Heart attacks in young women
At age 30 and seemingly in great health, Cindy DeMarco was jolted awake early one Saturday three years ago with nausea, upper back pain, shortness of breath and a strange pressure in her chest. She thought the pain had to be related to her distance running or the racquetball game she had played the previous evening.
She took some ibuprofen. When the pain hadn’t relented 12 hours later, she went to the hospital, where she was given muscle relaxers and advised to go home. Instead, DeMarco demanded an electrocardiogram. Even after the nurses reluctantly hooked it up, they thought the machine had to be malfunctioning when it indicated she was having a heart attack.
“Because I was young and female, they weren’t even thinking of that,” DeMarco said.
Like most women, the Alexandria, Va., attorney feared that she’d get breast or some other type of cancer one day. But in reality, 10 times as many women die of heart disease and stroke as they do of breast cancer -- about half a million each year in the U.S. A woman’s risk of heart disease rises substantially after menopause, but not all victims of heart disease have reached that milestone. About 10,000 women under age 50 died of heart disease in 1998, far greater than the 6,286 who died of breast cancer that year, the last year for which such figures were readily available.
Moreover, women under 50 are more than twice as likely to die of heart attacks as are men in the same age group. One reason: Women are more likely to be misdiagnosed in the emergency room.
Misdiagnoses occur in male and female heart attack patients. In a study of about 10,700 patients, at least 2% of heart attacks and cases of unstable angina were misdiagnosed in men and women, said Dr. Harry Selker, the study’s lead investigator. Selker, who is chief of clinical care research at Tufts-New England Medical Center and a professor at the Tufts University School of Medicine in Boston, says the error rate indicates that about 26,000 people having heart attacks are mistakenly sent home without adequate treatment each year in the U.S., making it the most frequent cause of malpractice complaints. Those not hospitalized were about twice as likely to die as those who were admitted, Selker said.
Women under age 55 were the prime candidates for misdiagnosis: They were 6.7 times more likely to be misdiagnosed and sent home.
“They [emergency room staffers] have a stereotype that a person having a heart attack looks like [Vice President] Dick Cheney -- in his 50s or 60s and white,” says Nancy Loving, executive director of the National Coalition for Women With Heart Disease, who had a heart attack at age 48 and who co-founded the nonprofit advocacy and support organization with two other women who had also suffered heart attacks.
Diagnosed as indigestion
Cases of misdiagnosis in younger women abound. Paula Upshaw of Laurel, Md., was in the bleachers, cheering her son’s football team when she had a heart attack at age 34. The emergency room doctors went through the proper protocol, asking numerous questions about risk factors and symptoms, checking her blood for enzymes that indicate a heart attack, and performing an electrocardiogram. But they told her the tests were normal and sent her home with instructions to take Mylanta for indigestion.
A week later, in pain she describes as being “off the charts,” she returned to the hospital and refused to leave until she was admitted. The doctor on duty still didn’t think she was having heart problems, until the staff cardiologist -- who had come in the next day to review EKGs -- asked to see “the 34-year-old who had the massive heart attack.” Upshaw immediately had double-bypass surgery.
She is unable to return to the busy job she had as a respiratory therapist at another hospital -- where she worked with heart patients. Upshaw remains permanently disabled 12 years later, with just 60% of normal heart function because of the extensive damage to her heart muscle. “I always tell women to ask to see the [test] results, and it’s happened 15 times since [that the staff hadn’t read the results],” Upshaw says. “Even if you don’t know what it means, act like you know what it means, because it forces the doctor to explain it and look at them himself. ... That’s the guilt I live with every day: that I wasn’t an advocate for my own self.”
Emergency room doctors and nurses have become better at recognizing the symptoms of heart attacks in a woman, thanks to awareness campaigns about the prevalence of heart disease in women -- 10% of women ages 45-74 and 25% age 65 and over suffer from it. Medical schools and hospitals have also improved training in evaluating symptoms.
Still, a lack of awareness among women remains a problem, contributing to the mortality rates. In women, the symptoms of a heart attack can be nausea and upper back and jaw pain -- with or without the crushing chest pain typically found in male heart attack victims. So, instead of telling emergency room personnel that they are having chest pain, women often say they have indigestion or muscle aches. That puts them lower on the priority list in crowded emergency rooms.
“The biggest issue is getting across [to women] that when they have an unbearable sensation, they shouldn’t be embarrassed to call 911 and go with the ambulance drivers and be saved,” said Dr. Debra R. Judelson, a cardiologist with the Cardiovascular Medical Group of Southern California in Beverly Hills.
The medical establishment is partly to blame for the relatively low awareness about the prevalence of heart disease in women, says cardiologist C. Noel Bairey Merz, medical director of the Women’s Health Program and the Preventive Cardiac Center at Cedars-Sinai Medical Center in Los Angeles. “We wrote a lot in the 1960s, ‘70s and ‘80s that women were protected from heart disease, and that with the exception of diabetics, they never get it.”
Doctors may know less about women and cardiovascular disease because so few women have been studied by researchers. Even now, only 25% of subjects in heart-related research are women -- up from just 20% in 1990, says the National Coalition’s Loving.
Women get just one-third of the bypasses, angiograms, stents, angioplasties and implantable defibrillators in heart patients; men get the rest. “We have to be half-dead before we get treated,” Loving says.
About 80% of heart disease is predictable and understandable in both men and women, said Cedar-Sinai’s Bairey Merz.
Most heart attacks are caused by coronary artery disease, which is usually the result of atherosclerosis. This buildup of plaque inside the arteries causes them to harden and narrow, leaving less room for the movement of blood. Heart attacks occur when blood flow becomes too restricted or when the plaque comes loose. (Artherosclerosis can also occur elsewhere in the body, leading to strokes and poor circulation in the legs.)
The typical risk factors for coronary artery disease, commonly referred to as heart disease, include high blood pressure, high cholesterol, diabetes, and a family history of heart disease (particularly those with a parent who had a heart attack before the age of 50). Smoking dramatically elevates the risk.
Being overweight, as one-third of Americans are, also is a factor, doctors say, primarily if the person is morbidly obese. It is particularly a factor in women if they are more apple- than pear-shaped, with the concentration of weight around the belly. Women are at greater risk of heart attacks a year or so after giving birth, because the associated hormones cause laxity in the blood vessels. Birth-control pills elevate the risk; depression also seems to contribute to the risk.
Dr. Nanette Wenger, an Atlanta cardiologist, says acceptable blood pressure, blood sugar and cholesterol levels have changed over the last 15 years. “Moderate elevations of multiple risk factors cause the majority of heart attacks in both men and women,” says Wenger, a professor of medicine at Emory School of Medicine and chief of cardiology at Grady Memorial Hospital.
Heart attack as first sign
Many middle-aged women, such as Toni Miller of West Los Angeles, never know they are at risk until they have a heart attack. Miller’s occurred in October 2001 at age 50.
She didn’t smoke or drink, she wasn’t obese and she was energetic -- skating over to her mother’s house, running a busy oral surgeon’s office and being what she calls the “go-to gal” when friends and family needed things done.
“I wasn’t sitting on the couch eating butter for the past 10 years, I was active,” Miller says with a raucous laugh.
Her friend Debbie A. Kelly agrees: “I saw and still see her as a vibrant woman. Heart disease seems like an old folks’ malady.”
Miller had kept up with her Pap smears and mammograms. But like many other women, she had relied on her gynecologist for primary medical care, she hadn’t had any cholesterol tests and she hadn’t paid much attention to her family history (both of her parents had heart disease).
It took several months to recuperate from the initial heart attack, a second attack suffered while she was doing a stress test on a treadmill, and triple-bypass surgery for three blocked arteries. Miller still tires easily. In addition, she was diagnosed with breast cancer about a year ago and has been undergoing chemotherapy.
These days, Miller is taking drugs called statins, which have reduced her cholesterol levels. She’s become a hawk when it comes to reading food labels: She’s cut saturated fats such as ice cream, butter, red meat and sour cream from her diet.
Now, she says, she wants to do whatever it takes so she can meet her future grandchildren, which might be a while since neither of her daughters, ages 19 and 25, has any such plans at the moment.
“It’s so cliche, but I so appreciate just the green trees, or just being able to walk the dogs,” says Miller.
Recent studies have indicated that the hormone replacement therapy that many women were taking during and after menopause increases the risk of heart disease, opposite of the effect it was thought to have. As a result, many gynecologists now refer women who may be at risk of heart disease to a cardiologist before prescribing hormones.
That way, a woman can get a full work-up and the doctor can give her a stress test, a physical workout that can be an indicator of heart disease. However, the tests aren’t completely reliable, and they seem to be about 7% to 10% less reliable in women than in men, Bairey Merz said. They produce false negatives in about one-third of the cases, she added.
Tests that are generally more reliable (and more expensive) include a nuclear scan, in which radioactive material is injected into a vein to show the working of the heart muscle ; echocardiography, which changes sound waves into pictures that show the heart’s size, shape and movement and how much blood is pumped out by the heart when it contracts; and coronary angiography, which shows blood-flow problems and blockages in the coronary arteries.
Shame and self-blame
Even though heart disease is so prevalent, women who suffer from it often feel it carries a stigma -- one reason advocates have been unable to persuade any celebrities to talk publicly about their conditions. “Women have to have this youthful appearance, and if they admit they have heart disease, it’s always aligned with being old,” says Judelson, the Beverly Hills cardiologist. Women sometimes feel responsible for their problem. “It’s the shaming and the blaming,” says the Coalition’s Loving. “ ‘I smoked. I’m fat. I’m sedentary.’ But if men have one, it’s because ‘I’m an alpha male.’ It’s almost a rite of passage.”
Now, more women are coming out of the closet about having heart disease, following the path of advocates for breast cancer and AIDS patients. The Department of Health and Human Services recently launched the Red Dress Project, a campaign to raise awareness that heart disease is the leading killer of American women, and that much of it is preventable. Many of the women pictured in the group shot, wearing red dresses donated by designers, look healthy, confident and in shape.
Now age 33, DeMarco, a lawyer with the Army who for years has been a fit 5-foot-3 and 120 pounds, is nearly back to normal. She was lucky. The heart attack did little long-term physical damage, although it initially left her shattered emotionally and scared to do any of the exercising she loved.
In her case, doctors still don’t know the cause. She had none of the risk factors. Her grandfather and his brothers died of heart disease, but not her father, which would have indicated the most risk. Doctors told her it was a fluke.
“I feel better than I ever felt, because I pay attention and listen more to my body,” says DeMarco. “I don’t push myself to the limit like I did before.”
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Most heart attacks come on slowly
Women often don’t recognize that they’re having a heart attack and may ignore the warning signs. Experts say to call 911 if you have one or more of these symptoms:
* Chest pain or discomfort. Most heart attacks start slowly, with mild pain or discomfort, usually in the center of the chest. It can feel like uncomfortable pressure, squeezing, fullness or pain.
* Discomfort in the stomach, jaw, neck or back. Women frequently feel this type of pain, either in addition to or without the chest pain.
* Shortness of breath
* Cold sweat
* Nausea or a feeling of indigestion
* Lightheadedness accompanying these symptoms
