Womenís Gap in Knowledge About Heart Disease Can Be Deadly by Gina Shaw At first, Bonnie Brown just thought she had indigestion. Then 44 years old, the Baltimore, Md., woman would take an Alka-Seltzer and her stomach troubles would dissipate. But after a few days of symptoms, one Saturday morning in 1998, antacids didnít help. Brown knocked on the door of her sisterís bedroomóthe two women shared a homeóand told her she wasnít feeling well. ìShe took one look at me and said, ëIím calling an ambulance.í I tried to persuade her not to do that, but she did it anyway,î Brown recalled. Rushed to the hospital, Brown was told she had had a heart attack. Even after the doctorís diagnosis and nine days in the hospital, she still didnít believe it. ìI couldnít accept it. I wasnít ready to follow any changes in my lifestyle,î she said. ìI thought I was pretty healthy, and I was a woman in my 40s, not a man in his 60s. I didnít think I could have a heart attack.î Then lightning struck twice. Brown had been home from the hospital for only a few days when her sister, Joan Hamilton, started complaining of muscle spasms in her shoulder. The two women returned to the hospital and were stunned when the 49-year-old Hamilton was told that she, too, had had a heart attack. ìWe didnít have a family history; we werenít overweightóJoan weighed only 98 pounds,î Brown said. ìHow could this happen to us?î That, as it turns out, is exactly how a lot of women think about heart disease. Although heart attacks are the No. 1 killer of women as well as men, killing nearly 270,000 women each year (six times the mortality rate of breast cancer), many women still do not recognize what a threat heart disease is to them. According to a survey commissioned by the National Council on the Aging, 61 percent of women 45 to 65 name breast cancer as their greatest health fear, while only 9 percent are most concerned about heart diseaseóeven though 13 percent of women in that relatively young age group have already experienced a heart attack, according to WomenHeart, the National Coalition for Women with Heart Disease. Womenís attitudes about their risk of heart disease may simply reflect what they see in the media. A survey done at Mount Sinai School of Medicine in New York, released late last year, found that from 1990 to 1999, articles about breast cancer in womenís magazines outpaced heart disease articles by nearly three to one (286 breast cancer-related articles compared to only 109 heart disease articles). The gap widened in the later years of the survey. Whatever the reason, the gender gap in knowledge about the risks of heart disease can be deadly. A study published in the April 15 issue of the Journal of the American Heart Association found that sudden cardiac death was the first sign of heart disease for 69 percent of women with the disease, but nearly all these women had at least one risk factor for heart disease, such as high blood pressure or diabetes. If they had realized their risk factorsóor recognized their symptoms as a heart attack, as many women do notóthese women might have survived. Ann Stiegler knows that she might well have been one of the 69 percent. In 1994, at age 50, the retired mother of a grown son had the classic symptoms of a heart attack: chest pain, pain down both arms and tingling in her hands. ìI even said to my husband, ëGosh, it feels like Iím having a heart attack,í but I thought that couldnít be it. So I went to bed,î she recalled. ìThe next morning I didnít feel at all well, so I called my doctor and he told me to get right to the hospital.î She was hospitalized for 10 days and underwent angioplasty, a surgical procedure to relieve blockages in the heart. Stiegler didnít realize it at the time, but she now understands that she was a classic candidate for heart disease. ìI actually had a number of risk factors, though I didnít know it then. Iím diabetic, which more than doubles your risk of heart disease, and my father had a history of heart attacks,î she said. In fact, diabetes is considered equivalent to having had at least one previous heart attack as an added risk factor. ìIf Iíd been smarter and moved quicker, I would have been in much better shape,î Stiegler said. ìMy doctor told me, ëYou know, you might not have been alive this morning.íî New Center Aims to Educate Women In late June, the George Washington University Medical Center opened the Womenís Heart Program, the only comprehensive center devoted to womenís cardiovascular health in the Washington area and one of only 21 such centers in the nation. Four cardiologists and a nurse practitioner staff the center, according to Dr. Judith Hsia, co-director of the center and its director of research. ìThe technology, the access and the expertise are all there,î she said. ìCardiology is very specialized, of course, so while the cardiologist seeing a patient at the center may not be the leading expert in their particular condition, the patients will have access to GWís state-of-the-art equipment, specialists and facilities.î Community awareness is a primary goal of the center. ìWeíll be doing a wide variety of things to educate women in the Washington area about their risk factors for heart disease, such as community screenings and workplace-related screening activities,î Hsia said. ìWomen can fill out a simple questionnaire that is then run through a computer program to provide a personalized risk assessment that will tell them whether they need additional screenings, whether they need to meet with a cardiologist, and what their risk factors are and how they can manage them.î This type of center is particularly important in a multicultural community such as Washington because heart disease risk factors are even higher for particular racial and ethnic groups, such as African American and Hispanic women. African American women, for example, are almost twice as likely to die from heart disease as white women, and Hispanic women are particularly at risk of something called the ìmetabolic syndrome,î a combination of borderline health conditions that raises the likelihood of heart disease. ìHaving the metabolic syndrome means that you meet three of five criteria: blood pressure above 130 over 85 [either number], blood sugar of 110 or higher, triglycerides 150 or higher, HDL [good cholesterol] below 50 for women, and waist circumference greater than 35 inches for women,î Hsia explained. ìIf you have at least three of these factors, you have the metabolic syndrome, which confers increased coronary risk. ìBut many of these people have had borderline blood pressure, borderline blood sugar, and borderline lipids for years, and have never gotten treated for any of them because they were just on the borderline,î Hsia added. ìBut they often do cluster, and they heighten the risk factors.î Women also tend to have metabolic syndrome more often than men do. Heart Disease Risk Factors Having the metabolic syndrome, or any other risk factors for heart disease, isnít a death sentence. You can modify your risk factors, said Dr. Elizabeth Ross, a Washington Hospital Center cardiologist, American Heart Association spokeswoman and author of the book ìHealing the Female Heart.î ìThere are many steps you can take. One of the most important is to quit smoking,î Ross said. Studies have found that even light smoking doubles the risk of a heart attack in young women. ìItís very worrisome that 20 percent of graduating high school girls are smokers, which is about as high as itís been since 1977. That puts them on the path to heart disease.î So do obesity, unhealthy eating and inactivityóall lifestyle factors that seem to be on their way up in the United States. Indeed, women from other countries who come to the United States and adopt an American ìsuper-sizeî lifestyle, with more high-fat foods and less exercise, significantly raise their risk of heart disease. ìPeople who come to the U.S. from cultures where heart disease is relatively infrequent, such as Japan, have their rates of heart disease soar if they adopt more typically American exercise rates and eating habits,î Ross said. ìWe in our office see a lot of people from the diplomatic community; weíre always impressed with how much more they walk. They tend to go hiking, biking and keep up with more active lifestyles, and if that became more common among American women, their rates of heart disease would go down.î However, women actually are worse than men at changing their habits after a heart attack. ìUnfortunately, women are less likely to complete cardiac rehab and less likely to quit smoking. Theyíre not more motivated than men. The challenge is to recognize that this is not just a disease of older women,î Ross said. ìThis is a disease that can affect younger women. Whatís more, women who h ave heart disease, even in the same age group as men, do comparatively worse than men do after hospital treatment. Among patients between 40 and 60, the mortality is higher for women and complication rate is higher if they have a heart attack,î Ross added. Lifestyle changes arenít always easy, but they make all the differenceóand Bonnie Brown, Joan Hamilton, and Ann Stiegler are living proof. Five years later for Brown and Hamilton, and nearly 10 years later for Stiegler, all three are doing well, and they believe the dramatic changes in their habits have kept them healthy. ìWe both quit smoking, and we go to water aerobics and dance aerobics classes regularly,î said Brown. ìWeíve cut back on all the fried food and switched from red meats to turkey and chicken, and we make sure to eat more vegetables and salads.î Stiegler, too, said that sheís much more aware of what she eats. ìI donít eat red meat at all anymore,î she said. ìMy menu is pretty much low-fat everything, with lots of fruits and vegetables, and I get in all the exercise I can.î Of course, you canít necessarily change all your risk factors, such as diabetes or a past family history of heart disease, but if you know those risk factors, said Brown and Stiegler, youíll act faster than they did. ìIf Iíd realized I had several risk factors when I had those pains, I think I wouldíve been a little smarter,î said Stiegler. ìGet to the hospital immediately. Get to the hospital immediately. I was lucky that I didnít have a lot of heart damage, but I could have had.î And donít wait for the ìclassicî heart attack symptoms to summon help. For many women, the signs of a heart attack are different from what men experience. ìWomen can have nausea, extraordinary shortness of breath, or dizziness or palpitations with exercise,î said Ross. ìIf you notice a perceptible change in the way you deal with activityósay you suddenly start getting dizzy while carrying the laundry upstairs or feel abnormally winded when youíre taking the morning walk with the dogóthen you should be concerned.î ìI always thought that it just threw you to the floor in painóthat it was obvious that you were having a heart attack, and youíd be grabbing your chest,î said Brown. ìThat never happened to either one of us, and Joan and I each had different symptoms. If youíre feeling strange and something doesnít feel right in your body, then have it checked out right away, even if you donít think it could be a heart attack.î Making lifestyle changes, and coping with the aftermath of a heart attack or coronary disease diagnosis, are easier with the help of a support network. Often, family and friends donít understand how much heart disease changes your life. ìItís really helpful to talk to other people whoíve been where you are. Your friends and family think you should be perfectly fine again, because you look fineóbut you may not be,î said Stiegler, who found an ad in The Washington Post for what at the time was one of the first all-womenís heart disease support groups in the country. ìMy son was already grown and gone at the time, but what I heard from a lot of women who have children at home is that the kids all think, ëOK, Momís back home, she can do everything again.íî Brown said that working to educate other women about heart disease has helped her and her sister find a supportive community. ìAt one point, it was depressing to talk about it, but weíve met a lot of women in the process of doing this, some younger than we were when we experienced the heart attacks,î she said. ìYou realize that youíre not the first to go through this experience. It puts the depression on the back burner, because I feel like Iím helping to make others aware.î For more information on support groups for women and heart disease, risk factors, healthy lifestyle habits and new research, visit WomenHeart, the National Coalition for Women with Heart Disease at www.womenheart.org, the American Heart Associationís section on women and cardiovascular disease at www.americanheart.org, or the National Heart, Lung, and Blood Instituteís Heart Truth campaign at www.nhlbi.nih.gov/health/hearttruth/. Gina Shaw is the medical writer for The Washington Diplomat.