Women and Heart Disease: Frequently Asked Questions

Coronary artery disease is the number one cause of death in the United States. Over half a million women will die from some form of cardiovascular disease this year. This compares to approx 40,000 who will die of breast cancer and 40,000 women who will die from lung cancer. Our death rates from coronary artery disease have declined and, combined with increased life expectancy, women are living longer. The good news is that women develop heart disease later than men, and this time can be used to modify risk factors and hopefully improve the outcome.

I see one of your specialties is cardiac rehabilitation. Isn't that something most people can do on their own?
Cardiac rehab sounds like it's something people can do on their own, but the majority of people don't participate; even people who have a heart attack don't participate in their cardiac rehab program. Cardiac rehab in this day and age should include an exercise program and assessment of cardiovascular risk factors.
Are women less likely to get heart disease than men?
This is a question that has caused a lot of confusion. Women are actually equally likely to get heart disease as men. The problem occurs when at a specific age, there are fewer women than men who will get heart disease, but the overall numbers are equal. If we look at people who are 55, there will be more men who will have a heart attack, but what happens at 85 is that most of the men are no longer alive anymore, and women make up the larger population of people who have heart attacks.
What does preventative cardiology consist of?
Preventative cardiology would include assessment of cardiovascular risk factors, which would include diet and cholesterol, blood pressure control, exercise, presence/absence of diabetes, and hopefully the absence of smoking. We look at all these risk factors and try to modify them and prevent development of cardiovascular disease.
I've tried diet/exercise, but the gene factor is evident in my high cholesterol; what can I expect from using Lipitor?
In people who have inherited very high cholesterol, it often takes multiple drugs as well as diet to lower the bad cholesterol level. The drugs can come from several different classes.
When a woman has a heart attack, does she have pain like a man does?
Women can have chest discomfort just like men do. They can also have different types of discomfort in locations such as the very lower part of the chest or upper part of abdomen up into the jaw or the neck. The important thing for women to realize is that any type of discomfort that does not resolve promptly should prompt a woman to seek medical attention and have it evaluated. The pain can radiate into the shoulders or arms and occasionally can radiate to the back between the shoulder blades.
I've read that women usually take longer to get to a doctor. Why do they wait longer?
That's an excellent question. Often women believe that they can't have a heart attack. A lot of it is denial that they have a problem with their heart. They may also have chest discomfort that is not "classic" and could be confused with other conditions.
How big of a problem is high blood pressure in women, and what are their risk factors?
High blood pressure, or hypertension, is a major risk factor for both men and women. It's going to affect over 60 million people and is going to affect 50 percent of women who are aged 55 or over. More African-American women will have problems with high BP than white women. We've done a good job of increasing our awareness of hypertension, but we still have a significant proportion of women who do not have their BP under control. Other risk factors include high cholesterol. Even in women who have heart disease, we have measured the cholesterol levels but have a ways to go in bringing the cholesterol under control. The majority of high BP has unknown causes. There are other secondary forms of BP that are not as common but can often be screened with physician visits.
Why do so many women experience high blood pressure when they are pregnant? Is this dangerous for the baby?
It is true that high BP presents during pregnancy. It is important that this be checked as it is dangerous for both mother and baby, and this should be part of prenatal visits.
What medicines are used to treat high cholesterol?
Treatment of high cholesterol depends on several factors. First would be the level of the good cholesterol vs. the bad, the good being the HDL (you want that to be high). The bad cholesterol would be LDL (you want that value to be low). Most of the problems center on lowering the bad (LDL) cholesterol. Depending on the level and other associated risk factors, whether or not someone has atherosclerosis determines the treatment. A diet low in saturated fats is one of the initial parts of therapy. The patient should also lose weight if they need to get down to their proper weight. If this does not bring the bad cholesterol to the recommended goal, treatment with medications is often then initiated. There are various classes of medicines which can be used to lower LDL cholesterol. A common group would be HMGcoA reductase inhibitors. Included in this group would be Lipitor or atorvastatin, simvastatin, pravastatin, cerevastatin, fluvastatin, and lovastatin. They are often referred to as the "statins". These work by inhibiting an enzyme which is involved in the metabolism of bad cholesterol. The important part of treating cholesterol is to know the target or goal LDL and to make sure that the treatment effectively helps the patient to reach that goal. Women who have any type of atherosclerosis should aim for an LDL of less than 100 mg/dl. In the absence of significant atherosclerosis or significant number of risk factors, the goal should be an LDL less than 130.
What are some other treatments, non-medicinal, are there for high cholesterol?
Diet and medications are basically the only treatments.
Is diabetes a significant cardiovascular risk factor in women?
Diabetes is a major risk factor for women. In fact the risk of a heart attack in a diabetic woman is the same as that of a non-diabetic man. The risk of a heart attack in a diabetic woman is several times that of the non-diabetic woman, so it's very important that all risk factors are modified, particularly the LDL cholesterol.
Isn't it rare that a woman will have a heart attack before menopause?
It is less likely that a woman will have a heart attack if she is pre-menopausal, but it still occurs particularly in women who smoke. For half of women who have heart attacks before menopause in the Nurses' Health Study, their only risk factor was cigarette smoking.
My father had 2 heart attacks. I am his daughter--does that mean I am at risk, as well?
Family history is an extremely important risk factor. We are generally concerned with parents who have premature disease. This would be defined as a father who had heart disease before age 45 or a mother before age 55.
My cholesterol is 335 total, but 75 HDL isn't that still a safe ratio? My triglyceride level is 165
In women, it's important to look at both good and bad cholesterol fractions. Often women will have higher HDLs but the goal for LDL is the same. Without atherosclerosis or significant risk factors, the LDL should optimally be less than 130. A low HDL has been shown to be one of the major risk factors for women.
At a younger age, I would experience heart palpitations that my physician said was normal for a younger woman--however I am currently 35 and still experience these sometimes after exercise (though I don't exercise often). Is this something I should be concerned about?
Palpitations are variably defined. Fast, rapid heart rates that are uncontrolled should prompt further evaluation by your physician. A normal response to exercise is an increased heart rate.
If your only risk factor is being overweight and you have no family history of heart disease, how likely is it that a person will have heart disease?
Being overweight is linked to several cardiovascular risk factors, in particular high blood pressure and diabetes. In some studies being overweight has shown to result in increased risk by itself, but is more often tied to the risk factors mentioned above.
How long does one have to stay on Lipitor?
Treatment of lipid disorders is lifelong.
What does a heart palpitation feel like?
Different patients describe it differently, but often they refer to feeling their heartbeat in their chest, or 'flip-flopping' in the chest.
What role does hypothyroidism play in heart disease?
Hypothyroidism can be related to various cholesterol problems.
Does hyperthyroidism play a role too?
Patients with hyperthyroidism can have some cardiac problems and may have an abnormality of heart rhythm, the most common one being atrial fibrillation.
How do you figure your LDL?
LDL can either be calculated or directly measured. Most often it is calculated. The formula is: LDL = total cholesterol - triglycerides/5 - HDL.
How much exercise do you think people should do each day?
There is no specific answer that would apply to everyone. Every bit of exercise counts. We used to think that you had to exercise for 30 minutes at a time. While this is good, if it can be done, it is also beneficial to divide this up. For example, walking for 10 minutes three times a day also counts. Simple things like taking stairs or walking to the parking lot are a way to increase your activity if you don't have a normal exercise program. Ideally we would like to exercise 3-4 times per week or more if possible.
What are the uncommon symptoms of chest pain in women?
In thinking about coronary disease specifically, symptoms that result in stopping your activity should probably be further investigated. These could be such things as new-onset shortness of breath that is out of proportion or symptoms of indigestion that get worse with activity.
Does a woman who has taken birth control pills for longer than 10 years have any advantage/disadvantage in controlling heart disease?
The older oral contraceptives in women who are over 40 and who also smoke have been associated with an increased risk of heart attack.
Is it too late for a 32-year-old woman who is overweight to change her ways and improve her health?
It's never too late! Improvements in diet increase in exercise and stopping smoking result in decreased risk (particularly stopping smoking). Women who've had heart attacks and stopped smoking will decrease their risk of another heart attack within 1-2 years after quitting.
What about smoking low tar, lighter cigarettes? Do they make a difference?
There's actually been no improvement in risk of heart attack with the lower-yield cigarettes. There's no advantage. It's also important to completely stop; even women who smoke a few cigarettes a day have an increased risk of heart attack compared to someone who doesn't smoke any.
Can even slow walking do anything?
Walking is a great exercise. Just because you walk slower doesn't mean you're not reaping the benefits. It may just take longer to reach the same benefit, but the active person is always better off in many types of disease situations compared with the inactive person.
My mom is 62, has smoked for over 40 years, eats all the wrong foods, never exercises and has a strong family history of heart disease. What can I do to convince her to take healthy steps?
You can remind her that heart disease is the leading cause of death for women in the United States and that in addition to causing death it is one of the major causes of disability. People often forget that it is disabling and can result in loss of their independence. Smoking is also associated with increased risk of other diseases, particularly lung disease and cancer. You can tell your mom that you want her to live a full and healthy life.
Is it better to lose weight very slowly or as fast you can?
The best weight-loss programs work slowly, over time, and often result in a combination of diet and increase in exercise. Rapid weight loss is often just loss of water weight and can have associated medical problems. People who lose weight rapidly typically regain most of their weight.

Ellen Gordon, MD
Division of Cardiovascular Disease
University of Iowa Hospitals and Clinics