets bad enough to trigger a heart attack. "There's a lot you can do to protect yourself before your arteries get blocked from years of being overweight, smoking, or eating a high-fat diet," says Dr. Goldberg. "If gynecologists and primary-care doctors talked to every woman about heart disease, more lives would be saved."
Originally published in Ladies' Home Journal magazine, February 2004.