Gender matters: Heart disease risk in women
Gender matters: Heart disease risk in
Heart disease is the leading cause of death
among women — and one of the most preventable.
Research is giving us insights into how we
can control our risk.
We’ve come a long way since the days when
a woman’s worry over heart disease centered
exclusively on its threat to the men in her life.
We now know it’s not just a man’s
problem. Every year, coronary heart disease,
the single biggest cause of death in the United
States, claims women and men in nearly equal
numbers, totaling about 500,000 lives. More than
6.5 million women have some form of it. Of those
who survive a heart attack, 46% will be disabled
by heart failure within six years.
Risk still underappreciated
In a survey conducted by the American Heart
Association, about half of the women interviewed
knew that heart disease is the leading cause
of death in women, yet only 13% said it was their
greatest personal health risk. If not heart disease,
then what? Other survey data suggest that on
a day-to-day basis, women still worry more about
getting breast cancer — even though heart
disease kills six times as many women every year.
Why the disconnect?
Breast cancer affects body image, sexuality,
and self-esteem in ways that a diagnosis of heart
disease does not. Also, heart disease tends to
show up at an older age (on average, a woman’s
first heart attack occurs at age 70), so the
threat may not seem all that real to younger
women. Most 50-year-old women know women their
age who’ve had breast cancer but none who’ve
had heart disease.
In addition, many women say their physicians
never talk to them about coronary risk and sometimes
don’t even recognize the symptoms, mistaking
them instead for signs of panic disorder, stress,
and even hypochondria.
heart attack symptoms in women
month before a heart attack
a heart attack
of breath (58%)
of breath (42%)
Source: Circulation 2003,
Vol. 108, p. 2621.
Sex differences evident
Most of our ideas about heart disease in women
used to come from studying it in men. But there
are many reasons to think that it’s different
in women. A woman’s symptoms are often
different from a man’s, and she’s
much more likely than a man to die within a year
of having a heart attack. Women also don’t
seem to fare as well as men do after taking clot-busting
drugs or undergoing certain heart-related medical
procedures. Research is only now beginning to
uncover the biological, medical, and social bases
of these and other differences. The hope is that
new knowledge will lead to advances in tailoring
prevention and treatment to women.
Heart disease may start in childhood, develop
silently over time, and arrive without warning
as a heart attack, often a deadly one. So we
shouldn’t wait for symptoms to appear,
or research to tell us more, before taking proven
steps to reduce our risk.
differences in coronary risk and treatment
Research is identifying gender differences
in heart disease that may help fine-tune
prevention, diagnosis, and treatment in
women. Here are some examples.
Blood lipids. Before menopause,
a woman’s own estrogen helps protect
her from heart disease by increasing HDL
(good) cholesterol and decreasing LDL (bad)
cholesterol. After menopause, women have
higher concentrations of total cholesterol
than men do. But this alone doesn’t
explain the sudden rise in heart disease
risk after menopause. Elevated triglycerides
are an especially powerful contributor
to cardiovascular risk in women. Low HDL
and high triglycerides appear to be the
only factors that increase the risk of
death from heart disease in women over
Diabetes. Diabetes increases the risk of heart disease in women more
than it does in men, perhaps because women
with diabetes more often have added risk
factors, such as obesity, hypertension,
and high cholesterol. Although women usually
develop heart disease about 10 years later
than men, diabetes erases that advantage.
In women who’ve already had a heart
attack, diabetes doubles the risk for a
second heart attack and increases the risk
for heart failure.
Metabolic syndrome. This
is a group of health risks — large
waist size, elevated blood pressure, glucose
intolerance, low HDL cholesterol, and high
triglycerides — that increases your
chance of developing heart disease, stroke,
and diabetes. Harvard Medical School research
suggests that, for women, metabolic syndrome
is the most important risk factor for having
heart attacks at an unusually early age.
In a study of patients undergoing bypass
surgery, metabolic syndrome produced a
greater risk for women than it did for
men of dying within eight years.
Smoking. Women who smoke
are twice as likely to have a heart attack
as male smokers. Women are also less likely
to succeed in quitting, and women who do
quit are more likely to start again. Moreover,
women may not find nicotine replacement
as effective, and — because the menstrual
cycle affects tobacco withdrawal symptoms — they
may get inconsistent results with antismoking
Symptoms. Many women don’t
experience the crushing chest pain that
is a classic symptom of a heart attack
in men. Some feel extremely tired or short
of breath. Other atypical symptoms include
nausea and abdominal, neck, and shoulder
pain. In one study, women reported deep
fatigue and disturbed sleep as much as
a month or two before a heart attack. During
a heart attack, only about one in eight
women reported chest pain; even then, they
described it as pressure, aching, or tightness
rather than pain.
Diagnosis and treatment. Women
have smaller and lighter coronary arteries
than men do. This makes angiography, angioplasty,
and coronary bypass surgery more difficult
to do, thereby reducing a woman’s
chance of receiving a proper diagnosis
and having a good outcome. Women tend to
have more complications following surgery.
And they’re twice as likely to continue
having symptoms several years after coronary
angioplasty. (They’re usually older
than men and have more chronic conditions
at the time of their first coronary event.)
Women’s responses to standard exercise
stress tests are also different from men’s,
so it’s difficult to interpret the
results. Fortunately, these problems are
diminishing thanks to advances in technology
and better understanding of heart disease
First things first
Several things in your control can help reduce
your risk for heart disease.
Don’t smoke, actively or passively. Your
chance of having a heart attack doubles if you
smoke as few as one to four cigarettes per day.
Even if you don’t smoke, regular exposure
to someone else’s smoke can increase your
Be more active. Get at least 30
minutes per day of moderate-intensity exercise,
such as brisk walking, most days. Fit even more
activity into your life: Take the stairs rather
than the elevator, do yard work, park farther
from your destination and walk.
Eat healthfully. Studies at Harvard
Medical School and elsewhere have identified
several crucial ingredients of a heart-healthy
diet — whole grains, a variety of fruits
and vegetables, nuts (about 5 ounces per week),
poly- and monounsaturated fats, fatty fish (such
as wild salmon), and limited intake of trans
Reduce stress and treat depression. Your
risk for heart disease increases if you’re
depressed or feel chronically stressed. Stress-reducing
strategies include exercise, adequate sleep,
relaxation techniques, and meditation. Psychotherapy
can be especially helpful with depression and
Reach for the numbers. In 2004,
the American Heart Association (AHA) released
guidelines on preventing heart disease and stroke
in women (Circulation, Feb. 10, 2004).
According to the AHA, you can greatly reduce
your risk for these diseases by maintaining certain
body measurements and levels of cholesterol and
blood pressure (see chart below).
goals to reduce heart disease risk in
mass index (BMI)
Multiply your weight in pounds by 700,
then divide that number by the square of
your height in inches
Hold a tape measure at the level of your
navel and circle your abdomen with it.
(Measure below, not at, the narrowest part
of your torso.)
from information in Circulation 2004,
Vol. 109, pp. 672–93.
The AHA’s guidelines also include recommendations
based on a woman’s 10-year risk of having
a heart attack.
women take a daily aspirin?
In people who’ve already had a heart
attack or stroke, a daily aspirin can lower
their risk for another one. But in healthy
women, it’s unclear whether aspirin’s
benefits outweigh the risks of gastrointestinal
bleeding and hemorrhagic stroke.
We should know more when results of the
Women’s Health Study at Brigham and
Women’s Hospital in Boston are available
(2004). The study is testing the effects
of aspirin and/or vitamin E or a placebo
on the risk of cardiovascular disease and
cancer in 40,000 healthy women. For now,
expert guidelines for women suggest that
daily low-dose aspirin (81–162 mg)
be considered only in women who already
have heart disease or are at risk for it.
Can I be tested for heart disease risk?
Doctors can measure the levels of certain substances
associated with increased heart disease risk.
But it’s still unclear what levels put
you at risk or whether controlling them will
Elevated homocysteine. Homocysteine
forms when the body breaks down protein. Some
research has shown that people with high homocysteine
levels are more likely to develop heart disease.
(They also tend to be deficient in the B vitamins.)
We still don’t know whether reducing homocysteine,
especially by increasing B-vitamin intake, will
lower heart disease risk. Trials are under way
to find out. Routine screening is not recommended,
but if you have a strong family history of heart
disease and no traditional risk factors, your
physician may suggest that you be tested.
C-reactive protein. C-reactive
protein is a byproduct of blood vessel inflammation,
which sets the stage for atherosclerosis (see “What
is coronary heart disease?”). High C-reactive
protein levels predict heart disease in both
women and men and could help identify people
at risk who have normal cholesterol. However,
researchers haven’t yet determined the
appropriate target levels of C-reactive protein
for different genders, ages, and ethnic groups
or how to interpret the results.
is coronary heart disease?
Coronary heart disease results from atherosclerosis,
the buildup of cholesterol-laden plaques
inside the coronary arteries. These plaques
restrict blood flow to the heart muscle,
reducing its supply of oxygen. Angina (chest
pain) may result. If blood flow is entirely
disrupted, some of the tissue may die.
This is what is meant by a “heart
Heart scans. Ultra-fast computed
tomography (CT) scans of the heart can detect
calcium in coronary blood vessels. Calcium is
one of the components of atherosclerotic plaques.
But a calcium score can’t tell you whether
your coronary arteries are clogged. Rather, it’s
an estimate of the likelihood of plaque buildup.
In general, lower calcium levels suggest lower
risk for heart attack and stroke over the next
few years, and higher levels suggest higher risk.
But many people have calcium scores in the middle,
and no one knows what that means. Until further
research demonstrates that heart scans can predict
heart attacks, they have limited benefits, and
insurers won’t pay for them.