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VOL. 6 • NO. 6
© February 2012
Heart Disease in Women Lack of awareness adds to problems Wanda Tswago, a trained medical technologist, is a 44-year-old proud mother of two. And a heart attack survivor. Even though her sister had her first heart attack at age 40, another at 42 and a fatal one at age 45, Tswago still didn’t see it coming. Her major health fear was acquiring breast cancer — not heart disease. “I did not fit the profile,” she explained. “I was 31, had normal blood pressure and cholesterol and didn’t smoke.” She assumed her years as a dancer and gymnast — together with her small frame — offered her protection. But she was wrong. When it comes to heart disease misperceptions abound and partly explains the high death rate of heart disease in women — and particularly in younger women. Based on results from several recent studies, the majority of women are not aware of the disease and its link to other chronic illnesses. Nor do most women recognize the symptoms of a heart attack. That mistake can prove to be deadly. Heart disease is the number one killer in both men and women. Yet, if you ask women to name the biggest killer among women, many would answer “breast cancer.” Indeed breast cancer is the most common cancer in women and trails only lung cancer in the number of cancer deaths, but its numbers pale in comparison to heart disease. While roughly
Brenda Taylor (right) posed with Patti LaBelle at a recent health seminar promoting LaBelle’s new cookbook. Taylor had a heart attack and open heart surgery at the age of 43. (Photo courtesy of Brenda Taylor)
40,000 women die of breast cancer each year, in the 2012 updates of heart disease and stroke statistics, the American Heart Association (AHA) reports that nearly 200,000 women succumb to heart disease each year. A recent study commissioned by the AHA revealed that much work needs to be done to increase awareness of heart disease, particularly in women of color. Sixty percent of white women were aware of heart disease as the leading cause
of death among women, compared to roughly 43 percent of African American and Hispanic women and one third of Asian women. Awareness of signs of a heart attack is equally wanting. Only 56 percent of the women interviewed cited pain in the chest, neck, shoulder and arm as a warning sign. Less than one third recognized the threat of shortness of breath; 17 percent were aware of chest tightness and nausea. A scant 7 percent could cite fatigue as a factor.
In Tswago’s case, pain started in her lower back, an ache she initially blamed on the effects of an epidural she had during the delivery of her daughter two weeks earlier. “It was a dull, achy pain that did not go away,” she said. Her home remedy of painkillers did not do the trick. Not only did the pain get worse, it began to travel. When it reached the left side of her neck she applied a heating pad to soothe the pain. At least nine hours had passed. Later that night, “everything went south,” she said. “An uneasy feeling came over me. I felt disoriented.” By that time the pain had spread to both arms, her chest — and intensified in her back. “It felt like someone was stabbing me in the back,” she said. It was then her husband finally took her to the hospital. But there she was required to wait additional time even though new symptoms — shortness of breath and nausea — emerged. The triage in the emergency room did not recognize her symptoms either. An EKG eventually indicated that she had suffered a heart attack. A catheterization, a diagnostic test to look for clogged arteries, showed an almost complete blockage in one of the major arteries feeding the heart. A stent to open the artery provided only a Tswago, continued to page 4
Lifestyle changes can reduce risks Like many women, Mildred Rodriguez, 65, did not recognize the symptoms of a heart attack. Nor did she know she was at risk. She did not know that her mother’s heart attack at the age of 62 or her fluctuating blood pressure put her directly in the line of fire. She attributed the pain in her chest and bloating “gas pains” to a soda she drank at dinner. As for the ache in her left shoulder, she blamed that on a home improvement project she and her husband had recently completed. She could not account for the excessive fatigue; as a fulltime grandmother of eight, she knew life could be exhausting at times. She thought all she needed was a day of rest. That didn’t help either. Though she felt better, she still didn’t feel well. “Better” was not good enough for Rodriguez’s husband. He insisted she see her doctor. She was glad he did. An EKG indicated that Rodriguez had had a heart attack. “I walked around for three days with a heart attack,” she exclaimed. This revelation was only the beginning. She required surgery to bypass six significant blockages in arteries of her heart. When a stress test some time later was abnormal, Rodriguez wound up with four stents to open additional clogged blood vessels.
That was the turning point for Rodriguez. She realized after this second bout of treatment for her heart disease that she needed to take control of her health. She admitted that prior to her attack, she did not know her cholesterol level, nor did she have an inkling where her triglycerides ranked. “I looked more on the outside,” she said. “I looked healthy; that’s all that mattered.” She doesn’t believe that anymore. She knew she had to turn her life around. “When you have open heart surgery, you have to have a new way of life,” she said. “If not, you will not live much longer.” Symptoms of a heart attack can differ in women. Typical symptoms, such as chest pain, neck and jaw pain can be present in everyone. Women may experience shortness of breath, nausea, fatigue and tightness or squeezing in the chest. What’s also different is the length of time to seek treatment. “Women tend to report to the emergency room an average one hour later than men,” said Dr. Malissa Wood, co-director of the Corrigan Women’s Heart Health Program at the Massachusetts General Hospital Heart Center. “They think ‘I know this isn’t cardiac’ or ‘it’s not severe enough to go to the hospital.’ ” The differences between men and women and heart disease don’t stop at the emergency room. Take plaque, for instance. Plaque is an accumulation of fat, calcium and other
Mildred Rodriguez bicycles with her husband, Hector. At 52, Mildred had open heart surgery following a heart attack. She now works with WomenHeart of Miami Espanol. WomenHeart is a national coalition for women with heart disease. (Photo courtesy of Mildred Rodriguez)
waste that clings to the walls of arteries, including those of the heart. If the plaque builds up too much or breaks off and forms a clot, it can rob the heart of much needed oxygenated blood. This accumulation of plaque is the culprit behind angina, or chest pain, or heart attacks. The causes of plaque are many — smoking, high blood pressure, diabetes and inflammation, to name a few. Rodriguez, continued to page
heart disease is the #1 killer of women in the United States? Did you know that
Know your risks. Talk to your doctor about heart disease prevention. February is Heart Month
Congestive Heart Failure in Women What are the symptoms? • • • • • • • •
Weakness and fatigue Shortness of breath Swollen ankles, feet and legs Rapid or irregular heartbeat Swelling of the abdomen (ascites) Sudden weight gain Persistent cough Difficulty breathing when lying flat
What causes heart failure?
“Often, there’s more than one culprit,” explained Dr. Jan Cook, medical director of Blue Cross Blue Shield of Massachusetts. Untreated or poorly treated high blood pressure, a problem for nearly 40 percent of African American women, is the number one problem, according to the National Heart, Blood, and Lung Institute. Overweight and obesity, inactivity and high blood cholesterol — health issues affecting roughly 80 percent, 55 percent and 50 percent of African American women, respectively — raise odds for developing coronary artery disease (CAD) and heart attacks, another path to heart failure.
heart failure or worsen it. Try tackling one change at a time. Blue Cross Blue Shield of Massachusetts members can use online tools at www.mybluehealth.ma.com to set practical goals, create action plans and connect with experts. • Quit tobacco. That cuts your risk for CAD in half in one year. Get a step-by-step guide to quitting from Smokefree.gov (www.smokefree.gov or 1-800-QUIT-NOW). • Exercise regularly. Regular exercise helps maintain a healthy weight, normal blood sugar and normal blood pressure. • Eat heart-healthy foods (see sidebar below). This helps lower high cholesterol and high blood pressure. • Lose excess weight. This lightens the load on your heart and lowers risk for diabetes. • Keep blood pressure in a healthy range (below 140/90 mmHg.). Quitting smoking, exercising, losing extra pounds, easing stress and cutting down salt help you do so. Be sure to take medicine if prescribed.
Does heart failure differ in women?
Hear that rhythmic thump? Every beat of your heart pumps blood to cells throughout the body, delivering oxygen from the air you breathe and nutrients from the foods you eat. Congestive heart failure prevents the heart from filling with enough blood, or pumping blood forcefully enough, to meet the needs of the body. This life-threatening health problem affects roughly 2.7 million American women. In right-sided heart failure, not enough blood gets pumped through the lungs to pick up oxygen. In left-sided heart failure, not enough oxygen-rich blood gets pumped to the rest of the body. Some women have both. Struggling to do its job, the heart enlarges, says the American Heart Association. More muscle cells develop and the heart beats faster, too. Blood vessels throughout the body narrow, raising blood pressure to help compensate for power loss. The body shunts blood away from less essential organs to ensure that the brain and heart get sufficient supplies. Eventually, these strategies stop working as heart failure worsens.
Generally, women develop heart failure later than men and live longer with it. Among women, high blood pressure and heart valve diseases are more likely than CAD to be underlying causes of heart failure. However, CAD is such a powerful risk factor that women who have it are much more likely to go on to develop heart failure than women who have only high blood pressure. Ankle swelling, breathlessness and curtailed ability to be active seem to affect women more often than men.
How is heart failure treated?
Experts recommend lifestyle changes, for example an exercise program prescribed by your doctor, plus medicines aimed at easing symptoms and preventing worsening heart failure, if possible. For example, diuretics remove excess fluid build-up and sodium from the body, thus lowering blood pressure. Other drugs called beta-blockers and ACE-inhibitors ease the heart’s workload in different ways. Medical devices to help the heart pump or surgery, such as coronary artery bypass, are sometimes needed, too.
Which lifestyle changes help prevent or ease heart failure? Healthy habits can help prevent conditions that lead to
MyPlate , a product of the U.S. Department of Agriculture, illustrates the five food groups that are the building blocks for a healthy diet.
A heart-healthy diet Paint your kitchen red this February by choosing heart-healthy foods for the whole family. Research suggests that the DASH (Dietary Approaches to Stop Hypertension) diet may lower your risk for heart failure. The tips below are a good start. To learn more, check the Blue Cross Blue Shield of Massachusetts website (www.ahealthyme.com).
Go low on sodium (salt):
• Cut back. Shake on half the salt. Slowly cut back further. • Hide the salt. Boost flavor with spices or herb mixes. Try a squeeze of lemon or lime, or sprinkle on vinegar or hot pepper. • Check “Nutrition Facts” labels when shopping. Canned goods often are high in sodium. So are many store-bought breads. And even foods labeled “low sodium” may have more than you think. • Go low naturally. Fruits and vegetables are naturally low sodium. Frozen is as healthy as fresh. Select only canned produce in water with no added salt. • Eat less fast food, prepared food and processed foods. Limit brined or cured foods, such as olives, pickles, ham and bacon. All are hidden salt sources. • Choose healthy snacks, such as carrot or celery sticks, fruit slices or unsalted air-popped popcorn.
Other heart-healthy tips include:
• Go big on fiber and colorful fruits and vegetables, good sources of potassium and magnesium, which help control high blood pressure. • Choose whole grains (whole wheat, brown rice, oatmeal, cornmeal, popcorn and more) instead of refined grains (white flour, white rice) for more fiber and healthful nutrients. • Eat lean protein (beans, tofu, fish, poultry and lean cuts of meat). • Choose low-fat or fat-free dairy products. • Nibble heart-healthy nuts and seeds. • Use small amounts of heart-healthy oils (olive, corn, canola, safflower), limit saturated fats (butter, palm oil) and avoid trans fats (also called partially hydrogenated oil). • Limit sweets.
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Questions & Answers
1. Why are women of color at higher risk for developing heart disease? Women of color have an increased incidence of high blood pressure, obesity and metabolic syndrome, all of which are related to heart disease. For each risk factor you have, your risk of developing heart disease DOUBLES!
Signs and Symptoms Some symptoms of a heart attack are shared by both men and women, such as pain in the chest radiating to the arm. Some women, however, might experience less classical symptoms:
Maria T. Vivaldi, M.D. Corrigan Women’s Heart Health Program Massachusetts General Hospital Heart Center
2. Are the symptoms of a heart attack different for a woman? Women can experience different symptoms that may lead to a heart attack, such as indigestion, neck or jaw pain, shortness of breath and in the elderly, fatigue. If you have a new symptom, you need to be proactive and be evaluated by your doctor immediately. 3. Is heart disease preventable? Absolutely! In fact, 90 percent of all heart attacks are caused by risk factors that you can directly change or control. Start by knowing your numbers, including your weight, blood pressure, cholesterol, blood sugar and then if necessary, get help to work to improve those numbers. If you smoke, STOP, and try to participate in some exercise daily. Lastly, be aware of your family history for heart disease which increases your personal risk as well.
4. Why is smoking harmful to the heart and blood vessels? Cigarettes, cigars and pipe tobacco have a number of bad effects. All three contain nicotine which increases your heart rate and blood pressure. Nicotine also causes narrowing of the blood vessels in your body (particularly the tiny blood vessels in your heart). The carbon monoxide in tobacco “replaces” oxygen in our blood, which is the fuel our hearts need to do its work. Smoking also increases the risk of blood clots forming in our blood vessels. These changes caused by smoking can lead to blockages in the blood vessels and result in a heart attack or a stroke.
• Nausea or vomiting • Indigestion • Shortness of breath • Excessive fatigue • Lightheadedness • Breaking out in a cold sweat • Pain or discomfort in the arms, back, neck or jaw
Call 9-1-1
Women are hesitant to call 9-1-1, but the American Heart Association says it’s best to call EMS — even if you’re not sure it’s a heart attack. Patients who arrive by ambulance typically receive faster treatment at the hospital.
Risk Factors Some risk factors for heart disease cannot be controlled, such as age, race and family history. However, the risk factors listed below can be avoided or modified by lifestyle changes and adherence to medication advice. • Smoking, including second-hand smoke • High blood pressure and cholesterol • Diabetes • Obesity
• Unhealthy diet • Inactivity • Blood vessel inflammation • Metabolic syndrome • Chronic stress and anxiety
5. What is the link between diabetes and heart disease? Diabetes is a strong risk factor for heart disease. In fact, 50 percent of people with diabetes will develop heart disease. Therefore, diabetes is one of the most important risks for heart disease and you need to do all you can to control your diabetes, which includes watching what you eat, exercising, controlling your weight, taking your diabetes medications and monitoring your blood sugar. 6. How much physical activity and exercise is recommended to help prevent heart disease? The American Heart Association recommends a minimum of 30 minutes of moderate-intensity exercise, such as walking or biking, on most days of the week and 60-90 minutes if you need to lose weight. The more exercise you get, the more your heart will benefit! 7. Is there a relationship between hormones such as estrogen and heart disease? In the past, it was felt that since hormones, such as estrogen, protect women against heart disease, women were advised to take hormones in pill form when they reached menopause when the levels of these hormones decrease. However, studies have recently shown that these “replacement” hormones actually have the opposite effect and increase the incidence of heart attacks, stroke and blood clots in the lungs. Now, the recommendation to take these replacement hormones is reserved for women who experience severe symptoms of menopause, and further, it is recommended that these hormones be taken only for the shortest possible time and in the lowest combination or dose. 8. Should women take an aspirin a day? The recommendations for daily aspirin use by women and men are a bit different. Studies have shown that aspirin is helpful to protect men against heart attacks and should be taken daily beginning at age 35. For women though the studies led to different recommendations for the use of aspirin. The recommendation for daily aspirin in women is only for women who develop heart disease or for those women who are at very high risk for heart disease such as women with diabetes. A daily aspirin is also recommended for all women age 65 or older who have diabetes. 9. Why are plant-based foods like fruits and vegetables recommended to improve health? A number of studies have shown that if you increase your daily intake of fruit and vegetables from five to eight servings a day, you reduce chances of having a cardiac event. Also, for people with a family history for heart disease, increasing fruit and vegetable intake lowers the risk of developing heart disease to the same risk level as people without a genetic link or family history! In fact just two additional servings per day can decrease your risk of having a heart attack by 4 percent. So your mother was right about eating those fruits and vegetables! The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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short-term remedy. A couple of weeks later stents were required for blockage in additional arteries. Her cardiac woes did not end there. Two months after her second procedure, she was diagnosed with heart failure, or weakening of the heart, that often results after a heart attack. That is not unusual. The event of the heart attack is bad enough. Worse are the consequences that continue for several years in women. The National Heart, Lung and Blood Institute (NHLBI), a component of the National Institutes of Health, found that more women than men die within the first year of a heart attack. Within five
Wanda Tswago (left) did not know the severe pain in her back was a symptom of a heart attack. Tswago is pictured with her husband Gregg and daughter Alexxis. (Photo courtesy of Wanda Tswago)
years, 22 percent of women and 15 percent of men will have another heart attack. The median years of survival after a first heart attack is 17 in men and 13 in women. In spite of its prevalence and dire consequences, heart disease is largely preventable. According to a case-control study involving 52 countries (INTERHEART), control of nine easily measured and potentially modifiable risk factors could result in a 90 percent reduction in the risk of an initial heart attack. The research further concluded that this reduction was consistent in men and women and different ethnic groups. Risk factors are classified by those one can control and those beyond a person’s control. Age, family history and race are not modifiable risk factors. Family history is especially important in women, according to Malissa Wood, co-director of the Corrigan Women’s Heart Health Program at the Massachusetts General Hospital Heart Center. Family history is defined as heart disease or
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How do you measure up? Determine your Body Mass Index Weight in pounds
HEIGHT
a heart attack in a first degree male relative before the age of 55 or a first degree female relative before the age of 65. A first degree relative is a parent or sibling. Other risk factors can be prevented or controlled if diagnosed. High blood pressure and cholesterol, obesity, unhealthy diet, inactivity, diabetes and smoking are all correlated to heart disease. Even stress and emotion are considered heart risks. Having one risk factor doubles the risk; having more increases the risk exponentially, said Wood. A snapshot of risk factors in women indicates the gravity of the situation, especially among African Americans. Black women are more likely to have high blood pressure and diabetes and engage in very little physical activity. More than 70 percent are overweight or obese due largely to an unhealthy diet. African American women, compared to other women nationally, tend to consume a high amount of calories, fat and cholesterol per day. Like Tswago, Brenda Taylor did not initially recognize the onset of her heart troubles. She thought that she had simply eaten something that didn’t agree with her. Already troubled with acid reflux, a condition that causes heartburn among other symptoms, Taylor sought her usual relief of medications. But this time, according to Taylor, it was different. “I just wasn’t feeling well,” she said. “I didn’t have all my energy.” She popped antacids and sipped soda — anything to ease the discomfort. But nothing helped. Her condition worsened to the point when, finally, early the next morning she relented and went to the emergency room. She was not prepared for what a nurse told her. After viewing the results of Taylor’s EKG, the nurse yelled “I need a doctor STAT.” Taylor had had a heart attack. “I did not recognize the symptoms,” she said. But a catheterization told the tale. She had clogged arteries in her heart. The stent to open her arteries was not successful, and she underwent a double bypass. In hindsight Taylor realized she should have been more aware. Her father died from a massive heart attack at the age of 45, which increased her risk of heart disease. But, according to Taylor, no one discussed this with her. She religiously attended her “well woman” exams and kept track of her numbers, but no one suggested that she could be of risk. Taylor said she is determined that she will not be caught off guard again. “I have learned to be my own advocate,” she said. “I ask questions now and seek information regarding women and heart disease.”
Tswago, continued from page
100 110 120 130 140 4’10” 21 23 25 27 29 4’11” 20 22 24 26 28 5’ 20 21 23 25 27 5’1” 19 21 23 25 27 5’2” 20 22 24 26 5’3” 19 21 23 25 5’4” 19 21 22 24 5’5” 20 22 23 5’6” 19 21 23 5’7” 19 20 22 5’8” 20 21 5’9” 19 21 5’10” 19 20 5’11” 20 6’ 29 6’1” 6’2” Underweight 6’3” 6’4”
150 32 30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19
160 34 32 31 30 29 28 28 27 26 25 24 24 23 22 22 21 21 20 20
170 36 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22 21 21
180 38 36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23 22
190 200 210 220 230 240 250 260 270 280 290 300 38 37 36 35 34 33 32 31 30 29 28 27 27 26 25 25 24 23
39 38 37 36 34 33 32 31 30 30 29 28 27 26 26 25 24
38 37 36 35 34 33 32 31 30 29 29 28 27 26 26
Normal weight: 18.5-24.9 Overweight: 25-29.9 Obese: 30 and above 39 38 37 36 35 34 33 32 31 30 29 28 28 27
38 37 36 35 34 33 32 31 30 30 29 28
39 38 37 36 35 34 33 32 31 30 29
39 38 37 36 35 34 33 32 31 31
39 37 36 35 34 34 33 32
Extremely Obese 39 38 37 36 35 34 33
39 38 37 36 35 34
39 38 37 39 36 38 35 37
The Body Mass Index (BMI), a calculation based on height and weight, helps measure a person’s healthy weight. When combined with other measurements, such as waist size, the BMI is a helpful tool in determining whether a person should lose weight to reduce health risks. Measure your waist circumference Accumulation of weight around and above the waist (apple-shaped) rather than the hips and buttocks (pear-shaped) increases a person’s risk for cardiovascular disease.
PEAR-SHAPED
Desirable Waist Measurements Women: under 35 inches To accurately measure your waist:
• Place a tape measure around your bare abdomen just above your hip bone • Be sure the tape is snug but does not push into your skin • Check to make sure the tape measure is level all the way around • Relax, breathe out and measure your waist.
Waist to Hip Ratio APPLE-SHAPED
Measure your waist and your hips. Divide your waist measurement by your hips measurement.
Women: 0.80 or below
Calculate your risk for heart disease relative to your BMI and waist circumference. Source: National Heart Lung and Blood Institute
Waist Size Women: ≤ 35 inches
Waist Size Women: > 35 inches
25.0-29.9
Increased
High
30.0-34.9
High
Very high
35.0-39.9
Very high
Very high
BMI
40.0 and above Extremely high
Extremely high
Rodriguez, continued from page 1
right. She reached out to WomenHeart, the only But plaque can build up differently in national organization dedicated to promoting women, according to Wood. Instead of rupturwomen’s heart health through advocacy, educaing and causing a clot that typically happens tion and patient support. in men, the plaque sloughs off bit by bit in Rodriguez made a plan and stuck to it. women. That partly explains the differences in a One by one her numbers began to change. heart attack in women. While men’s attacks can “The numbers that needed to go up have gone be sudden, in women they are more gradual. up, those that needed to go down are down,” Another problem is that plaque can build she said. up in smaller arteries of the heart resulting in She’s got her exercising down pat, and what’s called microvascular disease, or cardiac even bought a treadmill to take away excuses. syndrome X. This makes diagnosis — and “We have time for everything but exercise,” she treatment — difficult. said. If she can’t get in one “Some of the diagnostic 30-minute walk a day, she and treatment procedures breaks it up into three 10are designed for the larger minute walks. House work arteries of the heart,” exadds to her regular exercise plained Wood. routine. The good news is Healthy eating is a that heart disease is highly challenge. That chicharrón treatable with good suc— fried pork skin — is oh so cess. Treatment ranges good she admitted, but oh so from medication to open unhealthy if eaten in volume. heart surgery. She might have a little bit It is also highly from time to time, but has preventable. And that stopped frying as a regular Malissa J. Wood, M.D. is Woods’ mission. She means of preparing food. developed HAPPY Heart Co-Director, Corrigan Women’s She learned to read to reduce the incidence food labels. She’s traded Heart Health Program of cardiovascular disease her white rice and bread Massachusetts General Hospital in low-income women. for brown rice and whole Heart Center The program combines wheat bread. She cut down screening and prevention techniques, such as on fatty meats and relies more on fresh vegexercise, smoking cessation and stress reduction etables and fruit. Salads are now a staple. to reduce their risk of heart disease. All these changes have paid off. Her BMI “Many of the traditional cardiovascular is now normal and she has dropped three dress risk factors, including obesity, hypertension, sizes. Her blood pressure is under control, and smoking and diabetes tend to be more prevalent her diabetes is maintained by oral medications. among low-income women,” said Wood. “Risk Her A1C, a test that shows how well glufactors are cumulative. The more you have the cose is maintained, hovers around 6 — well greater your risk.” within the range expected for people with type Rodriguez doesn’t have to be reminded 2 diabetes. The doctor told her, “I’m so proud anymore about reducing her risk factors. She of you.” took part in a cardiac rehabilitation program. Rodriguez gives herself a pat on the back She consulted a nutritionist to teach her to eat as well. She, too, is pretty proud of herself.
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.