Teaching Women and their Doctors to Take Heart by Gina Shaw Try this simple, one-question quiz. If youíre a woman, you can answer it yourself. If youíre a man, ask your wife or a woman you work with this question: What disease is the number-one killer of American women? If youóor sheóanswered breast cancer or another type of cancer, youíd be wrong, but hardly alone. Although 42,000 women a year die from breast cancer, heart attacks aloneónever mind congestive heart failure and other heart problemsókill almost 250,000 women annually. According to a recent American Heart Association survey, only 34 percent of American women realize that heart disease is the leading killer of women as well as men. Thatís hardly better than in 1997, when 30 percent of women viewed heart disease as the leading killer. The conundrum of women and heart disease stems from a variety of sources, experts say. For years, researchers didnít involve women in studies dealing with heart disease (and many other studies), because of beliefs that womenís varying hormonal levels might skew studies, fears of endangering pregnancies, and the old-fashioned belief that the male body represented the standard of human health. That left doctors with a knowled ge gap about how heart disease can manifest itself in women, and women themselves with a lack of information about their risk of heart disease. "Part of the problem for women is they have different signs and symptoms for heart attacks," said Scott Dahl, director of Business Development for Clinical Advantage, a program of VHA Inc. that seeks to help both women and their health care providers understand whatís different about womenís cardiovascular disease. "Men have traditional clutching pain in their chests, while women might be nauseous, dizzy, and feel pain in their lower back. They know thereís something wrong, but since itís not the clutching pain in their chest theyíve been taught to associate with a heart attack, they donít rush to the hospital." And when women do have some of the standard symptoms of heart disease or a heart attackósuch as severe chest painóthey may dismiss them as the result of stress. If women do seek treatment and ask whether their symptoms might be signs of a heart attack doctors sometimes fall victim to old gender stereotypes and send them home with a diagnosis of gas or heartburn, when theyíd admit a man with the same symptoms to the hospital. Victims of ëMetabolic Syndromeí Itís not just lack of awareness putting women in cardiac danger. In some cases, certain risk factors for heart disease are many times more deadly in women than in men. Cardiologists have identified a cluster of risk factors often referred to as "the deadly quartet." These four factorsóobesity, high blood pressure, diabetes, and high triglyceride valuesóincrease risk of death from cardiovascular disease and can cause poorer outcomes when a patient has heart surgery. Physicians at the Cleveland Clinic decided to examine how the "deadly quartet" affected the outcome of coronary bypass surgery in women compared with men. They looked at mortality eight to 10 years down the road after bypass surgery for a group of 6,000 patientsóand the results were overwhelming. "Men get up to about a threefold risk of death following coronary bypass surgery once you have all four ëmembers of the quartet,í" said Dr. Dennis Sprecher, section head for preventive cardiology and rehabilitation at the Cleveland Clinic. "In women, it becomes a tenfold risk. Of the women that had all four of these conditions, half were dead within 10 years of their bypass surgery, while the figure was closer to 20 percent in men." Doctors arenít entirely sure why the "deadly quartet," seems to hit women with so much more ferocity than men. "Basically, women do not do well with what we call the metabolic syndrome, and thatís what this is. Women do very poorly with it. And a lot of women have a tendency toward diabetes, high triglycerides and high blood pressure," said Sprecher. Why arenít women and their doctors focusing on heart disease as a risk factor? In part, said Sprecher, it has to do with youth and economics. Men are more likely to have heart attacks at a younger ageóweíve all heard the tales of 50-year-old executives collapsing on the golf course. For women, heart disease usually takes hold when theyíre in their 60s and olderóand then it hits with a vengeance. "Women donít know a lot of younger women who have heart disease. Now, if you just queried African American women in this country, youíd get a very different response because of the prevalence in that community. But for other women, the heart disease risk doesnít go up until later in life." Because more middle-aged women know someone with breast cancer than heart disease, they may focus on the one health concern and ignore the other. Thatís a mistake, most doctors agree, because smart heart habits in a womanís 30s, 40s, and 50s are likely to pay off with a decreased risk of heart disease later on. Although a major national study of womenís health, the womenís health initiative, wonít yield results for several years, Sprecher said that for the moment, "You go after the risks of cardiovascular disease that you know of in men. Watch your cholesterol, donít smoke, try to stay trim, exercise and eat right. Those are big risk factors in both men and womenóand it just may have a bigger impact on women than men. With the right targeting, you may get a lot more mileage for prevention in women." Worldwide Problem The "heart disease gap" in awareness, research, and access to treatment for women isnít just a U.S. problem. Last year, more than 500 attendees from more than 40 countries attended the First International Conference on Women, Heart Disease, and Stroke in Victoria, Canada. Heart disease and stroke, which are already the leading causes of death in women in developed countries, will also be the leading killers of women in poor countries by the year 2020, warned Dr. Ruth Bonita, director of the World Health Organization, in a symposium address to the conference. "The common view that cardiovascular disease [CVD] is a menís health problem has overshadowed the recognition of the significance of CVD for womenís health. Prevention of heart disease and stroke in women has been neglected, especially in poor countries," Bonita noted. Unfortunately, much of the research on the disparities in heart disease prevention and treatmentóand how these disparities affect womenís healthóhas been done in developed countries, such as the United States and European nations. The Victoria conference attempted to create a global network, bringing together whatís known about women and heart disease around the world to create strategies for education, prevention, research, and treatment. Womenís healthóincluding cardiovascular healthóis inextricably linked to their status in society, declared conference participants. "Womenís health benefits from equality and suffers from discrimination. And if womenís health status suffers, then the whole societyís prospects for future are dimmer, because they do bear the children and often have responsibility for the family," said Dr. Elinor Wilson, chief science officer for the Heart and Stroke Foundation of Canada, one of the leading organizations that sponsored the Victoria conference. View from Latin America In many Latin American countries, cultural factors play an enormous role in access to care. "Women, just as men, have the same access to new technology for diagnosis and treatment of coronary disease when they have Social Security or even for poorer people because in most countries there are public hospitals," said Dr. Palmira Pramparo, staff cardiologist and cardiovascular epidemiologist at the National Hospital Prof. Alejandro Posadas in Buenos Aires, Argentina, and former director of the Epidemiology and Prevention Council of the Argentine Society of Cardiology. "But often pharmacological treatments cannot be continuous after hospital discharge due to lack of coverage, economic instability, and unemploymentófactors which especially affect women." Pramparo, a participant in the Victoria conference, said that in Latin America, women often put themselves last when health care is needed. "Women are prepared to take care of the family members first, so when the money is not enough they try to solve first the necessities of children, husband and family." And women in Latin America seem to get the same double and triple whammy from the major risks of heart disease that women in the United States do. In the largest Latin American study to compare womenís risk for heart disease compared to that of men, FRICAS (Factores de Riesgo Coronario en America del Sur), conducted on patients in Argentina, Mexico, Venezuela, and Cuba, researchers looked at the relative risk of heart attack in men and women based on the major risk factors. In other words, how much more of a chance of having a heart attack did men and women in the study have if they smoked, if they had diabetes, or if they had hypertension? For every one of the risk factors, women had a higher risk of heart attack than menóa result that jibes with the results of studies done in the United States. "In this part of the world, women with risk factors have greater risk compared to men for an acute myocardial infarction [heart attack]," said Pramparo. In Latin America, just as in the United States, "great effort has to be made to educate women in primary and secondary prevention of cardiovascular disease," she said. This means, of course, giving up smoking, taking up regular exercise, a healthy diet, and controlling hypertension. "These measures are useful in any society and at any socioeconomic level." In the Americas and the Caribbean, Pramparo said, a group called the InterAmerican Heart Foundation, through its task force Women and Cardiovascular Disease in the Americas, is working hard to improve knowledge about women and cardiovascular disease. "They have recently published guidelines on early detection and proper treatment of cardiovascular risk factors in women at any age," she noted. "These recommendations have been disseminated at a number of scientific meetings focused on gynecologists, cardiologists, general practitioners, and other health professionals." Changing Focus in Pakistan Many women cardiologists who attended the Victoria conference returned home with a renewed sense of the importance of public education about cardiovascular disease in women in their countries. One of these physicians is Dr. Sania Nishtar, president of Heartfile, the National Heart Foundation of Pakistan, which is similar to the American Heart Association in the United States. "Womenís health issues are thought of as being synonymous with reproductive health issues in countries such as ours," Nishtar said. "Women are not economically independent in South Asian culture and they depend on their men folk for access to health care. In a society where women die from postpartum hemorrhage on the long journey from their village to the health care facility, lobbying for cardiovascular disease was farfetched," she noted. The Victoria conference, she said, offered a wonderful public education platform to help her and her colleagues in South Asia initiate womenís cardiovascular health initiatives. Participants in the Victoria conference issued an international declaration on women, heart disease, and stroke, which Nishtar said is particularly relevant for poor countries, with its focus on health as a fundamental human right, not a privilege; the importance of women as well as men in leadership roles in the health community; and the linkage between womenís status in society and their physical health. "It is an eye-opener in creating a global awareness relating to this important public health challenge and has done so for the fist time with such a great thrust," she said. Nishtar and her colleagues at Heartfile have taken the "Victoria ball" and run with it. "Subsequent to the conference, we have revised our strategy with a renewed focus on womenís cardiovascular health issues, and weíve begun addressing these independently." For example, they have started a weekly column featuring advice on cardiac health, including heart-healthy recipes that appear in the largest womenís newspaper in Pakistan, read by more than 10 percent of Pakistani women. "We are now replicating our strategy in Bangladesh and Sri Lanka," Nishtar added. Conference organizers plan to follow up on Victoriaís success with a second international conference in 2003, said Wilson. "It will be held somewhere in the United States, mainly because we need to solidify corporate support and thatís where most of the research is coming from. Then the plan for the next one would be to move it out into a location where itís more accessible to developing countries, perhaps in Asia or in Eastern Europe." Gina Shaw is a freelance medical writer in Washington, D.C.