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Susan Blumenthal, M.D. Headshot

Heartfelt Advice for Women: Take Care of Your Heart

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This Valentine's Day, while you are concerned with matters of the heart, take some time to consider the health of your heart. Nearly all women are at risk for heart disease and should be more aggressive about lowering their risk. Yet, in a recent survey on health concerns, when asked what disease they feared most, the number one response from women was breast cancer. Long viewed as just a man's disease, the fact is that worldwide, cardiovascular disease (CVD) is the largest single cause of death among women, accounting for one third of all deaths. In the United States, more women die from cardiovascular diseases -461,000 women-- each year than from all types of cancer and the next three leading causes of death combined. And did you know that each year, heart disease and stroke kills more women than men? One woman dies every minute in our country from cardiovascular illnesses. In the US, 38.2 million women are living with cardiovascular disease and the population at risk is even larger. Minority women are particularly at risk for heart disease and stroke. For example, nearly half of African American women (45%) have some form of cardiovascular disease, compared to 32 percent of white women. As women get older, their risk increases. One in 10 American women aged 45 to 64 has some form of heart disease, and this rises to one in four women over the age of 65. In addition, 2 million women have had a stroke, and 93,000 women die of this condition each year--that's 40,000 more women than men. The human toll and economic impact are enormous. In 2006, in the United States alone, over $403 billion was spent on health care and in lost productivity as a result of CVD as compared with an estimated $190 billion on cancer and $29 billion for HIV/AIDS.

The good news: cardiovascular disease is in large part preventable. However, in the past, most research on cardiovascular disease was conducted in men only but the findings were extrapolated to guide treatment and prevention decisions for women. For decades, doctors were trained to think of heart disease as a man's disease and still today most primary care physicians don't know that heart disease kills more women each year than men. Education campaigns and media stories focused on these diseases in men only. As a result of the lack of public and scientific attention to these diseases in females, women have not known they were at risk and have often been under-diagnosed, not as aggressively treated and not offered critical preventive interventions as compared with men. Women receive only 33% of angioplasties, stents and bypass surgeries, 28% of implantable defibrillators, and 36% of open-heart surgeries. Drug and medical device effectiveness may differ in women and men, yet doctors and researchers often don't know how safe and effective a particular medicine or device is for women. Women comprise only 24% of participants in all heart-related studies. As a result of these gender disparities, since 1984 more women have died each year from heart disease than men and the gap between men and women's survival continues to widen. 42% of women who have heart attacks die within 1 year as compared to 24% of men. Under age 50, women's heart attacks are twice as likely to be fatal as men's.

Today, a new national focus on women's health over the past 15 years ---the focus of my career as the country's first Deputy Assistant Secretary for Women's Health in the US Department of Health and Human Services--is yielding important new knowledge about cardiovascular illnesses in women and also addressing health disparities for women of color. February is Heart Health Awareness Month. This past week, the American Heart Association released some new guidelines (published in its scientific journal, Circulation) for women to help lower their risk -- highlighting what works and what doesn't-- to prevent heart disease and stroke. The guidelines urge women to take more control of their own health underscoring that nearly all American women are in danger of these conditions and should be more aggressive about lowering their risk. So here are some critical things that every woman needs to know about cardiovascular disease including some simple steps that can be taken to keep your heart healthy.

What is cardiovascular disease?

Both heart disease and stroke are known as cardiovascular diseases, disorders of the heart and blood vessel system. Coronary heart disease, the most common form of heart disease, affects the blood vessels of the heart, known as the coronary arteries. This illness takes many years to develop and can begin as far back as childhood. In a process known as atherosclerosis, fatty substances called plaque build up inside the walls of blood vessels. The vessels narrow and harden, becoming less flexible. The buildup and narrowing proceed gradually and result in decreased blood flow and, eventually, the development of symptoms. Cholesterol has been implicated in this buildup in heart attacks and now in stroke. When blood flow to the heart is reduced, chest pain, called "angina," can result. As plaque builds up, the blood vessels narrow and harden, thereby decreasing blood flow. Plaque can rupture and cause blood clots that cut off circulation to a part of the body. If this occurs in the heart, the result is a heart attack; if the clot is in the brain the result is a stroke. However, 50% of women who have a heart attack do not have elevated cholesterol. Research has found that chronic inflammation is another mechanism that may substantially contribute to the clogging of blood vessels and subsequent development of cardiovascular disease.

What are the risk factors?

The new AHA guidelines classify women as high risk, at risk, or at optimal risk and provides definitions for these categories. Consult your doctor and visit www.goredforwomen.org for an on-line tool to help determine your risk. Habits or traits that make a person more likely to develop cardiovascular disease fall into two groups: those we can control and prevent and those beyond our control. Fortunately, many major risk factors are within our control. These include smoking, physical inactivity, being overweight, poor nutrition, high cholesterol and high blood pressure. Women with hypertension experience a risk of developing CVD that is 3.5 times higher than females with normal blood pressure. Other preventable risk factors include diabetes, stress, alcohol and use of birth control pill. Smoking and diabetes exacerbates the risk from birth control pills. Diabetes doubles the risk of a second heart attack in women but not in men. However, other risk factors cannot be controlled, such as age. One in ten women between the ages 45 - 64 years old suffers from heart disease. This increases to one in four women 65 years old and above. Other risk factors include race, a family history of early heart disease and having previously survived a heart attack or stroke.

While a high cholesterol level is a well recognized risk factor for heart disease, an estimated 50 percent of people who have heart attacks have cholesterol readings within normal ranges. This poses some intriguing questions about what other factors might contribute to the development of heart disease. Researchers believe that inflammation is another cause and have discovered some biological markers in the blood that appear to be associated with an increased risk including C-reactive protein (CRP), homocysteine, fibrinogen, and lipoprotein(a). More research is needed to better define their association with heart disease.

Another important thing to know is that the various risk factors for heart disease and stroke do not add their effects in a simple way. Rather, they multiply each other's effects - so, for example, if you smoke, have high blood pressure and high cholesterol, you're eight times more likely to develop heart disease than a woman with no risk factors. Even just one risk factor at age 50 will significantly raise your chances of having heart-related problems or a stroke later, but the more risk factors you have the more likely you are to develop cardiovascular disease - and the more concerned you should be about protecting your heart health. Only about 10% of women over age 50 do not have any risk factors! A goal of the new AHA Guidelines is to get women and doctors to focus on the long-term risk of high blood pressure, smoking, elevated cholesterol, and being overweight---even if a woman's current health seems fine. Women should not wait until they have symptoms to take action!

Symptoms

One of the most common symptoms of heart disease is chest pain or pressure. Chest pain typically occurs behind the breastbone and may cause numbness or tingling in the left arm or up your neck and shoulders, or may be experienced as a squeezing or pressing sensation that does not change with breathing. The pain usually lasts two to five minutes. Reduced blood flow to the heart can also cause a lingering chest pain, occurring in a different location than behind the breastbone. But nearly two thirds of the deaths from heart attack in women occur in women who have no history of chest pain. Some women may experience shortness of breath, indigestion, nausea, lightheadedness or significant fatigue. Other women will not have any of these symptoms before or during a heart attack. Likewise, symptoms can be either mild or severe and can subside and then return. Frequently, women and health care providers may mistake this pain signaling a heart attack as indigestion. It is important to know that women's symptom presentation may differ from that of men. If a woman should have such symptoms, she should contact her doctor immediately or call 911. If treated, the prognosis is excellent. Without treatment, however, the symptoms of heart disease may recur, worsen and can lead to a heart attack.

Women are more vulnerable to strokes than are men. The symptoms of a stroke include sudden weakness or numbness of parts of one side of the body, usually the face, arm, or leg, sudden dimness or loss of vision, particularly in one eye, loss of speech, or trouble talking or understanding speech, sudden severe headaches with no known cause, or unexplained dizziness, unsteadiness, or a sudden fall. If these symptoms persist for more than a few minutes, call 911.

Diagnosis

Diagnostic tests are needed to confirm the presence and to assess the severity of coronary heart disease and stroke. Often more than one test is required because different tests supply different information. The main tests for coronary heart disease are: blood tests, an electrocardiogram (EKG), stress test (or treadmill test), echocardiography, nuclear scan, CTa, and coronary angiography. However, studies have shown that men's plaque distributes in clumps whereas women's distributes more evenly throughout artery walls. This results in women's angiographic studies being mininterpreted as "normal." Characteristic EKG changes are also less frequently present in women. Stroke is diagnosed by several techniques including neurological examination, blood tests, CT, MRI scans, and arteriography.


Treatment and Prevention

There are three main types of interventions to combat cardiovascular disease - lifestyle changes, medication, and special procedures for advanced atherosclerosis. Medication may be necessary if a woman has significant chest pain, high blood cholesterol or high blood pressure that positive lifestyle changes do not reduce. Doctors may also use surgical procedures such as angioplasty, stents, and coronary bypass surgery to treat severe atherosclerosis. Women are 2-3 times as likely to die following heart bypass surgery. Younger women between the ages of 40-59 are up to 4 times more likely to die from heart bypass surgery than men the same age. However, simple, affordable and effective lifestyle changes can keep many women from requiring these interventions. That's because prevention is the best way to reduce a woman's risk of heart disease. It is estimated that as much as 60% of heart attack and stroke risk could be prevented by lifestyle modifications. That means you hold much of the future of your heart's health in your own hands.

So here are some steps towards a healthier heart future that incorporate the new American Heart Association guidelines for prevention of cardiovascular disease in women:

  • Know and control your numbers - Have your blood pressure, cholesterol and triglyceride levels checked regularly. This is a cornerstone to preventing heart disease. Blood pressure should be at or below 120/80mmHg. Total cholesterol should be under 200mg/dL. The normal level for HDL, the 'good' cholesterol, should be 50mg/dL or higher. LDL, or the 'bad' cholesterol, should be less than 100mg/dL and under 70 if you are at high risk for heart disease or have diabetes. Your triglyceride level should be under 150mg/dL. Healthy eating, physical activity, maintaining a healthy weight, alcohol consumption in moderation, and sodium restriction will go a long way in keeping these numbers under control. If a healthy lifestyle does not sufficiently reduce these levels, medication may be necessary when blood pressure is equal to or higher than 140/90 mm Hg or at an even lower blood pressure in the setting of chronic kidney disease or diabetes. Additionally, lipid lowering medications with lifestyle interventions is indicated to reduce elevated cholesterol levels.
  • Don't smoke, avoid second hand smoke and environmental air pollution - Women should not smoke. Women who smoke are 2 - 6 times more likely to suffer heart attack. Once you quit your risk drops sharply even in the first year. Women who are exposed to environmental tobacco smoke have a higher risk of disease. Recent research has found that nicotine is more addictive in women and interferes with lung function and growth more in girls than in boys. To stop smoking, use counseling, behavioral approaches, nicotine patches or gum, and medications if necessary. Not smoking is a cornerstone to ensuring a healthier future. Additionally, recent RESULTS FROM THE NIH funded WOMEN'S HEALTH INITIATIVE has FOUND THAT AIR POLLUTION IS LINKED TO CARDIOVASCULAR DISEASE IN POST MENOPAUSAL WOMEN. FOR EACH 10 MICROGRAMS PER CUBIC METER OF AIR POLLUTION, THERE IS A 24% INCREASE IN THE RISK OF A CARDIOVASCULAR EVENT AND A 76% INCREASE IN DEATH FROM HEART DISEASE IN WOMEN. THIS IS ANOTHER COMPELLING REASON WHY WE MUST INCREASE RESEARCH AND WORK TO ELIMINATE ENVIRONMENTAL HEALTH HAZARDS FROM WOMEN'S LIVES.

  • Engage in physical activity - It's one of the very best things you can do to feel great today and to improve your health tomorrow. Choose activities you like, such as walking, dancing, biking, or gardening. Aerobic activity is important for your heart's health. Take the stairs instead of the elevator, walk instead of drive. Aim for at least 30 minutes a day of moderately intense exercise such as brisk walking on most and preferably all days. The AHA Guidelines recommend 60-90 minutes of moderate intensity physical activity if you need to lose weight. Use a pedometer and take 10,000 steps a day. Physical activity helps lower 'bad' cholesterol and raise 'good' cholesterol.
  • Eat smart - It's a recipe for heart health. Consume a diet rich in fruits, vegetables, fiber, whole grains, fish at least twice a week, vitamins, and calcium. Drink lots of water. Cut back on saturated fats from meat, cheese and butter to 10% of energy- 7% if possible--, reduce trans fats to less than 1% of calories, and limit salt to less than a teaspoon and cholesterol intake to less than 300 milligrams a day. The AHA guidelines recommend considering omega-3 fatty acid (fish oil) supplements (850--1000 milligrams) if you already have heart disease and higher doses (2 to 4 grams) for treatment of women with high triglyceride levels. The guidelines do not recommend that women take additional folic acid or antioxidant supplements like vitamins B, C and beta carotene for heart disease prevention. Curb your intake of alcohol to no more than one drink per day. These steps will help keep blood pressure, cholesterol and triglyceride levels within a healthy range.
  • Maintain a healthy weight - Keep your Body Mass Index (BMI) between 18.5 and 25 and your waist circumference less than 35 inches. Excess weight greatly increases your risk of heart disease, stroke and diabetes. Lose weight slowly and steadily. Even reducing weight by just a few pounds can have significant health benefits.
  • Medications--While studies have shown that aspirin is effective in reducing the risk of heart attacks in men, research has found that aspirin protects against stroke in women but not heart attack until a woman is 65 or older. Routine use of aspirin in women under age 65 is not recommended to prevent heart attacks. However, the new AHA guidelines recommend that women at high risk of cardiovascular disease should up their daily aspirin dose to 325 milligrams from 162 mg. a day. Women over 65 should consider taking a low dose, 81 milligram, aspirin daily. Aspirin has been found to reduce the chances that women who have already had a heart attack will have, or die from, another one. The AHA guidelines suggest that all other women should consider taking an 81 milligram "baby aspirin" or 100 milligrams every other day for stroke prevention. But this recommendation is somewhat controversial. Some specialists warn that regular aspirin use is not indicated in women under age 50 because it may cause ulcers and dangerous bleeding. Therefore, any potential benefit must be weighed against the possible risks. For example, aspirin can be dangerous for women whose blood pressure is not under control--another reason women should consult their doctor before starting it. The AHA guidelines also report on interventions that research has found not to be useful or may even be harmful for cardiovascular disease prevention in women. Hormone replacement therapy (HRT) should not be used to prevent heart disease in women. Results from the NIH supported Women's Health Initiative, a major study of postmenopausal women, has shown that HRT increased the risk for heart attack, stroke, and blood clots. The AHA guidelines also state that SERMS (selective estrogen-receptor modifiers) such as tamoxifen and raloxifene used to prevent breast cancer in high risk women should not be used to prevent cardiovascular disease in women. The guidelines also do not support routine use of antioxidant supplements (e.g. Vitamin E, C and beta-carotene) for the primary and secondary prevention of cardiovascular disease in women.
  • Schedule regular checkups with your doctor - Know your family history and share it with your doctor. Know and be alert for cardiovascular symptoms to detect problems early. MAKE SURE YOU HAVE YOUR YEARLY DOCTOR'S CHECK UP WITH THOSE LIFESAVING EARLY DETECTION SCREENING EXAMS DEPENDING ON YOUR AGE FOR CHOLESTEROL, TRIGLYCERIDES, GLUCOSE LEVELS, BLOOD PRESSURE, PAP SMEARS, MAMMOGRAMS, AND COLONOSCOPIES. ASK YOUR DOCTOR ABOUT CRP AND HOMOCYSTEINE LEVELS--MARKERS OF INFLAMMATION LINKED TO HEART DISEASE. YOU SEE, AN ESTIMATED 50% OF PEOPLE WHO HAVE HEART ATTACKS HAVE CHOLESTEROL levels WITHIN NORMAL RANGES. ALSO ASK YOUR DOCTOR ABOUT THE ADVISABILITY OF GETTING A BASELINE EKG AT AGE 40. SOME DIAGNOSTIC TESTS AND PROCEDURES APPEAR NOT TO BE AS ACCURATE IN WOMEN SUCH AS THE EXERCISE STRESS EKG. REMEMBER TO KEEP YOUR IMMUNIZATIONS UP TO DATE--ADULTS NEED THEM TOO. THE BOTTOM LINE: EARLY DETECTION AND REGULAR PREVENTIVE CARE REDUCES YOUR RISK OF DISEASE AND DISABILITY, SAVES LIVES AND BILLIONS OF DOLLARS IN HEALTH CARE COSTS FOR OUR NATION.
  • Find your own stressbuster and maintain a strong social support system. Research has shown a connection between stress, depression and heart disease. 1 OUT OF FIVE AMERICANS WILL SUFFER FROM A MENTAL DISORDER EVERY YEAR. TWICE AS MANY WOMEN SUFFER FROM DEPRESSION as do men. SCIENCE IS SHOWING THAT WOMEN'S HEARTS APPEAR TO BE MORE SUSCEPTIBLE TO THE EFFECTS OF STRESS AND DEPRESSION RAISING THEIR RISK FOR HEART DISEASE AND RESULTING IN POORER OUTCOMES AND DECREASED LIFE EXPECTANCY FROM CARDIOVASCULAR ILLNESS. So find activities to reduce stress that you enjoy like yoga, meditation, walking and reading. Be sure to take time for yourself every day. If you are experiencing symptoms of depression that persist for more than a few weeks, seek professional help. Also, remember that FAMILY AND FRIENDS ARE CRITICAL TO DISEASE PREVENTION. RESEARCH HAS SHOWN THAT PEOPLE WITH MORE SUPPORTIVE FRIENDS AND FAMILY LIVE LONGER AFTER A HEART ATTACK. ALSO IT'S MORE FUN AND EASIER TO ENGAGE IN HEALTHY BEHAVIORS IF OTHERS JOIN YOU.
  • BE A SAVVY WOMEN'S HEALTH CONSUMER -- READ AS MUCH AS YOU CAN. KNOW YOUR HEALTH PLAN. BE INFORMED. KNOWLEDGE IS POWER WHEN IT COMES TO YOUR HEALTH AND THE HEALTH OF YOUR FAMILY. CALL 888-MY HEART OR VISIT GOREDFORWOMEN.ORG AND USE A FREE ONLINE TOOL THAT can HELP YOU to CALCULATE YOUR RISK FOR HEART DISEASE. **

  • AND FINALLY, BE AN ADVOCATE FOR YOUR HEALTH. National and global public policies can make a lifesaving difference to your health. Every woman can have her voice heard. Consider signing a petition to support the HEART for Women Act, national legislation introduced on February 14th , 2006 that supports Federal programs to improve the diagnosis, treatment and prevention of heart disease and stroke in women and also to increase knowledge about sex differences in these conditions. The legislation supports programs to:

    1. Educate healthcare professionals about the prevalence and unique aspects of care for women in the prevention and treatment of cardiovascular diseases. It also authorizes the Medicare program to conduct an educational awareness campaign for older women about their risk for heart disease and stroke.
    2. Provide gender and race-specific information for clinicians and researchers. The legislation would require that healthcare data that is already being reported to the federal government be stratified by gender, as well as by race and ethnicity. Among the information that would be reported by gender includes clinical trial data, pharmaceutical and medical device approval data, medical errors data, hospital quality data, and quality improvement data.

    3. Improve screening for low-income women at risk for heart disease and stroke. The Centers for Disease Control and Prevention (CDC) currently administers a program called WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) that provides heart disease and stroke prevention screening, such as tests for high blood pressure and high cholesterol, to low-income uninsured and underinsured women in 14 states. The legislation would authorize the expansion of WISEWOMAN to all 50 states.



So during February, Heart Health Awareness Month, learn about cardiovascular disease prevention in women and take some simple steps all year long to give yourself the Valentine of a healthier future.

** For more information about heart disease and stroke in women and how to prevent these conditions, visit www.goredforwomen.org. This Campaign of the American Heart Association is dedicated to increasing awareness and taking the necessary actions to eradicate heart disease in women. A personal heart health assessment is available on the website as well. Other helpful sites for more information are www.hearttruth.org and www.4woman.gov.

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