By Suzanne Batchelor
Sunday, August 12, 2001
Women's vulnerability to heart disease has long been overshadowed by cancer concerns. Yet heart disease is responsible for half of all women's deaths, and it is unclear if hormone replacements are an effective preventative.
AUSTIN, Texas (WOMENSENEWS)--A 42-year-old woman recently sought emergency room treatment here for chest pain. She did not get the standard work-up for chest pain, an electro-cardiogram, that a man of the same age would very likely have received.
The woman herself thought she was having heartburn. Later examination showed that she had suffered a heart attack, undetected in the emergency room.
Now the woman has cardiomyopathy, damage to the heart muscle, according to her cardiologist, Dr. Parul Desai, head of the women's program at Heart Hospital in Austin. "That damage could have been prevented if both the woman and her emergency room doctors had considered heart disease," she said.
Doctors are overlooking and undertreating heart disease in women, and women themselves don't understand that they are at risk. For too long, heart disease has been seen by both women and medical professionals as a man's disease.
Moreover, although many believe that hormone treatment will protect postmenopausal women from heart disease, that premise has yet to be fully verified. In fact, on July 24, the American Heart Association announced a recommendation that women not take hormone replacement therapy in order to prevent heart disease.
The reasons for this misapprehension aren't clear, but its persistence in the United States has been documented since 1997 by the American Heart Association. Some progress has been made in education, diagnosis and treatment, says Dr. Desai, but, she adds, "We've got a long way to go."
The situation can only be cured by women themselves, says American Heart Association president and cardiologist Dr. Rose Marie Robertson.
"Women need to be more proactive about their heart health, especially if you consider that nearly half of all women will die from heart disease," she says.
Meanwhile, Dr. Robertson says, far too many women die waiting for that funny chest pressure to go away. People expect the "Hollywood heart attack," she says. "Women and men are often waiting for some enormous symptom--and that's not what it feels like."
Heart attacks do not often cause severe chest pain, Dr. Robertson explains.
"More often it's a discomfort, a tightness, pressure in the chest. If these symptoms are unexplained--that is, you didn't just pull a muscle and you don't have gastric reflux disease--and last more than five minutes, call 911," instructs Dr. Robertson. "Of the people who suddenly die out of the hospital, each year, 220,000 were in the early stages of a heart attack and were waiting for the feeling to go away."
The association found only a small improvement in heart disease awareness among doctors and women from 1997 to 2000.
Heart disease for women and men begins when they are in their teens and twenties, Dr. Robertson said, not in later years, as many believe. Though women's hormones appear to offer some protection up to menopause, women still develop the disease far earlier than they believe, she said.
The most recent survey showed that women get more heart health information from media--magazines and television--than from their doctors, Dr. Robertson said in an interview.
While research reveals that women with heart disease are at greater risk of death than are men, too many women and doctors still overlook the disease that kills more women than any other.
Surveys by the American Heart Association reveal:
Many women believe they won't get heart disease, and their doctors aren't looking for it, according to the 1997 and 2000 Women and Heart Disease Study surveys by the association. Yet more women die from heart disease than any cancer, including breast cancer, according to a joint statement by the American Heart Association and American College of Cardiology in May 1999. Heart disease in women, as in men, is largely preventable, yet doctors "are missing opportunities to prevent coronary heart disease," it said.
Similarly, a recent survey by the Centers for Disease Control and Prevention reported that, in routine doctor visits "women were counseled less often than men about exercise, nutrition and weight reduction."
At the same time, the definitive answer on whether hormone replacement therapy offers some protection to postmenopausal women is not yet available.
In fact, the answer may be five years off, when the results are in from a major study, the Women's Health Initiative, by the National Institutes of Health.
"That study will show pretty clearly whether primary prevention with hormone replacement therapy can prevent the development of heart disease," explains Dr. Robertson. "But right now, you don't want to be thinking you're protected because you're taking hormone replacement therapy.
"For many of us the message of the 1993 Heart and Estrogen/Progestin Replacement Study is, if you have cardiovascular disease and have not started hormone replacement, there's no reason to start it," Dr. Robertson adds.
In addition, a May 15, 2001, journal report from the American Heart Association is entitled, "Older Women Less Likely Than Men to Get Warfarin for Irregular Heartbeat." Warfarin is called "the most effective medication" for atrial fibrillation, yet doctors weren't prescribing it for their women patients.
Research published in the Archives of Internal Medicine, May 28, 2001, concluded that women known to have high blood pressure are being undertreated by doctors. Led by Dr. Steven M. Asch, it concluded that, on average, women are receiving only 64 percent of the medical care recommended for hypertension, saying that "most patients did not receive adequate initial history, physical examination or laboratory tests."
Undertreatment is one issue; another is that women do not respond as well to existing medical procedures.
Women's survival rates following heart bypass surgery are improving, according to a study led by Dr. Daniel J. O'Rourke and published in The Annals of Thoracic Surgery earlier this year. While certainly good news, the background to this advance is that since the beginning of heart bypass surgery, more women have died in-hospital than men.
Also, according to a study published in April in Circulation: Journal of the American Heart Association, "Women are more likely to develop a stroke after cardiac surgery than men, and their strokes are more likely to be fatal." Researchers admitted they do not fully understand why women are at greater risk.
And another study published by the American Heart Association in November 2000 found that the "deadly quartet"--the combination of diabetes, obesity, high blood pressure and high triglyceride levels--is more dangerous for women and children than for men. Dr. Dennis L. Sprecher, who led the research team, said that a woman undergoing heart bypass surgery, even with just one of these risk factors, has "nearly three times the risk of death" of a man.
Cardiologist Desai, head of the women's program at Heart Hospital in Austin, says doctors don't fully understand why women are more likely to die with the surgery. Dr. Desai notes that the gains made in lowering the death rate came mostly from new techniques used on both sexes, not from special attention to women's higher mortality rate. While bypass surgery has greatly benefited both sexes, women undergoing the treatment still remain at higher risk than men.
Dr. Robertson of the American Heart Association explains that a major part of the problem is that--when it comes to heart disease--less medical data is available on women than on men.
For years, she said, young pregnant women were excluded from heart studies for fear of harming a fetus. And although heart disease and stroke strike women later than men, researchers also excluded older women.
Because women with serious heart disease tend to be older than men and have other disease complications as well, researchers previously didn't want to include them because they would be comparing older, sicker women with younger men, and the comparisons would not be clear-cut and conclusive.
But research increasingly has focused on women since the mid-1980s. Dr. Robertson says medical researchers now find more funding available for studies of women's or gender issues, and they now are including more women in research studies, while taking precautions to protect pregnancies.
Dr. Robertson believes continuing research into women's unique physiology is crucial for understanding how and why women and men differ in heart disease and other illnesses.
"Women grow up--even from the first couple of cells--in a different milieu than men do. This affects every cell in the body, not just blood vessels," she says.
The symptoms of "just getting old" may hide treatable heart disease. Dr. Robertson gives the example of a patient at Tennessee's Vanderbilt Heart Institute, a 70-year-old woman who came in because, she said, her doctor had not helped her with her fatigue. Her doctor had told her she was tired because she was getting old.
But the woman told institute doctors, "I'm so tired for the last couple of years, I have to sit on the floor to vacuum." She was found to have an uncommon form of low blood pressure. Treatment for the condition restored her energy, to take care of herself and to enjoy life.
Suzanne Batchelor, a free-lance writer in Austin, Texas, has also written on health, medicine and science for "Healthline Texas" and the national "Earth and Sky" radio series.