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This site is an excellent first place to turn to for more information about all cardiac concerns. You can find information about the New Guidelines for Women.
This link takes you to the American Heart Association's article about the new "2007 Guidelines for Preventing Cardiovascular Disease in Women".
This is one of the National Institutes of Health and a very important information resource.
This site has much valuable information about heart healthy diets.
The Framingham Heart Study has its own website that provides fascinating background information about the study and in depth discussions of its risk assessment tools and its findings.
Episode number: 
407

Heart disease is the number one killer in the U.S.  With doctors and researchers racing to stop heart disease in its tracks, diagnostic technology and treatment options are breaking new ground at astounding speed.  But are there dangers?   Can technology tell us too much?  Our experts dive into the high-tech world of cardiac care.

About heart disease

Heart disease is the leading cause of death in the United States for men and women. The American Heart Association says that more than 15 million people have some form of it.  Younger men (in their 40s) have a higher risk of it than women of the same age. But as people get older, the risk for women increases until it almost equals men's.

The heart is essentially a muscle, about the size of a fist, whose main job is to pump blood to all parts of the body, bringing needed nutrients and oxygen and removing waste products.  The coronary arteries are the blood vessels that bring blood to the heart.  When these arteries become hard and narrowed, the blood supply to the heart becomes reduced.  Arteries usually harden and narrow because they get clogged with a fatty substance called plaque.  This build up of plaque is known as coronary artery disease (CAD), coronary heart disease (CHD), or atherosclerosis.

Coronary artey disease

Coronary artery disease is a leading cause of cardiac ischemia. Ischemia means that the flow of blood (and therefore oxygen) to a part of the body has been reduced; cardiac ischemia means not enough blood and oxygen are flowing into the heart.  Cardiac ischemia usually causes chest pain, a condition known as angina or angina pectoris. 

A heart attack means the supply of blood and oxygen to the heart has been so drastically reduced that cells in the heart die.  The more severe the heart attack, the more of the heart that dies.  The technical name for the heart muscle is the myocardium, and the most widely used technical term for a heart attack is myocardial infarction.  But you may also hear the terms coronary thrombosis or coronary occlusion.  

Cardiovascular disease

Another term to know is cardiovascular disease (CVD).  It's refers to conditions or diseases of the heart and blood vessels in general, including coronary artey disease, angina, congestive heart failure (a condition in which a weakened heart doesn't pump efficiently, causing excess body fluids to back up into the lungs and elsewhere), high blood pressure, and stroke.  

Stroke is related to heart disease.  Just as a heart attack results from an interruption of blood flow to the heart, a stroke is the interruption of the flow of blood to any part of the brain.  Just as a heart attack damages or destroys heart tissue, a stroke damages brain tissue.  And just as a heart attack can be caused by atherosclerosis of the coronary arteries, a stroke can be caused by atherosclerosis of the carotid arteries – the arteries that supply blood to the brain. Therefore, the steps taken to prevent heart attack can also help prevent stroke. 

Several earlier episodes of Second Opinion also explored various aspects of heart disease. You'll find lots of valuable information at

  • Second Opinion, Heart Failure (Cardiomyopathy), Episode 102
  • Second Opinion, Heart Rhythm Disorder (Arrhythmia), Episode 110
  • Second Opinion, Heart Attack, Episode 113
  • Second Opinion, Women's Cardiac Health, Episode 209
  • Second Opinion, Depression and Heart Disease, Episode 302 
    And you can find information about stroke at
  • Second Opinion, Stroke, Episode 205 

Quick Facts

  • How often does the average heart beat (expand and contract) each day? About 100,000 times.  How much blood does it pump?  About 2,000 gallons. If you live to age 70, your heart will beat more than 2.5 billion times.
  • Although some risk factors for a heart attack are beyond our control, many more are not.  To prevent a heart attack, live in a "heart-healthy" way.  That means:
    • get more physical exercise
    • eat a heart-healthy diet
    • keep your blood pressure under control
    • keep your cholesterol under control
    • stop smoking
    • stop drinking alcohol heavily
  • Smoking is the most prevalent and preventable risk factor for cardiovascular disease in women younger than 45. 
  • Fewer than half of all women are aware that heart disease is the number 1 killer of American women. Most women identify cancer as the leading cause of death.
  • African-American women are more at risk for heart disease than Caucasian women.
  • The body manufactures more cholesterol at night than during the day.  Therefore, cholesterol lowering medicines are most effective when taken during the evening, at dinner or before bed.
  • Learn CPR (cardio-pulmonary resuscitation) and how to use an AED (automated external defibrillator).  The American Heart Association has courses that combine CPR and AED training.  They take only about four hours.  Contact your local chapter to find out when they're given. You may save a life Get information about AHA's CPR and AED classes.
  • About 4,000 people are currently on the waiting list for a heart in the U.S.  About one third of them – more than 1300 people – will die waiting.  Become an organ donor. 
  • A heart attack is not a death sentence.  Today, the majority of people who have a heart attack survive it and go on to live normal, active lives. Following a program of secondary prevention (usually involving taking medicines and making some lifestyle changes) can prevent a second heart attack.

Ask Your Doctor

This list questions will provide a good starting point for a discussion with your doctor.  However, it is not a complete list.

  • What is my blood pressure?
  • What are my cholesterol numbers?
  • What is my blood sugar level, and does it mean I'm at risk for diabetes?
  • What is my risk for heart disease? 
  • What is the current condition of my heart and coronary arteries? 
  • What life-style changes (such as diet, exercise, etc.) should I make to prevent heart disease?
  • Do I need screening tests, even though I don't have heart disease symptoms?
  • I've noticed these symptoms . . . What medical tests should I take to get an accurate diagnosis?
  • How can I tell if I'm having a heart attack?

If your doctor recommends tests:

  • What kinds of tests will I have?
  • What do you expect to find out from these tests?
  • When will I know the results?
  • Do I have to do anything special to prepare for any of the tests?
  • Do these tests have any side effects or risks?
  • Will I need more tests later?

If your doctor finds evidence of heart disease:

  • How dangerous is my condition?
  • What life-style changes (such as diet, exercise, etc.) should I make to treat my condition?
  • What medications can I take to slow down the progression of my condition?
  • What are the treatment options, and what are their benefits, risks, and side effects?
  • What follow-up care will I need?
  • If I have pain, how will it be managed?

If your doctor finds recommends medicines:

  • What is the name and purpose of the medication?
  • What time of day do I take it, with food or without, and for how long?
  • How successful is this medicine?
  • What are the potential side effects and what should I do if they occur?
  • What should I do if I miss a dose?
  • Should I swallow it whole or can it be crushed?
  • Will this drug interact with any other medications I am currently taking – prescription, OTC, or herbal?
  • While taking this medication, should I avoid certain foods, alcohol, or dietary supplements?
  • How long will I have to take this medicine?
  • Are other treatments available?  Do I need them?

Key Point 1

The impact of cardiac risk factors for women under the age of 70 are not as well understood as risk factors in men and in women over 70.  But no matter your age or gender, you should work with your doctor to understand your own risk factors. 

What are risk factors?  They're things that increase your chance of getting a disease or developing a condition.  By definition, risk is uncertain.  If you have a lot of risk factors for a disease, that does not mean you will get it; if you don't have a lot risk factors, that does not guarantee you will not get it. 

But knowledge is power.  If you know you have a lot of risk factors, you can take steps to reduce their effect.

Some risk factors for coronary artery disease and heart attack are beyond our control, such as:

  • Genetics: a family history of heart disease and early heart attack can increase one's risk of heart attack.
  • A history of coronary artery disease, high blood pressure, and other heart problems.
  • Age: the heart muscle weakens with age, so that men over 45 and women over 55 are at a higher risk of having a heart attack.
  • Diabetes: uncontrolled diabetes increases the risk of developing coronary artery disease.
  • Peripheral arterial disease (clogged vessels in the arms and legs):  people with PAD may form blood clots, increasing their risk of death from heart attack or stroke.
  • Chronic renal disease: kidney disease can be a cause or a consequence of cardiovascular disease.  It is also closely related to hypertension and diabetes.

Other risk factors, such as not getting enough exercise, smoking, and having too much cholesterol in the blood, are controllable.  They relate to how we live, and we can always change that if we try; we can always choose to live in a heart-healthy way.  For information about heart-healthy living, go to Key Point 3.

Much of what we know about these risk factors comes from the Framingham Heart Study. Begun in 1948, directed (in collaboration with Boston University since 1971) by what is now the National Heart, Lung, and Blood Institute (one of the National Institutes of Health), the study started with 5,209 people, ages 30-62, from Framingham, Massachusetts, who had no overt symptoms of cardiovascular disease or stroke.  It then tracked their health until the present (or their death) with the goal of  learning "the circumstances in which cardiovascular diseases arise, evolve and end fatally in the general population."

Through regularly scheduled, in-depth medical exams (now including sophisticated new technology such as bone scans, eye exams, and echocardiograms) and interviews, plus information from the subjects' primary care physicians, and other data, the study began the process of identifying major risk factors for CVD.  In fact, the study actually coined the term "risk factor."  Before then, the idea that "risk factors" for specific diseases could be discovered, and people could change their lives to reduce their effect, was simply unheard of. 

In 1971, the "Offspring Study" began, as more than 5000 adult children (and their spouses) of the original participants were enrolled in the research program. Having two generations worth of data created an especially rich source of data. The third generation study, focusing on the children of the 1971 group, began in 2002.

So far, the study has yielded more than 1200 scholarly research articles. Perhaps more important, it has made so many "ordinary people" aware of how high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity can increase the risk of heart disease. 

It has also produced a coronary prediction algorithm, a risk assessment tool that estimates a person's risk of having angina or a heart attack, or dying from heart disease, during the next ten years.  The risk factors considered include age, "good" and "bad" cholesterol, blood pressure, smoking, and diabetes.  Separate score sheets for men and women indicate a person's risk score or risk classification.

Finally, the study has deepened our understanding of the effects of gender, age, and psychosocial issues on heart disease.  There seem to be important differences in the way risk factors affect men and women, and some different factors for each.  Among these differences are:

  • Both men and women have coronary heart disease (CHD) more often than other cardiovascular events such as stroke or congestive heart failure.
  • At younger ages, men suffer coronary events twice as often as women; but as people age, the numbers become almost equal.
  • For women, angina (chest pain) is the most common first symptom of CHD;  
    for men, heart attack is the most common first coronary event.
  • Women with angina do better than men, because men with angina have more underlying heart disease. 
  • Women with angina have five times the risk of future coronary events than women without angina.
  • More women than men have unrecognized heart attacks. 
    • When heart attack is the first coronary event, nearly half are unrecognized in women, one-third in men.  
    • Most men and women with unrecognized heart attacks had either no symptoms or such unusual symptoms that neither they nor their physician suspected a heart attack.  Routine ECGs revealed the heart attacks.
  • Heart attacks are more often fatal for women than men, but women heart attack survivors generally have the same prognosis as men.
  • Menopause seems to increase a woman's risk of  heart disease.
  • Diabetes poses a greater risk of CHD in women then men.
  • Women who smoke heavily (two packs daily) are less likely to quit than men.
  • Both men and women who "weight cycle" (repeatedly loss weight then gain it back) have a higher risk of heart disease, including fatal heart disease.

More research is needed to explain these differences, although some have been addressed in the American Heart Association's "2007 Guidelines for Preventing Cardiovascular Disease in Women."   For more information on these guidelines, go to Key Point 3.

Key Point 2

The tests you get to diagnose heart disease are based on who you are and your risk factors.  When getting tests, it's important to know that sometimes technology has outpaced our ability to know what to do with the results, and you need to ask if the tests will make a difference in your outcome.

If you discuss possible coronary problems with your doctor, the first thing to do is to give as open, honest, accurate, and complete a report of your symptoms and your lifestyle as possible.  Make sure you tell your doctor about your eating habits, sleeping habits, lifestyle choices (such as whether and how much you smoke). Never be afraid to discuss the "little details;" they actually may be very important to helping your doctor arrive at an accurate diagnosis. 

Certainly the first tests to have are the old standbys: blood pressure, cholesterol level, weight, and blood sugar.  Then you might move on to the other diagnostic tests currently available, such as:

  • Blood tests
  • Electrocardiogram (EKG, ECG, or cardiogram): a measurement of the heart's electrical activity (which controls the heartbeat) made by an EKG machine, which is attached to the chest with wires called electrodes.  If an EKG doesn't give conclusive results, a portable EKG machine, called a "Holter monitor," may be used.  It monitors the heart rate and notes any arrhythmias (irregularities).
  • Stress EKG (stress test): an electrocardiogram made while the person is exercising (usually by jogging on a treadmill or riding a stationary bike).  If a patient is unable to exercise, a drug can be injected that makes the heart react as it would during exercise.
  • Echocardiogram: sound waves are bounced off the heart to produce still and moving images of it (similar to ultrasound imaging used with pregnant women to produce images of fetuses).  A stress echocardiogram is a stress test and echocardiogram done at the same time.
  • Myocardial perfusion imaging: an imaging test in which a small dose of a harmless radioactive tracer is injected into the patient, who then exercises (as in a stress echo test) while a specialized camera detects the tracer passing through the heart, creating images of the heart at work and at rest.
  • MRI (magnetic resonance imaging): an imaging technique that "sees through" bones and other obstructions (like an x-ray) to produce detailed cross-sectional pictures of internal organs and body parts; a coronary MRI can help discover a wide range of cardiovascular problems.
  • Cardiac catheterization: in this more invasive test, a small tube (catheter) is inserted through a blood vessel and threaded up into the heart, to measure blood flow and pressure; a tiny sample of the blood vessel can be removed for examination in the medical laboratory.
  • Coronary angiogram (also called arteriogram): an x-ray of the inside of the coronary arteries to look for blockages.  During cardiac catheterization, a contrast dye is injected into the catheter that enables blockages to be seen on the x-ray.  The process of making an angiogram is called angiography.

Recently, a new type of imaging test, often called a "heart scan" but actually known as EBCT (electron beam computerized tomography or "Ultrafast CT"), has received a lot of publicity.  It's a type of computerized tomography (popularly known as CT scan or CAT scan).  Computerized tomography is a sophisticated imaging system that creates a series of very detailed, cross-sectional images of organs and tissues. EBCT is a variation that works much more quickly.  It provides an accurate measurement of calcium deposits in the coronary arteries.  These calcium deposits are reported as a calcium score; the higher the score, the greater the amount of calcium deposits.  Scores range from 0 (no evidence of calcium deposits) to over 400 (very high amounts of calcium are present).

There does appear to be a correlation between large calcium deposits in the coronary arteries and the development of coronary artery disease.  However, the correlation seems age-dependent; that is, it is stronger for younger people (up to about 50) than older (above 50).  People over 50 seem to develop calcium deposits naturally, so they're not as accurate a predictor of future CAD. 

Moreover, the medical profession believes certain standards must be met before a screening test (a diagnostic tool, such as EBCT) can be called cost-effective. One of these is that it must provide information that will affect treatment and prognosis.  So far, there are no studies showing that EBCT heart scanning has any significant effect on reducing deaths from CAD or improving the lives of people with it. 

For example, EBCT will identify small build-ups of calcium (such as 10-20%), but these results generally don't lead to changes in treatment, other than re-emphasizing the importance of reducing risk factors, such as smoking and cholesterol.  Further, the test finds only calcium deposits that have become hard, called hard plaque; it does not find soft plaque which can also cause heart attacks.

Besides being of limited value in the early detection of CAD, EBCT is unavailable in many areas, expensive, and generally not covered by insurance.  In early 2007, a committee of the American College of Cardiology Foundation (ACCF) updated the report on EBCT issued by it and the American Heart Association in 2000.  It found that there is still not enough solid data about the cost-effectiveness of EBCT on which to base medical decisions or set policy.

The committee did report that it may be reasonable to consider use of EBCT for people with intermediate risk ratings, but no symptoms.  It does not recommend using it for people at low risk, for the general population, nor for people at high risk (because they would already be candidates for intensive risk reducing therapies).

Three-Dimensional Helical Computed Tomography (or DHCT) is another advanced variation on traditional CT scanning.  Like EBCT, there are many places where it isn't available, it's expensive and generally not covered by insurance, and at present may be of limited value in the early detection of CAD.

Key Point 3

Heart disease is the number one killer in the U.S. If you don't know if you are at risk of heart disease, work with your doctor to find out.  There are dietary, pharmacological and lifestyle actions you can take to help prevent having a heart attack.

The most familiar and most effective lifestyle actions are simply to live in a "heart-healthy way." This means living in a way that promotes general health, by emphasizing exercise, non-smoking, moderation in alcohol use, and a healthy diet.  Specifically, for a heart healthy lifestyle:

  • Start and maintain a program of regular physical exercise.  The choices are virtually endless, from taking a simple (but not too slow) walk to swimming to team sports to exercises classes with a professional trainer.
  • Stop smoking
  • Stop drinking alcohol heavily
  • Keep your blood pressure under control.  If you need blood pressure lowering medicine, get it and use it.
  • Keep your cholesterol under control. If you need cholesterol lowering medicine, get it and use it and eat a heart-healthy diet.

In February 2007 the American Heart Association published its "2007 Guidelines for Preventing Cardiovascular Disease in Women" in Circulation: Journal of the American Heart Association. They updated the 2004 guidelines by saying healthcare professionals should focus on women's lifetime heart disease risk, not just on short-term risk. They included a new paradigm for risk assessment based on risk factors and family history, as well as the Framingham risk score.  (For information on the Framingham risk score, go to Key Point 1.)

In the past, women were classified as being at high, intermediate, or low (optimal) risk for heart disease.  The new classifications are high risk, at-risk, or optimal.  Optimal represents an estimated ten percent of women.

The 2007 guidelines also offer new directions for using aspirin, hormone replacement therapy, and vitamin and mineral supplements for heart disease and stroke prevention in women.  The highlights of the new guidelines are:

  • Manage blood pressure with weight control, increased physical activity, alcohol moderation, sodium restriction and eating fresh fruits, vegetables and low-fat dairy products.
  • Reduce saturated fats intake to less than 7 percent of calories if possible.
  • Eat oily fish (a source of omega-3 fatty acid) at least twice a week.
  • Supplement omega-3 fatty acid intake.  Women with heart disease should consider taking a capsule supplement of  850–1000 mg of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid).  Women with high triglycerides should consider taking 2 to 4 grams.
  • Control cholesterol.  Women at very high risk for heart disease should aim for LDL ("bad") cholesterol of less than 70 mg/dL. Women at high-risk should aim for LDL of less than 100 mg/dL.
  • Exercise at least 30 minutes per day.  Women who need to lose weight or maintain weight loss should exercise moderately (e.g., brisk walking) at least 60 to 90 minutes on most if not all days.
  • Quit smoking.  Get counseling, nicotine replacement, or other forms of smoking cessation therapy.  Also, avoid secondhand smoke.
  • Consider "aspirin therapy:"
    • The upper dose of aspirin for women at high-risk has been raised to 325 mg per day (from 162 mg).
    • Women 65 and over should consider taking low-dose aspirin routinely regardless of their risk level.
    • Women under 65 need not take aspirin routinely, but it has been shown to have a benefit for stroke prevention only.
  • Be aware of the following:
    • Hormone replacement therapy and selective estrogen receptor modulators (SERMs) are not recommended to prevent heart disease in women.
    • Antioxidant supplements (such as vitamin E, C and beta-carotene) should not be used for primary or secondary prevention of cardiovascular disease (CVD).
    • Folic acid should not be used to prevent CVD.

In the same issue of Circulation, the AHA also reported on results from several other research studies:

  • Age, rather than health care disparities, seems to explain why more women than men die in the hospital after a heart attack; women are generally older than men when they have a first heart attack.
  • Differences in an estrogen gene do not appear to affect the risk of heart attack and stroke in response to hormone replacement therapy, as was previously thought. The gene may, however, be associated with an elevated risk of breast cancer.
  • Some 40 percent of postmenopausal women have "pre-hypertension," associated with a 58 percent higher risk of cardiovascular death.
  • Taking calcium/vitamin D supplements had no effect on heart disease and stroke risk in generally healthy postmenopausal women.
  • Estrogen, when delivered by patch or gel, does not seem to increase the risk of blood clots in the vein (venous thromboembolism or VTE). Only estrogen taken orally seems to increase this risk.

Medline Plus

Medline Description: 

Conduct an off-site search for Cardiac Breakthroughs information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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