Doreen McHugh remembers coming home from school one day and telling her mom, Nicki, that she should quit her two-pack-a-day smoking habit.
"I had just learned at school that a cigarette a day cuts off a minute of your life," Doreen McHugh recalls. But her mother replied: "Well, God already has destined for me when I'm going to die, so this isn't going to matter,' " says McHugh, now a UC Irvine junior.
But she and her father, Encino accountant Dan McHugh, are convinced smoking did matter--that it stole Nicki McHugh from them three years ago, when she died of oxygen insufficiency at age 44.
Nicki McHugh was an anomaly, a woman with a heart disease that killed her suddenly and early in life. But she provides a dramatic symbol of a danger that women are being warned about only now: Heart disease is an equal-opportunity killer.
Long treated in the popular press and even in doctors' offices as primarily a problem for middle-aged men, heart disease has been the No. 1 killer of women in the United States since 1908; it remains that to this day.
Twice as many women die of cardiovascular disease than of all types of cancer. Just under half of the 520,000 fatal heart attacks in America every year occur in women, according to the American Heart Assn.
A woman faces a lifetime 1-in-11 chance of developing breast cancer but a 1-in-2 chance of developing cardiovascular disease, the broad category of conditions that includes high blood pressure, stroke and coronary heart disease, which leads to heart attacks.
Indeed, the number of heart attacks in women will continue to rise as the baby boomers grow older, because the overwhelming majority of heart attacks occur in women after age 65.
So why haven't women heard more about this before?
Blame the later onset and different nature of the symptoms of coronary heart disease in diagnosing it in women, and a scientific and medical Establishment that has concentrated its resources on men because they often show their first signs of heart disease in middle-age dramatically, with a heart attack.
Blame it also, some would add, on the fact that a 45-year-old male heart attack victim has a much higher profile and perceived socioeconomic value than does a 65-year-old lifelong housewife.
But whatever sex or age bias there may have been in the past, the graying of America over the next few decades means that the definition of "old" and of "premature" heart disease is changing, said Trudy Bush, an epidemiologist and women's health researcher at Johns Hopkins University.
"The medical Establishment has been geared to preventing premature disease, which is by definition before age 50 or 60--and women don't get heart disease before these ages," Bush said. "Now, Jane Fonda is 51, and all of a sudden 51 looks really good. Now we're thinking, 'Well, 60 and 65 isn't old any more'--and so any disease that occurs in the 60s is considered remature."
If Bush is right, that change in thinking will stand to benefit women, in whom the incidence of heart disease doesn't begin to rise substantially until six to 10 years after menopause. (An average women reaches menopause at age 50.) Before age 60, one in 17 women has heart disease; by age 65, one in three women have it.
Concerned about the obscurity of women's problems with heart disease, the American Heart Assn. launched a nationwide initiative lastweek to educate women and their doctors on their need to be vigilant about heart disease.
The effort included the unveiling of a new educational booklet and video at a Washington conference, where the McHughs shared their family's story.
Her voice sometimes cracking, Doreen McHugh, 20, discussed how difficult it was for her to have no mother to lean on when she went off to college just a few months after Nicki McHugh's death in June, 1987.
"It's the family that they leave behind--we have to deal with her mistake," she said.
Her father told of handing out to smokers thousands of flyers detailing his family's tragedy. He especially tries to give the pamphlet to women with children. "Do whatever is necessary to give up smoking . . . the pain of the alternative isn't worth it!" the flyer says.
Unlike 44-year-old Nicki McHugh, most women don't have a problem with heart disease until after menopause, when heart disease rises dramatically. The reasons are the subject of much speculation but little hard evidence, researchers agree.
It is clear that the female hormone estrogen, which the ovaries stop secreting at menopause, raises the levels of protective HDL cholesterol in women's blood.
This is thought to be the mechanism that accounts for women having such low levels of heart disease before menopause, said Dr. William Castelli, medical director of the Framingham Heart Study.
A number of studies indicate that giving women estrogen pills after menopause reduces heart disease deaths by at least 50%, Bush noted. (Indications that it also promotes cancer, however, have made this method controversial as a therapy to prevent heart disease.)
But since cardiovascular disease in men is considered a result of a process that takes 30 years, why does it develop so quickly in women? Some suspect there is an underlying, undetected pathological process going on earlier in life.
"It may be that what happens with women is that before menopause, we have a smoke screen, where all this is happening but it's behind the screen. The estrogen is there but it's not really a protection--maybe it's a screen," said Margaret Chesney, an epidemiologist at UC San Francisco.
If that is the case in a given woman, it is likely to go undetected, said Dr. Renee Hartz, a cardiac surgeon at Northwestern University.
Chest pain, an early indicator of heart problems in men, often is in women a symptom of other less serious conditions, such as a heart valve not closing symmetrically. So doctors don't pay as much attention to chest pains in women as they do in men, Chesney said.
In addition, standard diagnostic tools for detecting early heart disease--such as the treadmill exercise test--are rarely used with women, Hartz said. When they are used, they often don't give the clear-cut results doctors seek, primarily because women's disease usually isn't as advanced as it is in men. And, because doctors know about the low-risk of advanced heart disease in premenopausal women, they are reluctant to use these ambiguous results to justify more definitive but potentially dangerous tests such as angiograms.
(This procedure involves inserting a catheter into the artery and can itself result in death from heart attack, which happens more often in women than in men.)
Yet Hartz remains convinced that if the medical community begins taking women's risk of heart disease more seriously, it would find women with problems sooner; this would improve their chances of surviving procedures such as coronary bypass operations because they would be younger when diagnosed, she said. A woman is two to eight times as likely to die shortly after this surgery than a man is, Hartz said.
Another problem in trying to identify women at risk of heart attack is evidence that they may be subject to different life-style risk factors than men, Chesney said. Although she and others agree with warnings against saturated fats, smoking and a sedentary life style, there are hints of other risk factors in women, she said.
One Swedish study found that, among men managers at a Volvo plant, blood pressure and levels of the stress hormone norepinephrine began declining after they left work. But for women managers, blood pressure stayed up and the hormone level rose into the evening. Researchers suggested this was because the women were coping with their second job, the home.
Chesney noted that studies at UCSF have shown that working women react to stress by adopting unhealthy behaviors.
"Women under stress sleep less, exercise less, weigh more, feel more anger and smoke more," Chesney said. "So it may be that working plays a role in increasing heart disease through other channels, other standard risk factors."
Sorting out the confusion has not been done mainly because most cardiovascular research has been concentrated on men and on heart attack, rather than the less dramatic symptoms that women with heart disease tend to have, Chesney and others said.
Dr. Barbara Packard, of the National Heart, Lung and Blood Institute, noted that the institute has started three long-term studies that should help show if there are early markers of heart disease in women: One is monitoring the health of elementary-school girls; another is following the health of men and women ages 30-45, and a third is monitoring effects of estrogen replacement therapy in post-menopausal women.
Castelli, whose 41-year heart study puts him among the deans of cardiovascular research in America, bristles at suggestions that the scientific Establishment has been remiss in not answering basic questions about women and heart disease.
Using federal recommendations and data on 1,600 premenopausal women whom the Framingham study began following in 1948, he suggest ways women can hold down their risk of heart disease:
* Stop smoking. Seventy percent of heart attacks in women less than 50 years old are blamed on smoking, Chesney said. The risk is even higher if a woman takes birth control pills.
* Keep blood pressure below 140/90.
* Know your cholesterol levels but in more detail than the 200-mg-per-deciliter of blood serum, the maximum viewed as healthy. Although the average woman heart attack victim has a total cholesterol level of 335, another 20% of all heart attacks occur in people who have levels below 200, he noted.
These are the numbers Castelli believes are important for women: The ratio of total cholesterol to HDL cholesterol should be 4.5 or less. HDL levels should be at least 40 mg. Levels of LDL, the "bad" cholesterol carrier, should be under 160 (130 if there are other risk factors such as smoking). The level of triglycerides, another fat in the blood, should be below 150.
These figures, plus a basic analysis of a woman's risk factors for heart disease, can help doctors right now to find the 1 in 17 women under age 60 who are headed for a heart attack, he said.
Bush also recommends that women who take birth control pills have their cholesterol levels checked at least annually, although the National Cholesterol Education Program would consider every five years as adequate, if a woman had no heart disease risk factors. The program does not consider taking The Pill or being a post-menopausal woman risk factors for heart disease.
And Hartz contends that middle-age women should not rely on their gynecologists to monitor their total health. "Women need to get other doctors. It's not a gynecologist's job to find heart disease," Hartz said.
These ideas represent the kinds of debates that can be expected in the next few years over signposts of good cardiac health care in women.
But, in older women at least, the focus should be on pushing heart attacks back rather than on eliminating them entirely, suggests Bush.
"We all have to die of something. What I want us to do is not to die prematurely," she said. "I'd like to live to 88 and then drop dead of a heart attack. That would be fine. I just don't want people dropping dead of heart attacks in their 60s and 70s. It's just not necessary."
WOMEN AND HEART DISEASE * One in nine women aged 45 to 64 has some form of cardiovascular disease, and the ratio climbs to one in three after age 65. * About 247,000 of the more than 520,000 heart-attack deaths that occur each year happen to women. That makes heart attack the No.1 killer of American women. * Women who have heart attacks are twice as likely as men to die within the first few weeks. * Thirty-nine percent of women die within a year after a heart attack compared to 31% of men. * Among black women, the figures are even higher. The age-adjusted death rate from coronary heart disease in black women is 22% higher than for white women, and for stoke it is 75% higher. * About 22 million American women smoke, making their risk of heart attack two to six times that of a nonsmoker. * Women smokers who use oral contraceptives are up to 39 times more likely to have a heart attack and up to 22 times more likely to have a stroke than women who don't smoke or use birth control pills. Source: American Heart Assn.