Listen to Your Heart

To her coworkers at Heinen's Fine Foods supermarket headquarters in Warrensville Heights, Ohio, Sue Andrews's presentation on a new store operations plan seemed beautifully done. But she felt terrible: dizzy, short of breath, sweating, and nauseated. After wrapping up, she called her husband and soon ended up in the emergency room. The diagnosis—a mild heart attack—came as quite a shock, since Andrews is only 50 and slim, eats wisely, and has no family history of cardiovascular disease. "I'm never sick," she says. "I never thought it might be a heart attack."

With the possible exception of those at highest risk—diabetics who smoke and are obese, for example—most women simply don't have heart disease on the radar. They're much more likely to worry about breast cancer, though cardiovascular disease (which includes high blood pressure and stroke) kills almost twice as many American women as all cancers put together. Nearly 1 in 2 will develop it in her lifetime, and 1 in 3 will die from it. Generally, trouble strikes women in their 60s, about a decade later than men, possibly because naturally protective estrogen levels decline. But a lower risk of heart disease at a younger age doesn't mean women in their 40s and 50s don't have to worry, especially if they're getting by on fast food and a once-a-month trip to the gym. Indeed, doctors are particularly interested in identifying and preventing disaster in the vast group of women who are at intermediate risk—they have a couple of bad habits and a family history, say—and are most likely unaware of the consequences. It's in this group that fully 70 percent of heart attacks occur.

What should women do to figure out where they stand and to protect themselves? Most urgently, pay attention to any troubling symptoms and see a doctor: Two thirds of women who die of heart disease have unrecognized symptoms, says Lori Mosca, director of preventive cardiology at New York-Presbyterian Hospital and chair of the committee that developed the most recent American Heart Association guidelines for prevention in women. While most women having a heart attack will experience the hallmark chest pressure, some have symptoms uncommon in men: excess sweating, extreme fatigue, nausea, jaw pain, or even headache. And the standard male template of danger signals may overlook women headed for a stroke, or those whose major heart vessels are clear but who have "coronary microvascular syndrome," dangerous narrowing of the tiniest arteries.

Symptomatic. Women who come in with symptoms will be tested—anything from an EKG to look for abnormal heart rhythms to a coronary angiogram, which threads a catheter into the blood vessels to search for blockages. If the angiogram comes up clear, you might want to ask your doctor if tests for microvascular syndrome are available locally. (One, an endothelial dysfunction test, uses a tiny probe to measure blood flow within the wall of the coronary artery.)

If you feel fine, your course of action depends on your individual risk. Women at high risk include those who have diabetes or chronic kidney disease, and those with greater than a 20 percent chance of heart problems in the next decade as measured by the Framingham risk score, which takes into account such factors as smoking habits, cholesterol levels, and blood pressure. "A woman in her 50s should have a good medical history done, a lab assessment, a physical, and a family history," says Mosca. A fasting cholesterol profile will measure your LDL ("bad" cholesterol), HDL ("good" cholesterol), and triglycerides; a fasting blood sugar test, your risk of diabetes.

Those at so-called optimal risk have no risk factors, a Framingham score of less than 10 percent, and a heart-healthy lifestyle. That entails at least 30 minutes of exercise most days and a diet low in trans fats, saturated fats, and sodium and high in fruits, vegetables, and fish. A huge group of women in between have at least one major risk factor for heart disease, like a smoking habit, poor diet, obesity, high blood pressure, or a family history of premature heart disease.

The AHA doesn't recommend routine imaging or invasive tests for anyone who's not having symptoms. But it's pretty clear what high-risk women need: the usual lifestyle steps, plus a stricter-than-usual cap on saturated fat and cholesterol intake and, very likely, drugs such as aspirin, blood pressure medication, or statins to stave off heart attack and stroke.