Women and Heart Disease

by Food and Drug Administration (FDA)

In the spring of her 58th year, Anita Chudnow of Milwaukee, Wis., was working in her garden when a sudden and extreme fatigue overcame her. She went in to lie down and didn't have the energy to get up to make dinner several hours later.

Convinced that something was amiss, her family insisted she see a doctor. He put her through a battery of tests, which revealed that three of Chudnow's heart arteries, called coronaries, were choked with a fat-like deposit called plaque. The plaque had narrowed her arteries, depriving her heart of the oxygen-rich blood it needed to function.

"I couldn't believe it," said Chudnow, recalling her surprise at learning she had coronary heart disease, although she was familiar with the condition because her father had it. "Maybe I thought heart disease was a man's disease because of all those years my father suffered from it. I went with him in the ambulance to the hospital so many times and I never thought the same thing could happen to me," she said.

Unfortunately, Chudnow isn't the only one with that misconception. Although heart disease has been the number one killer of women since shortly after the turn of the century when it overtook infectious diseases, most people aren't aware of how common — and how deadly — the disorder is in women.

"This is a problem," said cardiologist Nanette Wenger, M.D., of Emory University in Atlanta, "because unless women see heart disease as part of their disease profile, they're not going to adhere to heart disease prevention messages early in life and they're not going to respond to heart disease symptoms later on."

The lack of awareness of heart disease in women was fueled, in part, by the early findings of the landmark Framingham Heart Study. In this study, which began in 1948 and is still ongoing, researchers have scrutinized the habits and health of thousands of middle-aged men and women from Framingham, Mass. After collecting data for a little over a decade, they found that three times more men died from heart disease during this period than women, which led to the conclusion that women were somewhat protected from the condition.

Further analyses of the Framingham data and a study conducted at the Cleveland Clinic revealed, however, that women aren't spared from medical matters of the heart, but rather tend to develop them about 10 to 15 years later in life than men. According to the American Heart Association, 1 in 9 women aged 45 to 64 has some form of heart or blood vessel disease; this ratio soars to 1 in 3 at age 65 and beyond. The approximately 500,000 heart attack deaths that occur annually in this country, in addition, are evenly split between men and women. Each year, nearly twice as many women die from heart disease and stroke than from all forms of cancer combined.

Despite the prevalence and seriousness of heart disease among women, much of what is known and popularized about it is based on research done in men. The studies that have included women suggest, however, that many of the mainstays of diagnosis, treatment and prevention of coronary heart disease may not apply to the female gender.

As with other drugs and populations, FDA is responsible for the safety and effectiveness in women of medications for heart disease.

Discrepancies in Diagnosis

One of the telltale signs of heart disease is chest pain or tightness, known as angina, that occurs during physically demanding tasks such as climbing stairs, or under emotional strain. This pain can make a person short of breath. It can radiate to the jaw, neck, shoulders, or inner arms. Angina occurs because narrowed arteries in the heart deprive it of oxygen-rich blood. If a blood clot completely chokes off the blood supply in these arteries in what is known as a heart attack, chest pain usually becomes more severe and lasts longer.

But chest pain may not be as good a diagnostic clue of serious heart disease in women as it is in men. Nearly twice as many men as women with chest pain that may be angina actually have coronary heart disease. This finding is from the National Institute of Health's Coronary Artery Surgery Study. It may stem, in part, from women being more likely than men to have such conditions as heartburn or spasms of the esophagus or heart arteries, which can cause chest pain that resembles angina.

But given the dire consequences of heart disease that goes unrecognized, Wenger said that any woman complaining of chest pain should be taken seriously by her doctor. She and other experts at a 1992 conference convened by the National Heart, Lung, and Blood Institute recommended that doctors carefully evaluate women (and men) with chest pain, based on their symptoms and risk factors for heart disease, such as smoking or high blood pressure. These patients should then have tests to detect abnormalities prompted by narrowed heart arteries or a previously unrecognized heart attack.

But some of these commonly performed tests are less accurate in women then men and have prompted some cardiologists to reject their use in female patients altogether. One standard test is an exercise stress test, during which the patient exercises on a treadmill while the activity of the heart is electrically monitored. But this test falsely predicts heart disease in as many as half the women tested, studies show. In addition, many women cannot exercise long enough for such a test because, at their older age, they have exercise-limiting illnesses, such as arthritis.

Researchers recently developed statistical standards for the treadmill stress test in women that uses a woman's age and risk factors for heart disease to improve accuracy. Wenger is satisfied enough with these modifications to prescribe the treadmill stress test for her female patients, if they can exercise. But other cardiologists still question its accuracy because they think most doctors don't have the information they need to adequately assess a woman's risk factors for heart disease. "I don't do stress treadmill tests in women," said Marianne Legato, M.D., of Columbia University. "They're a waste of $600."

About the Author

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