Take Heart

Heart disease has long been considered an illness of men; in fact, it is more prevalent in women. More than 500,000 women die each year from heart attacks and strokes--10 times more than die from breast cancer. To combat this problem, every woman must become more aware of heart disease risks and take active steps to reduce those risks.

First, the bad news. When having a heart attack, a woman is less likely to suffer typical symptoms, reducing the chance that either she or her doctor will recognize the diagnosis. She is also less likely than a man to seek immediate medical attention, increasing the probability of dying or having major damage from the heart attack. Unfortunately, standard treatments such as “clot busting” drugs, angioplasty (using a balloon to open blocked arteries) and bypass surgery, though generally quite effective in women, pose greater risks than they do in men. Also, our common diagnostic tests (like the treadmill stress test) were initially designed for men and have turned out to be less accurate for women. As a result, for women, treadmill tests need to be supplemented with imaging techniques such as echocardiography (ultrasound) or nuclear images (using intravenous radioisotopes).

There is good news. Many studies have shown that women can definitely reduce their chances of having a heart attack or stroke by applying simple strategies. Regular exercise and a healthy diet have been preached for a while now. You do not have to be a marathon runner to help your heart.

You can reduce your heart attack risk with moderate activity, such as a four-day-a-week program of 20 minutes of aerobic activity: walking, running, swimming or bicycling. Even adjusting your routine a little can make a difference; for example, take the stairs instead of the elevator or walk to work (not a favorite pastime of Angelenos, I realize). Eating a low-fat, low-cholesterol diet will not only lower cholesterol levels, but also usually leads to weight loss.

And one of the most effective weapons against heart attacks is also the simplest--aspirin, that inexpensive, over-the-counter pain reliever. Aspirin reduces the risk of forming blood clots, the culprits of heart attacks and some strokes. The exact dose needed is still unknown, but most studies recommend doses between a daily “baby aspirin” (81 mg) and an every-other-day regular aspirin (325 mg) for women over 50 years old who have no bleeding problems, ulcers or aspirin allergy.

Some vitamins may also be beneficial. Recent studies have shown that a high level of homocysteine, a protein in the blood, may increase heart attack and stroke risk. More good news: Levels of this chemical can easily be lowered by folic acid and B vitamins at doses contained in most daily vitamins. The exact role of vitamins A, C and E, the antioxidants (chemicals that attack the “free radicals” damaging blood vessels), is not known. Women with the highest intake of vitamin E have the lowest incidence of heart disease, suggesting that daily supplementation of 400-800 IU of vitamin E may offer some protection.

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Now, more about cholesterol. Young women generally have lower cholesterol than men, but after age 50 the tide turns. The average cholesterol, specifically the LDL (or “lousy” cholesterol, as one of my patients calls it), level among women surpasses that of men. Many studies have shown that aggressive cholesterol lowering (often by a combination of a low-fat, low-cholesterol diet and medication) can be very effective at lowering heart attack risk in both women and men. For people with no known heart disease, we generally aim for a total cholesterol under 200, the LDL less than 130, and the HDL (the “healthy” cholesterol in that same patient’s dictionary) over 50. For someone who already has had a heart attack, the target levels are even lower.

What about hormone replacement therapy for postmenopausal women? Estrogen therapy (with progesterone for women who have not had a hysterectomy) definitely lowers cholesterol, but we do not yet have absolute proof that it lowers heart attack risk. Since hormone replacement therapy favorably affects cardiac risk factors, reduces fractures and usually improves well-being, I generally recommend hormones unless a woman has a personal or strong family history of breast cancer, as hormones may increase the risk of that cancer. Fortunately there are new drugs, such as raloxifene, that help the bones and possibly the heart without affecting breast tissue.

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Let’s not forget perhaps the most important thing: smoking. It increases by threefold the risk of a heart attack. Though smoking has declined in men, it has, unfortunately, increased in women, especially among teenage girls. But smokers should remember that it’s never too late to quit. A woman who quits today will find her heart attack risk almost normalized over the next five to 10 years. Many people have successfully stopped smoking with the help of the nicotine patch or gum, and more recently with a class of medications developed initially for depression. The bottom line: Though heart disease is common in women, it may be avoided with a few simple measures, including aspirin, vitamins, exercise and quitting smoking. You should also work with your doctor to consider hormone therapy and make sure your blood pressure, blood sugar (possible diabetes) and cholesterol are under control.

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Dr. Michele Hamilton is an associate clinical professor of cardiology at UCLA and co-director of the university’s Heart Failure Program.