Phases of the Heart
Cardiovascular Disease in Women
B Y K A T H L E E N Y O U N T
UAB Magazine
When you’re 17, it’s hard to imagine that the fries and Coke you’re enjoying with your friends could mean the difference between bouncing a grandchild on your knee at age 70 and dying before your first child graduates from high school. At 17, most girls haven’t given much thought to having kids at all—a teenage brain simply isn’t built to worry about health consequences 20 or 40 or 60 years down the road.
But between the soda and fast food something has to give, because heart disease is still killing women at a rate that outpaces all other diseases—as it has throughout the last century. And for most women, the first steps toward heart disease are taken in their teens.
“Everybody’s always looking for new ways to detect heart disease in women,” says Bonnie Sanderson, Ph.D., manager of cardiac rehabilitation at UAB Hospital. “But the bottom line is that most cases of heart disease can be prevented if we just focus on lifestyle factors: requiring physical education in schools, teaching our kids healthy nutrition, reducing obesity, and preventing smoking. If that’s established early in life, then the medical ambiguities of what to do later on will no longer be the big issues they are today.”
Researchers at UAB have been exploring those issues by taking part in a major study of women and heart disease—the WISE (Women’s Ischemic Syndrome Evaluation) study. But participating UAB cardiologist Vera Bittner, M.D., says she wants to focus on more than just the findings stated in the report, which was published in February. She and Sanderson want to talk about what’s not being said.
“We’ve all been studying and arguing about which test to use to detect heart disease in women in their thirties or forties,” says Bittner. “This research is very important, but it’s not changing the fact that the women in our study may have been 100 percent overweight for 30 years. We’re trying to find disease markers, which we must do, but we must also address the simplest solution: preventing disease by making lifestyle changes.”
Setting the Trends
Among its many nasty attributes, smoking is a major contributor to another condition that is underdiagnosed in young women: hypertension. |
One lifestyle choice that remains all too fashionable among young women is smoking. “Even though public-health messages about smoking are reaching other groups, younger women are not getting the message,” says UAB cardiologist Salpy Pamboukian, M.D. To be clear, the rate of smoking among women is still lower than that of men, but the gap is shrinking. And according to the 2001 Surgeon General’s report, women who smoke double their risk of heart disease.
Among its many nasty attributes, smoking is a major contributor to another condition that is underdiagnosed in young women: hypertension. “A lot of women, unless they go for yearly physicals, are not getting their blood pressure checked,” says Pamboukian. “And because it’s asymptomatic, young women may not even realize they have hypertension. They should be getting screened in their thirties, twenties, or even teens, especially if they have positive family histories.”
The African-American community is particularly vulnerable to hypertension. “Even if they’ve been diagnosed with high blood pressure, African Americans often aren’t adequately treated,” says Pamboukian. “We hear people say, ‘I’ve been told I have high blood pressure,’ but they’re not on medication.” The effects of untreated hypertension may not be seen until a woman is 50, but if she’s been hypertensive since her teen years, she could be diagnosed with heart disease much earlier. “I’ve had patients in their 20s with congestive heart failure,” says Pamboukian. “And it’s because they’ve had high blood pressure for so long.”
Marriage, Motherhood, Role-Modeling
It’s been another long and grueling day at the office. Before you go home you have to pick up the kids: one from school by 5:30 and the other from day care before 6. Your palace awaits you: a house full of laundry, a bathroom that needs cleaning, dinner that needs preparing. And on top of that, the dog is sick. Will you be able to find time to take him to the vet tomorrow? What about your dentist appointment next week? What about tonight’s dinner? It could be that Pizza Hut is in your family’s feeding future.
Meanwhile, the treadmill you put in your bedroom—hoping it would make it easier for you to fit some exercise into your day—well, it makes a great place to hang the shirts that still need ironing and pile the socks that need sorting.
In most households, the woman still runs the domestic show, and for many women that means stress. “Lots of women neglect their health because they’re busy looking after everybody else,” says Pamboukian. “They aren’t going to their doctors for well-woman visits or having their regular screenings. And a lot of women overeat when they have young children; when they take their kids to fast-food places, they end up eating the same food the kids eat—and sometimes finish off whatever the kids leave on their plates.”
This is a critical time to maintain a healthy diet and to exercise, but sadly, most young mothers tend to let those aspects of their lives slide. “Everybody has stress,” says Sanderson. “What’s important is how you deal with the stress. If you are active and you eat right and you don’t smoke, you’ll be better able to respond and to cope with stress—and enlist more productive problem-solving actions.”
Stress and a jam-packed schedule may also cause women to ignore the early signs of heart disease. “So many physicians see patients who say, ‘I’ve been having this symptom for two years, but I just ignored it because I assumed it was heartburn,’” says Pamboukian. “Women probably ignore their symptoms more often than men—and even when they do seek medical attention, they aren’t always taken seriously. When a woman comes in complaining of symptoms of heart disease, her doctor might tell her that it’s just stress or anxiety. If you’ve been brushed off before, you may think, ‘If I go to the doctor, they’re just going to tell me I’m anxious.’”
Pamboukian also says that women are at times more passive than men when describing symptoms to their doctors, asking questions, and requesting tests and screenings. “You really have to be your own advocate,” she urges. “If you’re concerned about your symptoms, if you feel that something isn’t right, you need to ask your doctor to do the screening tests.”
Sanderson says that mothers, in particular, must take the lead in promoting heart health. “Women, in my opinion, are the role models within their houses,” she says. “Most moms are the ones who cook, who do the grocery shopping, who arrange activities for the kids. Men are more involved with the children now than in generations past, but women are still often the major decision-makers. So they really have a huge responsibility, not only for their own health, but also for future generations.”
The Secret Syndrome |
Obesity and poor nutrition will speed a woman toward a diagnosis that is not often mentioned but very often associated with heart disease: metabolic syndrome. “During the last few years, research has shown a clear association between metabolic syndrome and risk of heart disease, so our patients need to avoid being in that state,” says UAB cardiologist Salpy Pamboukian, M.D. She notes that “metabolic syndrome” isn’t a term that many physicians use with patients, although it’s estimated that more than 50 million Americans fit the grim profile:
- established obesity, particularly excess fat around the abdomen;
- insulin resistance, or glucose intolerance, in which the body is unable to properly use sugars in the bloodstream;
- hypertension;
- blood fat disorders—such as low HDL cholesterol and high triglycerides—that encourage the buildup of plaque in the arteries;
- prothrombotic (blood-clot-promoting) states such as high fibrinogen or plasminogen activator inhibitor-1 levels in the blood; and
- pro-inflammatory states such as elevated levels of C-reactive protein in the blood.
Although metabolic syndrome is frequently linked to type-2 diabetes, Pamboukian says that the two are not always intertwined. “Not all people with type-2 diabetes fit the criteria for metabolic syndrome,” she says, “but those who do are veritable powder kegs in terms of their susceptibility to cardiovascular disease.” |
Doing What Works
By the time middle age sets in, decades of poor eating and lack of exercise weigh so heavily on many women that they’re simply tired and unmotivated to change. “When people have a certain lifestyle for a long time,” says Bittner, “they really have no recollection of what it’s like to feel good. We try to get the point across that if you exercise and lose weight, you’ll actually genuinely feel better.
“That should be the motivation. I don’t think we should be saying to people, ‘Exercise today to prevent a heart attack in 2025.’ The motivation should be, ‘If I sit around all day long, I’m going to feel terrible at the end of the day. So I’m going to get some exercise so that I’ll feel better.’ The problem is, people aren’t saying that to themselves—and maybe it’s because they just don’t remember what it’s like to feel good.”
“Maybe it’s that you think that exercising takes too long,” suggests Sanderson. “Or maybe you exercised today and you felt horrible so you’re not going to do it tomorrow. People don’t realize that it’s the everydayness of it—of eating right, exercising, not smoking—that provides the benefits. Pretty soon it just becomes a habit and you do feel so much better. But getting to that point is tough.”
A Hot Flash or a Heart Attack?
Your granddaughter has just learned to crawl, and boy does she keep her parents on their toes. You love to babysit her whenever you can, but sometimes you just don’t feel like yourself. You have heartburn and an upset stomach more often than you used to, and you can’t ever seem to get to a comfortable temperature. You don’t sleep well, and you’re more tired than you used to be. How do you know if it’s hormones, heart disease, or just a hectic day?
As women age, it often seems that hormones get all the attention. Between menopause and breast cancer—both of which are at their peak incidence in the age ranges of 50 to 65—issues such as high blood pressure and heart disease tend to take a back seat.
What effect do hormones—and hormone-replacement therapy—have on heart disease? “I think most people would say that there’s definitely a relationship between being either premenopausal or postmenopausal and the incidence of coronary disease,” says Pamboukian. “Estrogen seems to be protective; it’s associated with higher HDL [good] cholesterol and lower LDL [bad] cholesterol.”
But just replacing estrogen after menopause doesn’t appear to be the answer, she says. In the last four years, data released from the Women’s Health Initiative and the Heart Estrogen/Progestin Replacement Studies (HERS) have called into question the benefits of hormone-replacement therapy for postmenopausal women. “Right now hormone-replacement therapy is not indicated for prevention of heart disease,” says Pamboukian. “It is only indicated for women who are having severe symptoms of menopause.”
When trying to interpret all of the data, Bittner says it’s important to remember one thing: “You cannot disentangle age from menopause.” For that reason, she says, the exact relationship between hormones and the heart remains unclear.
How Low Must We Go? |
Among the screenings women need to have beginning in their 30s—if not before—are their cholesterol levels. “Cholesterol-lowering medicines are pretty standard for someone who’s been diagnosed with coronary artery disease or who is at risk,” says Pamboukian. “Even if cholesterol is measured as normal, we’re still very aggressive about bringing it down to the newest goals. For patients with risk factors but no diagnosed heart disease, the revised LDL goal is less than 100. If you develop heart disease, the goal for LDL [bad] cholesterol used to be less than 100; now it’s less than 70. A lot of people probably aren’t meeting the new target because it’s a really aggressive target.”
And what about good cholesterol? “You want to try to get your HDL cholesterol levels as high as you can,” she says. “Medication can help raise it, but weight loss, quitting smoking, and exercise are really the best ways to raise your HDL.” |
“Some people say that after menopause women have higher rates of heart disease than men. But that’s not true. If you look at absolute numbers of deaths, in the younger age groups, it’s four men to one woman. As women get older, the difference gets smaller and smaller. But even if you look at 80-year-olds, men still have a higher risk of dying from heart disease.
“What is true, if you look at absolute numbers of deaths, is that males die younger, so you’re left with a lot of older women. Many more older women die of heart disease than older men—but that’s because the men are already dead.”