-By Benjamin Wu, M.D., Ph.D., FACC, FACP
Dept of Cardiology
(408)-278-3645
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What is the number one cause of death in women?
If you answered “breast cancer” you would be wrong. In fact, one in two women will die of cardiovascular disease, compared to one in 25 women who will die of breast cancer. In a single year, half a million women will have a heart attack and a quarter of a million women will die of coronary artery disease (CAD). If you look at all manifestations of cardiovascular disease, half a million women a year die of coronary artery disease, stroke, high blood pressure, or vascular disease. Heart disease causes twice the number of deaths in women, more than ALL forms of cancer combined.

One of the more dangerous myths about heart disease is that it’s a man’s disease. According to the American Heart Association, only eight percent of women know that heart disease is a major health threat to them.

What contributes to this myth that cardiovascular disease is a male problem?
There may be several reasons. There is a lower prevalence of CAD symptoms in women than men before age 70. This is thought mainly to be due to the protective effects of estrogen in premenopausal women. Also, there are gender differences in symptoms, with women more likely to deviate from the textbook description of crushing chest pain that we normally associate with heart attacks.

Doctors refer to these as “atypical” symptoms (shortness of breath, fatigue, referred pain) with the “typical” symptoms having been initially described in studies of middle-aged men! Because women have been excluded from many older clinical trials there is a knowledge vacuum regarding many issues of cardiovascular care in women. The upshot is that due to the delayed recognition of CAD in women, vast differences exist in the rates of diagnostic testing, performance of angioplasty and surgical procedures, and use of effective medications between men and women.

Fortunately, the National Institute of Health is now funding studies that include women, helping to close this gap.

Your propensity for developing heart disease depends on the presence or absence of cardiac risk factors. Some of these are immutable, such as your age and family history. Fortunately, many of these are modifiable, including smoking, cholesterol levels, blood pressure, and diabetes risk.

Do you have to worry about your cardiac risk factors if you are a twenty something female?
The answer is yes. This is because the process that leads to a heart attack at age 65 and over actually begins decades before. The development of atherosclerosis (clogging and hardening of the arteries) can begin in your early twenties. It was once thought that heart attack victims who do not have any cardiac risk factors could put the blame on heredity. However, two recent studies this year examined this issue and found that up to 80-90% of patients with clinically significant CAD had at least one of the following traditional risk factors: smoking, diabetes, hypertension or hypercholesterolemia.

Men and women share the same risk factors for developing CAD, but the relative weight of the risk factor may differ. For example, smoking, diabetes and hypertension are stronger relative risk factors for stroke and heart failure in women than in men.

What can you do to reduce your chances of developing CAD?
First, stop smoking. This is the greatest modifiable risk factor for a heart attack. Nicotine causes narrowing of your blood vessels and increases your heart rate and blood pressure. Tobacco smoke contains over 4,800 chemicals, many of which damage blood vessels and lead to atherosclerosis in both your heart arteries and non-heart arteries. Women who smoke two to six cigarettes a day more likely to have a heart attack, and if they do have a heart attack, the smoker is more likely to die from it. If you take oral contraceptives and smoke, the risk of having a heart attack or stroke increases up to 30 times that of a non-smoker, especially in women over age 35.

You may ask “what if I just smoke a few cigarettes a day?” No amount of smoking is safe. The association with heart disease is so strong, that smoking one to four cigarettes a day has been shown to double your risk of cardiovascular disease. Once you quit smoking, we know your risk of heart disease starts dropping within a year or two and will normalize to that of a nonsmoker’s risk after a decade. The average smoker takes seven tries to successfully quit, so if you’ve tried and failed in the past, don’t be discouraged. Various smoking cessation aids are available, including nicotine patches, spray, or gum, and medications that blunt your craving for a smoke. Seeking professional assistance and setting a target stop date may just be the positive reinforcement you need to kick the nicotine habit.

Second, you can fight CAD with regular exercise. Exercise reduces cardiovascular disease by up to 50%. Why? It facilitates weight loss, which in turn reduces blood pressure, cholesterol levels and the risk of developing diabetes. It increases blood flow to your heart, training the heart to pump blood with less effort. The best exercise to start with is walking, since everyone knows how to walk. If you’re sedentary, start gradually with five minutes a day of walking on a level surface, increasing gradually to 30 minutes a day, five times a week. Talk to your doctor if you’re planning to start an exercise program.

Third, increase the amount of fruits, vegetables and grain products in your diet. Limit your red meat intake to a wallet-sized portion a week. Most of your protein intake should come from white meat and fish. Limit fat, especially saturated fat. The worst fats for your heart are the saturated and trans fats; both types of fats increase blood cholesterol levels and the risk of CAD. Beef, butter, cheese, whole milk, coconut oil and palm oils are rich in saturated fats. Limit your consumption of eggs to two-three times a week.

Omega-3 fatty acids are a type of polyunsaturated fat that has been shown in clinical trials to reduce the risk of heart attacks and sudden cardiac death. Fish such as salmon, mackerel and herring are the best sources. I would recommend four three-ounce servings of fish weekly. Among nuts, walnuts have the highest omega-3 fatty acid content. Flaxseed, soybeans, and canola oil are also good sources.

What about antioxidant supplements?
There is some science showing that vitamin C and E and carotenoids may prevent cholesterol from damaging arteries. Unfortunately, most of the randomized trials looking at these supplements have shown no cardiac benefit. Part of the problem is that we may not know what doses and what combinations of antioxidants to take. In addition, there are some studies suggesting that antioxidant supplementation may interfere with the cholesterol-lowering effects of statin drugs. Consequently, I recommend that your antioxidant intake should come from your diet rather than from supplements. Broccoli, tomatoes, strawberries, oranges, and green and red peppers are good sources.

Soluble fiber may also help lower your cholesterol levels. Good sources are oats, apples, oranges, grapefruit, and dried beans.

Fourth, maintain a healthy weight. The more body mass you lug around, the harder your heart has to work. Being overweight is associated with a higher heart rate and an increased demand for oxygen. For most people, the body mass index (BMI) gives an idea of your desired weight goals. A BMI of 25-29 is overweight and a BMI of 30 or higher is in the range of obesity. Studies have shown that a BMI above 25 is associated with higher blood pressure, cholesterol levels, and risk of stroke and heart attacks. The BMI measurement is not perfect. It doesn’t apply to women who are muscular (since muscle is heavier than fat) or if you’re pregnant, but for most average folks, it’s a reasonable estimate of your target weight. Talk with your doctor about measuring your BMI and your weight goals.

Finally, be pro-active at your next visit to your doctor. Ask about your risk of heart disease. At the end of the visit, you should know what your blood pressure is and what your lipid (cholesterol) blood levels look like. The “ideal” blood pressure has been getting lower over the years, as we learn more about the cumulative effects of high blood pressure. Normal blood pressure is now defined as being less than 120 systolic (top number) over 80 diastolic (bottom number). Your lipid levels consist of your total cholesterol (less than 200 milligrams per deciliter - mg/dL), triglycerides (less than 150 mg/dL), high-density “good” cholesterol (more than 60 mg/dL), and low-density “bad” cholesterol (less than 100 mg/dL). Whether you need cholesterol-lowering medicines depends on your risk factor profile and the presence of known CAD or diabetes.

Cardiovascular disease is the number one health problem in women. Your propensity for developing heart disease depends on your risk factor profile, many of which are modifiable. Work with your doctor to determine and manage your risks.

Benjamin Wu, M.D., Ph.D., FACC, FACP, is an Interventional Cardiologist for the San Jose Medical Group, 625 Lincoln Avenue, San Jose, CA 95126. His phone number is 408-278-3645.