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.
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.