Murkier matter. The prescription is less clear for the group in the gray area. Like everyone else, they should adopt heart-healthy habits, pronto. "You can never underestimate the effects of diet and exercise," says Paul Ridker, director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital in Boston. But will the potential benefit of adding medication outweigh the potential harm from side effects? The search is on for more sensitive ways to assess risk status in this group. Earlier this year, Ridker and his colleagues reported that adding family history and blood levels of C-reactive protein (a marker of inflammation that rises when arteries are blocked) to the factors included in the Framingham score could move many women up or down a notch. The newer test, dubbed the Reynolds Risk Score, can also project your risk out further than a decade. Some doctors now use CRP and the new score; others aren't convinced that they add any important information.
Many women might be tempted to ask for one of the high-tech tests now being marketed as a noninvasive way to get a glimpse inside the cardiovascular system. CT scans, for example, use multiple X-ray images to form a picture of plaque or other obstructions in the arteries. Ultrasound images of the carotid artery in the neck measure the thickness of the vessel and potentially dangerous clogs.
But while it sounds logical that taking a better look at the heart's vessels would cut the rate of heart attacks and death, these tests haven't yet been shown to do that in asymptomatic women. "People confuse testing with prevention," says Rita Redberg, director of women's cardiovascular services at the University of California-San Francisco. Moreover, radiation from CT scans can slightly boost the odds of getting cancer later in life, according to a study published this summer. And the results might make doctors feel obligated to perform more invasive procedures even if they're not needed.
Tiebreakers. That said, some doctors do use the tests as "tiebreakers" to tilt women in the medium-risk group toward or away from drug treatment, says Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. (That nasty image also sometimes motivates people to shape up.) Noel Bairey Merz, medical director of women's health at Cedars-Sinai Medical Center in Los Angeles, says she often prescribes a carotid ultrasound to make this kind of call. According to Marianne Legato, founder of Columbia University's Partnership for Gender-Specific Medicine, CT scans can tell old plaque from new and thus be used to track the effects of treatment.
But before you make an appointment, be sure you understand the risks, Merz cautions. A doctor can put the results in context. If they suggest further procedures are needed, you may want to start by getting a second opinion. And avoid the screening van at the local health fair.
Most doctors recommend that all women, regardless of risk, focus first and foremost on less sexy but tried-and-true preventive measures. "I'd be happy as a clam sitting on the couch watching TV all the time," says Ana Dierkhising, 39, a real-estate agent in San Francisco who has had diabetes since childhood, so knows she can't. She works out regularly with a group of women and last year ran a half marathon.
Andrews admits to a few weak links in her pre-heart attack routine. Now, in addition to being vigilant about taking her meds, she's watching her sodium intake and taking daily walks with her husband when the weather permits. She's also working out on the treadmill as part of her cardiac rehabilitation at the Cleveland Clinic and plans to keep it up.
Andrews is spreading the word, too, in the hopes of keeping her daughter and sister safe. "The woman at highest risk is the one who doesn't know she's at risk," says Duke University cardiologist Pamela Douglas. She's apt to take no action at all.