Mary didn't have any chest pain. She said she just felt tired. She went to the emergency room on that Thanksgiving Day only because her children insisted.
While she was in good health for a 67-year-old woman, she hadn't been feeling well for several days. But she didn't want to ruin her family's favorite holiday by complaining.
But it was clear when her children arrived to celebrate the day that something was very wrong. Mary was not herself.
Even so, Mary insisted: "I never get sick. I am sure everything is fine."
The truth is, Mary had been feeling dizzy, lightheaded and nauseous off and on for days. She attributed her symptoms to the stress of preparing for the holidays.
Mary had no idea that she was having a heart attack.
Heart Disease: The No. 1 Killer of Women
Heart disease is the No. 1 killer of women in the United States, a fact that may surprise many people. Patient surveys and Gallup polls have repeatedly shown that most women (and many doctors) presume that breast cancer is the most common cause of death in American women, an assumption that stems from successfully run cancer-prevention campaigns.
The reality is that heart disease accounts for 45 percent of all deaths in women, far greater than all cancers combined. In fact, women are four to six times more likely to die from heart disease than they are from breast cancer.
The popular notion that heart disease is a "man's disease" fails to account for the fact that women are three times more likely than men to die after a heart attack. Even more startling is the knowledge that two-thirds of women who drop dead from a heart attack (so-called sudden death) have no prior history of heart disease.
Understanding Heart Disease
Understanding how women differ from men is the first step in educating and protecting ourselves against the risks of heart disease.
It's not completely clear what accounts for the gender differences in heart disease. We know that there is a clear difference, however, in how women and men are evaluated and treated for heart disease.
We also know that women who come to a hospital with a heart attack are more likely to be misdiagnosed than their male counterparts. As a result, they are also more likely to die. There are many reasons for this disparity.
Understanding the Symptoms of Heart Disease
Women don't often experience crushing chest pain. They are more likely to feel fatigued, short of breath, dizzy or nauseous. In other words, their symptoms are not typical for a heart attack. Nor are these symptoms specific for any disease, so there may be many possible causes — other than a heart attack — for the symptoms.
Additionally, women are usually much older than men when they have their first heart attack because the risk of coronary artery disease increases after menopause.
Historically, women have not been included in many of the clinical trials for advances in prevention, diagnosis and treatment of heart disease. Therefore, there has been a dearth of evidence for treatments that could help prevent heart attacks in women.
And while the evidence is now mounting, women still are often not given medications that could help prevent heart disease.
Diagnosis and Treatment for Heart Disease
Women, in particular minorities and the poor, are less likely to undergo diagnostic procedures such as stress testing (treadmill testing), cardiac catheterization (angiogram), angioplasty (balloon procedure), coronary artery stenting or coronary artery bypass grafting (bypass operation or CABG, pronounced "cabbage"). Women are also less likely to receive thrombolytics (clot-busters).
These disparities beg many questions: How can we prevent heart disease in women? How can women protect themselves from heart disease? How can women become advocates for themselves?
Step No. 1: Know What Heart Disease Is
There are a number of conditions that can be classified as heart disease, including heart attack, angina, coronary artery disease, congestive heart failure, valve problems, hypertension, vascular disease, arrhythmias or irregular heart beats, and sudden cardiac death, to list a few.
While there are many causes of heart disease, the problem often stems from blockages in the coronary arteries that supply the heart with blood. These blockages develop from a combination of cholesterol and fats in the bloodstream. The result is a hard, calcified plaque that narrows the artery and restricts blood flow to the heart.
Over time, small to moderate blockages can deprive the heart of oxygen. The result can be heart failure.
In other cases, the plaques can crack or develop fissures, causing a blood clot to form. The artery becomes completely blocked, a condition that starves the heart of oxygen and actually causes it to dieheart to be oxygen-starved and die. The oxygen deficit is called ischemia, and can cause the pain many people know as angina. The death of part of the heart muscle is called myocardial infarction or heart attack. If the blockage occurs in one of the main arteries of the heart, the result can be sudden cardiac death.
Step No. 2: Know the Symptoms of Heart Disease
We know that there are many different symptoms of cardiovascular disease, particularly heart attack or myocardial infarction. So, it's important to be familiar with them:
- Left-sided chest pain
- Chest tightness
- Shortness of breath
- Unexplained fatigue
- Nausea or vomiting
- Symptoms of heartburn that which are unrelieved with typical remedies
- Numbness, tingling, fullness or discomfort in the jaw, left shoulder pain or pain that radiates down the left arm
If you experience these symptoms, or think that you might be having a heart attack, call 911 immediately for transport to the nearest emergency department.
If possible, chew an aspirin and let the paramedics know that you have done so once they arrive.
If you have a history of angina and have your nitroglycerin handy, use the spray or place a tablet under your tongue and repeat every five minutes for a total of three times until emergency help arrives.
Step No. 3: Know Your Risk Factors for Heart Disease
There are a number of medical problems and lifestyle issues that can contribute to the development of heart disease. Some of these factors, like obesity, you can control, while others, like genetic predisposition, you cannot.
In many cases, lifestyle changes or medications can help decrease your risk for heart disease and early cardiac death.
To manage cardiac health, every woman should understand what her personal risk might be.
If you answer "yes" to three or more of the following questions, you should call your doctor immediately.
- Do you have a family history of heart attack or heart disease (especially sudden cardiac death)?
- Elevated cholesterol?
- Are you postmenopausal?
- Do you smoke?
- Are you obese, or do you lead a sedentary lifestyle?
- Are you often under heavy stress?
- Do you have a prior personal history of heart disease or heart attack?
If you answered "yes" to more than three of these questions, you have a significant risk for developing coronary artery disease and you should talk to your doctor about ways to reduce your risks.
Many of these risk factors can be changed by adopting a healthier lifestyle. Get guidance and support from your physician and from friends who have made heart-healthy changes in their lives.
Step No. 4: Choose a Healthy Lifestyle
The medical evidence overwhelmingly shows that healthy lifestyle changes can reduce your incidence of heart disease.
A landmark study published in 2000 reported that patients who aggressively pursued a heart-healthy lifestyle, including a low-fat diet, no smoking, stress management and aerobic exercise, substantially reduced their risk for heart attack, cardiac surgery and death.
Other studies show that men and women of all ages who have low cholesterol and are non-diabetic, non-hypertensive and non-smokers have 92 percent fewer heart attacks than people with these risk factors. In addition, there is a significant decrease in their risk of stroke and cancer.
Being your own "medical manager" is important as well. Most women depend on their obstetricians or gynecologists for their health-care needs. While it's important to continue routine gynecologic care, more women need generalized care, too.
Choosing an internist or family physician is the best place to start. Ask your doctor about routine screening for common diseases such as diabetes, heart disease, hypertension, and breast and colon cancer.
Dr. Dolan is an attending physician and clinical instructor in emergency medicine at Georgetown University Hospital in Washington, D.C. She has a particular interest in women's health.