Medicine Turning Its Attention to Women and Heart Disease : Health: After decades of believing heart-attack risks were greater for men, doctors now think differently. After menopause, experts say, the odds even out.
The myth began in the small community of Framingham, Mass.
There, in the late 1940s, a sweeping, government-funded study began to track the cardiovascular health of thousands of men and women, noting what they ate, how they lived and from what they died.
Early in the now-famous Framingham Heart Study, researchers noticed that men began suffering heart attacks in middle age, while women seemed unaffected. The experts guessed that because women have high levels of the hormone estrogen, they were protected against heart disease.
“The early conclusion from that study was that women were not suffering from heart attacks, that women are immune due to estrogen,” says Dr. Edward B. Diethrich, medical director of the Arizona Heart Institute and author of the new book “Women and Heart Disease.”
That explanation was accepted as fact. Two decades later, while in medical school, Diethrich recalls a professor telling him: “Don’t worry about women.”
Wrong.
Physicians now recognize that while estrogen--or something--does seem to protect most women against heart disease in the first half of life, after menopause the rate of heart disease soars in women and is almost equal to the rate in men by age 65. For example, men age 65 and older suffer an estimated 440,000 heart attacks each year, compared to 374,000 in women age 65 and older.
But many women still do not get prompt diagnosis and treatment of heart disease, experts say. And many women have failed to educate themselves about the risks and warning signs.
“If you ask doctors what the biggest killer of women is, I think a lot of doctors would give the wrong answer,” Diethrich says. Heart disease is the leading killer in women, accounting for 240,497 deaths in 1989, the last year for which statistics were available.
“And most women don’t realize that once you are post-menopausal, the risk is equal (to men),” he says.
Many of the studies on heart disease have been done on men, leaving physicians with a serious lack of understanding of the disease in women, Diethrich says.
He tells two stories to illustrate the persistence of the myth: In one case, a woman came to an emergency room four times complaining of chest discomfort. Her complaints were dismissed as stress-related. It’s “nerves,” she was told.
The next time the pain hit, she didn’t make it to the emergency room--and she died, Diethrich says.
In another case, a women frantically drove her husband to the emergency room because he had chest pain. While waiting for her husband to be checked, she suffered from an attack of pain. Physicians rushed to attend to her, but she waved them off.
“She said, ‘It was nothing. I’m here for Sam,’ ” Diethrich recounts. The doctors persuaded the woman to submit to an exam and, Diethrich says, “We operated on this woman for heart disease three days later.”
Efforts never have been greater, however, to close one of medicine’s most embarrassing gender-based knowledge gaps. Already this year several studies have advanced the understanding of heart disease in women. And the recent annual American College of Cardiology meeting in Anaheim gave the gender issue top billing.
“We’ve called attention to this problem,” says Dr. C. Noel Bairey Merz, director of the Preventative and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center. “Now, we need to do more studies in women. And, in addition, we have previous studies that can be looked at now with a new angle.”
Recent studies point to the obvious need for better diagnosis and treatment of women:
* According to the largest national registry of heart-attack patients, women over age 70 are more likely to suffer heart attacks than men of same age (56.5% compared to 32.7%).
* Studies also show that early treatment with thrombolytic, or clot-busting, therapy offers the best chance of survival. But a recent survey found that women were less likely to be treated with such drugs within four hours of the start of chest pains. Not surprisingly, women with delayed treatment were more likely to die.
* Women who undergo angioplasty, in which a tiny balloon is used to clear clogged arteries, are 10 times more likely to die in the hospital. The female angioplasty patients were more likely to be older and sicker than men. But even after age-related risk factors were taken into account, women were still 4.5 times more likely to die in the hospital. Doctors are puzzled by this and are calling for more studies to determine possible reasons for the higher death rates.
* Symptoms of heart attack in women may differ from men, according to research released last month. While a man may experience a crushing chest pain that radiates through the chest or left arm, a woman may have a more lingering pain, vague chest discomfort and nausea.
“Because all the (early) studies on heart disease were done in men, what we call typical is a man’s standard,” says Bairey Merz. “The standard may be different for women. We need to tell older women it may feel different.”
However, it’s not yet clear how much of these differences in women is due to poor or delayed treatment. It’s also possible that heart disease is different in women and harder to treat, experts suggest.
Before menopause, it is widely believed, natural estrogen works to prevent the buildup of fatty deposits and blood-clot formations that are the hallmark of heart disease. A recent Finnish study also showed that high levels of iron may contribute to the heart-attack risk in men. Women, however, may be protected from this risk because they lose a lot of iron during menstruation.
But at menopause, a woman’s risk increases dramatically. In addition to being post-menopausal, they also are subject to the same risk factors as men, including smoking, high blood pressure, high cholesterol, diabetes, a sedentary lifestyle and stress.
Even if a physician suspects heart disease in a woman, it is often harder to diagnose, experts say. For example, several common diagnostic tests and treatments appear to be less successful in women, including the stress test, thallium scan and electrocardiogram.
“For these reasons, the physician may say, ‘These tests aren’t reliable,’ ” Diethrich says.
Doctors also may be more reluctant to do cardiac catheterization in women--in which the heart is examined by threading a small tube into a vein or artery and into the heart--because women’s veins are smaller and the risk for complication is greater.
But these are not reasons to avoid the tests, Diethrich says. “You just have to do it.” Still, even with appropriate treatment, women don’t fare as well.
According to the National Institutes of Health, 49% of women who have had heart attacks die within one year, compared to 31% of men. Because women are older when they first experience heart disease, they may have other diseases that accompany aging, such as hypertension or diabetes.
“You’re operating on a patient 10 to 15 years later than the average man,” Diethrich says.
And says Bairey Merz, “Your average 75-year-old woman with cardiovascular disease is sicker than the average 75-year-old man.”
She believes the difference may lie in the way women’s bodies react to stress. Her studies show that stress increases blood pressure and heart rate and causes the arteries to squeeze shut in post-menopausal women.
But, she says, “Women on estrogen don’t get that squeeze. They tend to be protected.” However, no one understands yet how estrogen protects against heart disease.
One of the most promising areas of research on women involves the use of hormone replacement therapy (which includes estrogen) to prevent heart disease. Some studies suggest that giving estrogen to post-menopausal women may cut the risk of heart attack in half. To test the hypothesis, Dr. Howard L. Judd of Cedars-Sinai Medical Center is directing a 15-site, five-year study called HERS.
“HERS is one of the first studies ever to focus exclusively on women who have heart disease,” says Judd. “It’s trying to answer the question, ‘Does hormone replacement therapy help or reduce the risk of heart disease in women?’ ”
Patients eligible for the study, which will eventually include 2,400 women, must be under age 76 and have hard evidence of heart disease, such as having suffered a heart attack or undergone bypass surgery or angioplasty. Women will either be assigned to take hormone replacement therapy or a placebo. They will receive full gynecological care for the five years of the study. (Hormone replacement therapy is not without risks; it has been associated with an increased chance of breast cancer.)
However, Evelyn Sapiro, 60, is an eager participant. The Venice woman had open-heart surgery a few years ago after suffering severe angina. She is typical in that she didn’t suspect her illness was heart disease.
“When I had the chest pains, I didn’t even think of heart disease,” she says. “I thought I might have breast cancer.
“Maybe this study won’t help me,” Sapiro adds. “But maybe it can help my daughter. It’s exciting to be part of it. There just hasn’t been anything for women with heart disease. Everything has been geared to men.”
